Delayed neurological deterioration following resection of arteriovenous malformations of the brain

Michael K. Morgan North and West Cerebrovascular Unit, Department of Surgery, University of Sydney, Sydney, Australia; and Departments of Radiology and Intensive Therapy, Royal North Shore Hospital, Sydney, Australia

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Lali H. S. Sekhon North and West Cerebrovascular Unit, Department of Surgery, University of Sydney, Sydney, Australia; and Departments of Radiology and Intensive Therapy, Royal North Shore Hospital, Sydney, Australia

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Simon Finfer North and West Cerebrovascular Unit, Department of Surgery, University of Sydney, Sydney, Australia; and Departments of Radiology and Intensive Therapy, Royal North Shore Hospital, Sydney, Australia

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 M.B.B.S., M.R.C.P., F.R.C.A.
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Verity Grinnell North and West Cerebrovascular Unit, Department of Surgery, University of Sydney, Sydney, Australia; and Departments of Radiology and Intensive Therapy, Royal North Shore Hospital, Sydney, Australia

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Object. The aim of this study was to analyze delayed neurological deficits following surgical resection of arteriovenous malformations (AVMs).

Methods. The authors report on a consecutive series of 200 patients with angiographically proven AVMs of the brain that were surgically resected between January 1989 and June 1998. The 30-day mortality rate for patients in this series was 1%, with one death caused by AVM resection and one death attributed to basilar artery aneurysm repair following successful AVM resection. The Spetzler—Martin grading system correlated well with the difficulty of surgery. No permanent incidence of morbidity resulted from resection of Grade I or II AVMs; the percentage of patients with a significant neurological deficit due to resection was 7.8% for those with Grade III lesions and 33.3% for those with Grade IV or V AVMs. However, this grading system did not accurately predict the development of delayed neurological deficits.

Ten patients (5%) developed delayed neurological deficits after recovering from anesthesia and surgery. The delayed deficit was due to hemorrhage in four of the 10 patients and all four had undergone resection of AVMs measuring at least 4 cm in diameter. An increase in blood pressure during the first 8 postoperative days precipitated hemorrhage in these patients. Edema arising as a consequence of propagated venous thrombosis (two patients) was associated with extensive venous drainage networks rather than large AVM niduses. Both hemorrhagic and edematous complications can be included under the umbrella term of “arterial-capillary-venous hypertensive syndrome” to describe the common underlying pathogenesis accurately. An additional four patients developed a delayed deficit as a result of vasospasm. Vasospasm occurred when resection had involved extensive dissection of proximal anterior and middle cerebral arteries; in such cases the incidence of vasospasm was 27%.

Conclusions. On the basis of their analysis of these complications, the authors recommend strict blood pressure control for patients with lesions measuring 4 cm or more in diameter (particularly those with a deep arterial supply). Thromboprophylaxis with aspirin and heparin is prescribed for patients with extensive venous drainage networks, and prophylactic nimodipine therapy and angiographic surveillance for vasospasm are suggested for patients in whom extensive dissection of proximal anterior or middle cerebral arteries has been necessary.

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  • 1.

    Albert P: Personal experience in the treatment of 178 cases of arteriovenous malformations of the brain. Acta Neurochir 61:207226, 1982 Albert P: Personal experience in the treatment of 178 cases of arteriovenous malformations of the brain. Acta Neurochir 61:207–226, 1982

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Al-Rodhan NRF, , Sundt TM Jr, & Piepgras DG, et al: Occlusive hyperemia: a theory for the hemodynamic complications following resection of intracerebral arteriovenous malformations. J Neurosurg 78:167175, 1993 Al-Rodhan NRF, Sundt TM Jr, Piepgras DG, et al: Occlusive hyperemia: a theory for the hemodynamic complications following resection of intracerebral arteriovenous malformations. J Neurosurg 78:167–175, 1993

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Batjer HH, , Devous MD Sr, & Meyer YJ, et al: Cerebrovascular hemodynamics in arteriovenous malformations complicated by normal perfusion breakthrough. Neurosurgery 22:503509, 1988 Batjer HH, Devous MD Sr, Meyer YJ, et al: Cerebrovascular hemodynamics in arteriovenous malformations complicated by normal perfusion breakthrough. Neurosurgery 22:503–509, 1988

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Batjer HH, , Devous MD Sr, & Seibert GB, et al: Intracranial arteriovenous malformation: relationship between clinical factors and surgical complications. Neurosurgery 24:7579, 1989 Batjer HH, Devous MD Sr, Seibert GB, et al: Intracranial arteriovenous malformation: relationship between clinical factors and surgical complications. Neurosurgery 24:75–79, 1989

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Davis C, & Symon L: The management of cerebral arteriovenous malformations. Acta Neurochir 74:411, 1985 Davis C, Symon L: The management of cerebral arteriovenous malformations. Acta Neurochir 74:4–11, 1985

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Day AL, , Friedman WA, & Sypert GW, et al: Successful treatment of the normal perfusion pressure breakthrough syndrome. Neurosurgery 11:625630, 1982 Day AL, Friedman WA, Sypert GW, et al: Successful treatment of the normal perfusion pressure breakthrough syndrome. Neurosurgery 11:625–630, 1982

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Hamilton MG, & Spetzler RF: The prospective application of a grading system for arteriovenous malformations. Neurosurgery 34:27, 1994 Hamilton MG, Spetzler RF: The prospective application of a grading system for arteriovenous malformations. Neurosurgery 34:2–7, 1994

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Heros RC, , Korosue K, & Diebold PM: Surgical excision of cerebral arteriovenous malformations: late results. Neurosurgery 26:570578, 1990 Heros RC, Korosue K, Diebold PM: Surgical excision of cerebral arteriovenous malformations: late results. Neurosurgery 26:570–578, 1990

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Jomin M, , Lesoin F, & Lozes G: Prognosis for arteriovenous malformations of the brain in adults based on 150 cases. Surg Neurol 23:362366, 1985 Jomin M, Lesoin F, Lozes G: Prognosis for arteriovenous malformations of the brain in adults based on 150 cases. Surg Neurol 23:362–366, 1985

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Luessenhop AJ, , Ferraz FM, & Rosa L: Estimate of the incidence and importance of circulatory breakthrough in the surgery of cerebral arteriovenous malformations. Neurol Res 4:177190, 1982 Luessenhop AJ, Ferraz FM, Rosa L: Estimate of the incidence and importance of circulatory breakthrough in the surgery of cerebral arteriovenous malformations. Neurol Res 4:177–190, 1982

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Luessenhop AJ, & Rosa L: Cerebral arteriovenous malformations. Indications for and results of surgery and the role of intravascular techniques. J Neurosurg 60:1422, 1984 Luessenhop AJ, Rosa L: Cerebral arteriovenous malformations. Indications for and results of surgery and the role of intravascular techniques. J Neurosurg 60:14–22, 1984

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Morgan MK, , Anderson RE, & Sundt TM Jr: A model of the pathophysiology of cerebral arteriovenous malformations by a carotid-jugular fistula in the rat. Brain Res 496:241250, 1989 Morgan MK, Anderson RE, Sundt TM Jr: A model of the pathophysiology of cerebral arteriovenous malformations by a carotid-jugular fistula in the rat. Brain Res 496:241–250, 1989

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Morgan MK, , Day MJ, & Little N, et al: The use of intraarterial papaverine in the management of vasospasm complicating arteriovenous malformation resection. Report of two cases. J Neurosurg 82:296299, 1995 Morgan MK, Day MJ, Little N, et al: The use of intraarterial papaverine in the management of vasospasm complicating arteriovenous malformation resection. Report of two cases. J Neurosurg 82:296–299, 1995

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Morgan MK, , Drummond KJ, & Grinnell V, et al: Surgery for cerebral arteriovenous malformation: risks related to lenticulostriate arterial supply. J Neurosurg 86:801805, 1997 Morgan MK, Drummond KJ, Grinnell V, et al: Surgery for cerebral arteriovenous malformation: risks related to lenticulostriate arterial supply. J Neurosurg 86:801–805, 1997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Morgan MK, , Johnston I, & Besser M, et al: Cerebral arteriovenous malformations, steal, and the hypertensive breakthrough threshold. An experimental study in rats. J Neurosurg 66:563567, 1987 Morgan MK, Johnston I, Besser M, et al: Cerebral arteriovenous malformations, steal, and the hypertensive breakthrough threshold. An experimental study in rats. J Neurosurg 66:563–567, 1987

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Morgan MK, , Johnston IH, & Hallinan JM, et al: Complications of surgery for arteriovenous malformations of the brain. J Neurosurg 78:176182, 1993 Morgan MK, Johnston IH, Hallinan JM, et al: Complications of surgery for arteriovenous malformations of the brain. J Neurosurg 78:176–182, 1993

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Mullan S, , Brown FD, & Patronas NJ: Hyperemic and ischemic problems of surgical treatment of arteriovenous malformations. J Neurosurg 51:757764, 1979 Mullan S, Brown FD, Patronas NJ: Hyperemic and ischemic problems of surgical treatment of arteriovenous malformations. J Neurosurg 51:757–764, 1979

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Parkinson D, & Bachers G: Arteriovenous malformations. Summary of 100 consecutive supratentorial cases. J Neurosurg 53:285299, 1980 Parkinson D, Bachers G: Arteriovenous malformations. Summary of 100 consecutive supratentorial cases. J Neurosurg 53:285–299, 1980

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Pikus HJ, , Beach ML, & Harbaugh RE: Microsurgical treatment of arteriovenous malformations: analysis and comparison with stereotactic radiosurgery. J Neurosurg 88:641646, 1998 Pikus HJ, Beach ML, Harbaugh RE: Microsurgical treatment of arteriovenous malformations: analysis and comparison with stereotactic radiosurgery. J Neurosurg 88:641–646, 1998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Sekhon LHS, , Morgan MK, & Spence I, et al: Normal perfusion pressure breakthrough: the role of capillaries. J Neurosurg 86:519524, 1997 Sekhon LHS, Morgan MK, Spence I, et al: Normal perfusion pressure breakthrough: the role of capillaries. J Neurosurg 86:519–524, 1997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Sisti MB, , Kader A, & Stein BM: Microsurgery for 67 intracranial arteriovenous malformations less than 3 cm in diameter. J Neurosurg 79:653660, 1993 Sisti MB, Kader A, Stein BM: Microsurgery for 67 intracranial arteriovenous malformations less than 3 cm in diameter. J Neurosurg 79:653–660, 1993

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    Spetzler RF, & Martin NA: A proposed grading system for arteriovenous malformations. J Neurosurg 65:476483, 1986 Spetzler RF, Martin NA: A proposed grading system for arteriovenous malformations. J Neurosurg 65:476–483, 1986

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Spetzler RF, , Wilson CB, & Weinstein P, et al: Normal perfusion pressure breakthrough theory. Clin Neurosurg 25:651672, 1978 Spetzler RF, Wilson CB, Weinstein P, et al: Normal perfusion pressure breakthrough theory. Clin Neurosurg 25:651–672, 1978

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Steinmeier R, , Schramm J, & Müller HG, et al: Evaulation of prognostic factors in cerebral arteriovenous malformations. Neurosurgery 24:193200, 1989 Steinmeier R, Schramm J, Müller HG, et al: Evaulation of prognostic factors in cerebral arteriovenous malformations. Neurosurgery 24:193–200, 1989

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Sundt TM Jr, , Piepgras DG, & Stevens LN: Surgery for supratentorial arteriovenous malformations. Clin Neurosurg 37:49115, 1991 Sundt TM Jr, Piepgras DG, Stevens LN: Surgery for supratentorial arteriovenous malformations. Clin Neurosurg 37:49–115, 1991

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Teasdale G, & Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:8184, 1974 Teasdale G, Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84, 1974

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Yamada K, , Hayakawa T, & Yoshimine T, et al: Surgery of high-flow arteriovenous malformation: with special reference to normal perfusion pressure breakthrough phenomenon. No Shinkei Geka 14:741748, 1986 Yamada K, Hayakawa T, Yoshimine T, et al: Surgery of high-flow arteriovenous malformation: with special reference to normal perfusion pressure breakthrough phenomenon. No Shinkei Geka 14:741–748, 1986

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    YaŞargil MG: Microneurosurgery. New York: Thieme, Vol 3B, 1988 YaŞargil MG: Microneurosurgery. New York: Thieme, Vol 3B, 1988

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