Combined surgical treatment of the cerebral arteriovenous malformations in patients with the torpid course of the disease

Abstract

Objective – to optimize the results of surgical treatment of the cerebral arteriovenous malformations (AVM) with a torpid clinical course of the disease. Materials and methods. The results of combined surgical treatment of cerebral AVMs of 36 patients without a history of AVM rupture were analyzed (this variant of clinical course was defined as «torpid»). Patients were treated in the departments of vascular neurosurgery at the Romodanov Neurosurgery Institute NAMS of Ukraine during the period from 2010 till September 2019. Among the patients there were 18 (50 %) men and 18 (50 %) women. The average age of patients was 28.1 years (10–47 years). Clinical, neurological, laboratory, instrumental, functional and morphological methods of examination were used as well as neuroimaging evaluation and follow-up investigation. Results. The «torpid» course of disease in patients with AVM was presented as heterogeneous epileptiform manifestations in 24 (66.7 %) cases. One (2.8 %) patient had seizure that were combined with internal hydrocephalus, 9 (25 %) patients had different severity cephalalgic syndrome (according to the International classification of headache – 3β). Progressive neurological deficit was detected in 2 (5.55 %) patients. The distribution of AVMs according Spetzler–Martin scale (1986) was as follows: grade I – in 2 (5.55 %) patients, grade II – in 10 (27.8 %), grade III – in 13 (36.1 %), grade IV – in 9 (25.0 %), grade V – in 2 (5.55 %). In most cases (94.44 %), AVMs were supratentorial, and in 2 (5.55 %) cases they were subtentorial. The average AVM size in the largest dimension was 3.7 cm (2.8–6.7 cm). Intranidal aneurysms in the AVM structure were diagnosed in 8 (22.2 %) patients, fistulas – in 7 (19.4 %) cases. In all cases, at the first stage, endovascular embolization (EE) of AVM was performed. All 36 patients underwent 64 endovascular procedures. Curative treatment after 1 stage was performed in 16 (44.4 %) patients, after 2 stages – in 13 (36.1%), after 3 stage – in 6 (16.66 %), and after 4 stage in 1 (2.77 %) patient. In 36 (56.25 %) cases, embolization was performed with Onyx composition (eV3), in 24 (37.5 %) – with n-butylcyanoacrylate, and in 3 (4.7 %) – with their combination. In 1 (1.56 %) patient, the fistula was excluded from the blood flow using detached balloon-catheter. Embolization was supplemented with radiosurgical treatment (RST) in 30 (83.3 %) cases, microsurgical removal – in 2 (5.55 %), radiotherapy – in 2 (5.55 %) patients. In 1 (2.77 %) case EE was combined with shunting procedure and RST. One (2.77 %) patient after EE with RST suffered hemorrhagic stroke with intracerebral hematoma formation. An operation was performed for hematoma removal and partially functioning AVM resection. In 7 (10.9 %) cases after EE of AVM, patients developed motor deficits. At the time of discharge, they regressed completely in 6 patients, and partially in 1 patient. In (1.5 %) case homonymous hemianopsia had occurred. After RST, total obliteration of AVM was achieved in 17 (58.6 %) patients, in 5 (17.2 %) – subtotal (repeated RST was recommended). In 7 (24.1 %) cases, positive signs of AVM obliteration was noted, and the timing of radiation exposure did not reach the recommended ones. In 2 (3.1 %) patients after microsurgical resection, the AVM was removed completely, which was confirmed by cerebral angiography. After radiotherapy, decreasing of the AVM size and a positive neurological dynamics were noted. There were no fatal outcomes. According to the modified Rankine scale, patients were distribution to group 0 (33 (91.7 %)) and group I (3 (8.3 %)). Conclusions. The obtained data indicate the promising result of combined surgical treatment of cerebral AVM with a torpid type of clinical manifestations. The leading technique in the applied staged combined surgical treatment of AVM was EE. Its successful use is due to the effectiveness of its impact on all components of the «complex» AVM.

Keywords

• arteriovenous malformation; combined surgical treatment; torpid type of disease; endovascular embolization; microsurgical removal; radiosurgical treatment.