Background and Purpose-We sought to define determinants of neurological deficit after surgery for brain arteriovenous malformation (AVM).Methods-One hundred twenty-four prospective patients (48% women, mean age 33 years) underwent microsurgical brain AVM resection. Patients were examined by 3 study neurologists immediately before surgery, postoperatively in-hospital, by in-person long-term follow-up, and with a structured telephone follow-up. They were classified according to the 5-point Spetzler-Martin grading system, with its 3 elements: size, venous drainage pattern, and location. The functional neurological status was classified with the modified Rankin scale. Multivariate logistic regression models were applied to test the effect of patient age, gender, and the 3 Spetzler-Martin elements on early and long-term postoperative neurological complications.Results-Twelve patients (10%) were classified as Spetzler-Martin grade 1; 36 (29%) as grade 2; 47 (38%) as grade 3; 26 (21%) as grade 4; and 3 (2%) as grade 5. Postoperatively, in-hospital, 51 patients (41%) showed new neurological deficits (15% disabling [ie, Rankin scale score >2] and 26% nondisabling [ie, Rankin 1 or 2]). At long-term follow-up (mean follow-up time 12 months), 47 patients (38%) revealed surgery-related neurological deficits (6% disabling; 32% nondisabling), The rate of neurological complications increased by Spetzler-Martin grade. Female gender, AVM size, and deep venous drainage were significantly associated with neurological deficits at in-hospital and long-term evaluation, For patient age and AVM location, no significant association was found.Conclusions-The findings suggest that female gender, AVM size, and AVM drainage into the deep venous system may be determinants of neurological deficit after microsurgical AVM resection.

Background and Purpose Focal neurological deficits (FNDs) in patients with arteriovenous malformations (AVMs) have been widely attributed to the phenomenon of ''cerebral steal.'' The incidence of focal deficits was investigated in a large prospective sample.Methods Using data from patient history and examination, CT or MRI, and transcranial Doppler sonography, we studied 152 consecutive, prospective AVM patients for evidence of FNDs unrelated to a hemorrhagic event. Feeding mean arterial pressure was measured during superselective angiography.Results Two (1.3%) of 152 patients met the criteria for a progressive FND. Nonprogressive FNDs were seen in 11 (7.2%) patients (stable in 4.6%, reversible in 2.6%). The median observation time period was 17 months (range, 1 to 60 months). There were no differences in transcranial Doppler mean velocities in feeding arteries in FND versus non-FND groups (118+/-44 versus 112+/-37 cm/s, P>.05) or pulsatility indexes (0.53+/-0.20 versus 0.55+/-0.15, P>.05). Feeding artery pressure was similar in FND (n=10) and non-FND (n=96) groups (39+/-16 versus 39+/-16 mm Hg at a systemic pressure of 82+/-18 versus 75+/-14 mm Hg, NS).Conclusions Nonhemorrhagic focal neurological syndromes in AVM patients are infrequent. Progressive deficits are especially rare. There was no relation between feeding artery pressure or flow velocities and FND. There does not appear to be sufficient evidence to assign steal as an operative pathophysiological mechanism in the vast majority of AVM patients.

Young, W L; Prohovnik, I; Pile-Spellman, J; Fleischer, L H; Baker, K Z; Stein, B M Author Information

The surgical outcome in a series of small arteriovenous malformations (AVM's) that might have been considered optimal for radiosurgery is reviewed. In a total microsurgical series of 360 patients, 67 (19%) underwent resection of AVM's less than 3 cm in largest diameter, regardless of location. Many of these lesions (45%) were in locations that might be considered surgically inaccessible such as the thalamus, brain stem, medial hemisphere, and paraventricular regions. Complete angiographic obliteration of the AVM by microsurgical technique was accomplished in 63 patients (94%) with a surgical morbidity of 1.5% and no operative mortality. Patients with hemispheric AVM's had a cure rate of 100% and no neurological morbidity. Stereotactically guided craniotomy was used in 14 patients (21%) to locate and resect deep or concealed malformations. The results from five major radiosurgery centers treating similar-sized AVM's are analyzed. The authors' surgical results compare favorably with those from radiosurgery centers which, in their opinion, supports the conclusion that microneurosurgery is superior to radiosurgery, except for a small percentage of lesions that are truly inoperable on the basis of inaccessibility.

We identified 53 patients with non-neoplastic cysts of the pineal gland. In contrast to patients with pineal neoplasms, pineal cysts are usually asymptomatic. They infrequently obstruct the aqueduct to cause hydrocephalus or compress the tectum to produce the neuro-ophthalmologic signs of dorsal midbrain dysfunction. Obstructive hydrocephalus was present in only five patients (9.4%); three of them showed clinical signs of Parinaud's syndrome. CT and MRI typically reveal a cystic mass that averages 1.6 cm in anteroposterior (A-P) diameter with calcification at the periphery and faint rim-like contrast enhancement. Sagittal MRI is the most useful diagnostic test because it shows the anatomic relationship of the cyst to the aqueduct. The mass may compress the tectum and distort the proximal aqueduct; occasionally a large cyst may occlude the aqueduct. All patients with obstructive hydrocephalus had cysts greater than 2.0 cm in A-P diameter. Nine patients had suboccipital craniotomy. In all of them, the cysts contained clear fluid and were easily removed. We advocate conservative management with clinical observation of these benign lesions that may be developmental variants of normal pineal gland.

Surgical resection of 10 obscure arteriovenous malformations (AVM's) was accomplished with craniotomy guided by computerized tomography (CT) or angiography and the use of the Brown-Roberts-Wells stereotactic frame. Stereotactic craniotomy was invaluable for resection of the following types of AVM's: 1) AVM's with a nidus less than 2 cm in diameter, 2) AVM's located in an eloquent area of the brain, and 3) AVM's located deep in the brain. Stereotactic localization of these AVM's on preoperative radiological studies provides a precise route to the nidus, often avoiding important areas of the brain. This series included six male and four female patients with a mean age of 32 years. All patients presented with an intracerebral hemorrhage, from which eight made a complete neurological recovery prior to surgery. Two AVM's were located on the cortex, three were found subcortically, and five were situated near the ventricles or in the deep white matter. As a guide, angiography was used in six cases and CT in four cases. In each instance, the study providing the best image of the AVM nidus was employed. Postoperatively, no neurological deficits were found in eight patients and, in the two patients with preoperative deficits, neurological improvement was observed after recovery from surgery. Postoperative studies revealed complete removal of the AVM in all patients, and all lesions were confirmed histologically. The authors conclude that stereotactic craniotomy provides the optimum operative approach for the localization and microsurgical resection of AVM's that are either obscure or located deep in the brain.

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To investigate the cerebral hemodynamic changes associated with obliteration of arteriovenous malformations (AVMs), we studied 26 patients undergoing total microsurgical AVM resection during isoflurane and N2/O2 anesthesia. Detectors were placed 5 to 6 cm from the margin of the lesion and in a homologous contralateral position. Cerebral blood flow (CBF) was measured using the intravenous xenon-133 technique before and after AVM resection, during both hypocapnia and normocapnia at each stage. Intraoperative changes in CBF were related to a risk score system based on the patient's history and preoperative angiograms. Seven otherwise healthy patients undergoing spinal surgery were studied to control for anesthetic effects. Patient demographic and clinical data for the AVM group conformed to the expected strata of a large AVM population. The CBF increased after excision (22 +/- 1 ml/100 g/min before excision to 30 +/- 2 ml/100 g/min after excision; mean +/- SE, n = 25, P less than 0.002) without a hemispheric difference. CO2 reactivity increased slightly after excision (4.2 +/- 0.3% change/mm Hg before excision to 4.7 +/- 0.3% change/mm Hg after excision; n = 14, P less than 0.02). The baseline CBF and CO2 reactivity were not different from the control group. There was a weak correlation between the risk score and the percentage of change in the ipsilateral CBF, with a trend for the patients with the lowest risk to have the lowest CBF changes after resection. There was no relationship between CO2 reactivity and risk grade. None of the patients awoke from anesthesia with unexpected neurological deficits. The highest CBF increases were associated with postoperative brain swelling in one patient and fatal intracerebral hemorrhage in another. Both patients had normal CO2 reactivity before excision. One patient suffered postoperative intracerebral hemorrhage, attributable to technical problems, and had no increase in CBF. We conclude that, with an acute increase in the arteriovenous pressure gradient (and cerebral perfusion pressure) that results from shunt obliteration, there is an immediate global effect of AVM resection to increase CBF. Cerebrovascular reactivity to CO2 remains intact both before and after excision.

We report a case of intracerebral hemorrhages due to sporadic cerebral amyloid angiopathy in a 43-year-old male with a luxuriant giant cell reaction. The amyloid was resistant to potassium permanganate-sulfuric acid oxidation and reacted with an antiserum to synthetic β-protein. The distribution and histologic characteristics of the multinucleated giant cell reaction suggest that it represents a foreign-body reaction rather than giant cell arteritis.

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Measurement of regional cerebral blood flow (rCBF) using the i.v. 133Xe technique was carried out during resection of a right temporooccipital arteriovenous malformation (AVM) with ipsilateral middle and posterior cerebral arterial supply. Intraoperatively, a rCBF detector was in place over the right frontotemporal area, about 5 to 6 cm from the border of the AVM. Anesthesia was 0.75% isoflurane in oxygen and nitrous oxide. After dural exposure, the rCBF was 27 ml/100 g/min at a pCO2 of 29 mm Hg and a mean arterial pressure (MAP) of 90 mm Hg. The pCO2 was then elevated to 40 mm Hg, and the rCBF was increased to 55 ml/100 g/min at a MAP of 83 mm Hg. After AVM removal, the rCBF rose to 50 ml/100 g/min at a pCO2 of 27 mm Hg and a MAP of 75 mm Hg. The pCO2 was elevated to 33 mm Hg and the rCBF increased to 86 ml/100 g/min at a MAP of 97 mm Hg. During skin closure, the rCBF was 94 ml/100 g/min at a pCO2 of 26 mm Hg and a MAP of 97 mm Hg. The patient was neurologically normal postoperatively except for a mild, new visual field defect. After 2 to 3 days, the patient gradually developed lethargy, confusion, and nausea with relatively normal blood pressure. An angiogram revealed residual enlargement of the posterior cerebral artery feeding vessel. Computed tomography showed edema extending from the area of AVM resection as far as the frontal region, producing a significant midline shift anteriorly. Intraoperative rCBF monitoring revealed significant hyperperfusion after AVM resection, which was associated with signs and symptoms of the normal perfusion pressure breakthrough syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)

Young, W L M.D.*; Prohovnik, I Ph.D.+; Ornstein, E Ph.D, M.D.*; Sisti, M B M.D.°; Solomon, R A M.D.°; Stein, B M M.D.°; Ostapkovich, N R.E.E.G.T.* Author Information

Young, William L. MD; Prohovnik, Isak PhD; Ornstein, Eugene PhD, MD; Sisti, Michael B. MD; Solomon, Robert A. MD; Stein, Bennett M. MD; Ostapkovich, Noeleen REEGT Author Information