Brainstem arteriovenous malformations: lesion characteristics and treatment outcomes

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OBJECTIVE

Brainstem arteriovenous malformations (AVMs) are rare lesions that are difficult to diagnose and treat. They are often more aggressive in their behavior when compared with their supratentorial counterparts. The consequence of a brainstem hemorrhage is often devastating, and many patients are in poor neurological status at presentation. The authors examine the factors associated with angiographically confirmed cure and those affecting management outcomes for these complex lesions.

METHODS

This was a retrospective analysis of data gathered from the prospectively maintained Stanford AVM database. Lesions were grouped based on their location in the brainstem (medulla, pons, or midbrain) and the quadrant they occupied. Angiographic cure was dichotomized as completely obliterated or not, and functional outcome was dichotomized as either independent or not independent at last follow-up.

RESULTS

Over a 23-year period, 39 lesions were treated. Of these, 3 were located in the medulla, 14 in the pons, and 22 in the midbrain. At presentation, 92% of the patients had hemorrhage, and only 43.6% were functionally independent. Surgery resulted in the best radiographic cure rates, with a morbidity rate of 12.5%. In all, 53% of patients either improved or remained stable after surgery. Absence of residual nidus and female sex correlated with better outcomes.

CONCLUSIONS

Brainstem AVMs usually present with hemorrhage. Surgery offers the best chance of cure, either in isolation or in combination with other modalities as appropriate.

ABBREVIATIONS AP = anteroposterior; BS AVM = brainstem arteriovenous malformation; EVT = endovascular therapy; FD = functionally dependent; FI = functionally independent; IGS = integrated grading score; IVH = intraventricular hemorrhage; mRS = modified Rankin Scale; SM = Spetzler-Martin.

Article Information

Correspondence Gary K. Steinberg, Department of Neurosurgery, Stanford University Medical Center, 300 Pasteur Dr., Stanford, CA 94305. email: gsteinberg@stanford.edu.

INCLUDE WHEN CITING Published online February 17, 2017; DOI: 10.3171/2016.9.JNS16943.

Disclosures Dr. Steinberg serves on the Medtronic Neuroscience Strategic Advisory Board and is a consultant for Qool Therapeutics; Peter Lazic US, Inc.; and NeuroSave.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Pie chart showing scheme for classifying the quadrant of the brainstem involved by the lesion nidus, based on MRI and angiographic sequences.

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    Brainstem (midbrain) SM Grade III AVM. This patient presented with a hemorrhage. a: Axial T2-weighted MR image showing hemosiderin staining in the superior vermis (horizontal arrow) and abnormal vessels on the posterolateral pial surface of the midbrain on the right side (vertical arrow). b: Preoperative angiogram, anteroposterior (AP) view, showing the nidus (arrow) filled by the right superior cerebellar artery. c: Superselective catheterization of the distal right superior cerebellar artery showing the nidus (star) and vein draining into the straight sinus (arrow). d: Intraoperative view. A subtemporal approach showing the temporal lobe retracted (star) and the tentorium coagulated and cut (arrow), while carefully preserving the fourth cranial nerve (thick arrow). e: Magnified surgical view showing the pial AVM (star) and fourth cranial nerve (thick arrow). f: Postoperative angiogram, AP view, showing no residual nidus. From Madhugiri VS, Teo M, Steinberg GK: Surgery of basal ganglia, thalamic and brainstem AVMs, in Brain Arteriovenous Malformations and Arteriovenous Fistulas. Dumont A, Lanzino G, Sheehan J (eds), 2017, Thieme, www.thieme.com (reprinted with permission).

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    Preoperative images of a brainstem (pontine) AVM. Axial CT image (a) showing a large hemorrhage in the dorsolateral pons, extending into the middle cerebellar peduncle. Axial T2-weighted MR image (b) showing flow voids around the brainstem (arrow). Lateral (c) and AP (d) views of a left vertebral injection angiogram, showing the nidus (arrows) near the right pontomedullary junction, supplied by a branch of the V4 segment of the right vertebral artery. From Madhugiri VS, Teo M, Steinberg GK: Surgery of basal ganglia, thalamic and brainstem AVMs, in Brain Arteriovenous Malformations and Arteriovenous Fistulas. Dumont A, Lanzino G, Sheehan J (eds), 2017, Thieme, www.thieme.com (reprinted with permission).

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    Intraoperative and postsurgical images of the AVM shown in Fig. 3. This patient underwent operation via a far-lateral right-sided approach. a: Initial view after opening the dura mater and retracting the cerebellum (black star). The right posterior inferior cerebellar artery (solid arrow), vertebral artery (white star), and some lower cranial nerve rootlets (broken arrow) are seen. b: Magnified view of the pial AVM and the feeding arterial pedicle (arrow). c: Postoperative axial T1-weighted MR image obtained after addition of Gd contrast showing postresection changes and no abnormal vessels. d: Postsurgical angiogram, AP view, showing no residual nidus. From Madhugiri VS, Teo M, Steinberg GK: Surgery of basal ganglia, thalamic and brainstem AVMs, in Brain Arteriovenous Malformations and Arteriovenous Fistulas. Dumont A, Lanzino G, Sheehan J (eds), 2017, Thieme, www.thieme.com (reprinted with permission).

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    Bar graph displaying the distribution of lesions across the brainstem and various quadrants.

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