Image-Guided Microneurosurgical Management of Small Arteriovenous Malformation: Role of Neuronavigation and Intraoperative Doppler Sonography

Abstract

Introduction: The goal of this study was to evaluate the efficacy and reliability of neuronavigation and intraoperative microvascular Doppler sonography (MDS) for identifying afferent (feeding) and efferent (draining) vessels as well as for controlling the totality of the surgical resection of arteriovenous malformations (AVMs).

Methods: Between June 2000 and November 2005, twenty-five patients with small arteriovenous malformations (grades I-III) underwent microsurgical removal at our institution. A passive-marker-based neuronavigation system (Brain Lab, Munich, Germany), and an intraoperative MDS (Multi Dop X system, DWL, Germany) were used in this surgery. Blood flow velocities (BFV) in afferent and efferent vessels were recorded before and after removal of AVM. The preoperative neurological status and postoperative outcome were recorded. Patient follow-up monitoring ranged from 4 months to 3 years (mean: 16 months).

Results: The calculated registration accuracy of the neuronavigation computer ranged between 0.2-1.7 mm (mean: 1.1 mm). Before AVM removal the mean BFV of afferent vessels was 56.5±13.4 (28-98 cm/s) and the PI varied by 0.40±0.11 (0.25-0.66), after AVM removal these values reduced to 4.8±0.8 cm/s and 0.26±0.05, respectively. Similarly, before AVM removal, the mean BFV of efferent vessels was 13.5±4.5 (4-20 cm/s) and PI was 0.4±0.2 (0.34-0.56), after AVM removal both BFV and PI were not recorded. Complete removal of the AVMs was accomplished in 24 (96%) out of 25 patients which was confirmed with postoperative digital subtraction angiography (DSA). While there was no mortality, three patients (12%) had a worsening in their neurological status after surgery.

Conclusion: Image-guided microneurosurgery with intraoperative MDS is a safe, effective, and reliable method for identifying the afferent and efferent vessels and for confirming the complete resection of AVMs. These benefits of image-guided microsurgery were most apparent for small, deep-seated AVMs that were not visible on the surface of the brain. In addition these techniques reduce the operative time and blood loss during AVM resection.

Key words

arteriovenous malformation - intraoperative Doppler sonography - neuronavigation - clinical outcome

Publication History

Publication Date:
19 September 2007 (online)

• References

• 1 Matula C, Rossler K, Reddy M, Schindler E, Koos WT. Intraoperative computed tomography guided neuronavigation: concepts, efficiency, and work flow.. Comput Aided Surg 1998; 3: 174-182
• 2 Spetzger U, Laborde G, Gilsbach JM. Frameless neuronavigation in modern neurosurgery.. Minim Invas Neurosurg 1995; 38: 163-166
• 3 Wadley J, Dorward N, Kitchen N, Thomas D. Pre-operative planning and intra-operative guidance in modern neurosurgery: a review of 300 cases.. Ann R Coll Surg Engl 1999; 81: 217-225
• 4 Krombach GA, Spetzger U, Rohde V, Gilsbach JM. Intraoperative localization of functional regions in the sensorimotor cortex by neuronavigation and cortical mapping.. Comput Aided Surg 1998; 3: 64-73
• 5 Black KL, Rubin JM, Chandler WF, MacGillicuddy JE. Intraoperative color-flow Doppler imaging of AVM's and aneurysms.. J Neurosurg 1988; 68: 635-639
• 6 Murayama Y, Usami S, Abe T, Hata Y, Ganaha F, Massoud TF. Transvenous doppler guidewire sonographic monitoring during treatment of a complex vertebral arteriovenous fistula associated with neurofibromatosis type 1.. Neuroradiology 1999; 41: 328-333
• 7 Rubin JM, Hatfield MK, Chandler WF, Black KL, DiPietro MA. Intracerebral arteriovenous malformations: intraoperative color Doppler flow imaging.. Radiology 1989; 170: 219-222
• 8 Woydt M, Perez J, Meixensberger J, Krone A, Soerensen N, Roosen K. Intra-operative colour-duplex-sonography in the surgical management of cerebral AV-malformations.. Acta Neurochir (Wien) 1998; 140: 689-698
• 9 Woydt M, Vince GH, Krauss J, Krone A, Soerensen N, Roosen K. New ultrasound techniques and their application in neurosurgical intra-operative sonography.. Neurol Res 2001; 23: 697-705
• 10 Jennett B, Bond M. Assessment of outcome after severe brain damage.. Lancet 1975; 1: 480-484
• 11 Hassler W. Hemodynamic aspects of cerebral angiomas.. Acta Neurochir Suppl (Wien) 1986; 37: 1-136
• 12 Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations.. J Neurosurg 1986; 65: 476-483
• 13 Pikus HJ, Beach ML, Harbaugh RE. Microsurgical treatment of arteriovenous malformations: analysis and comparison with stereotactic radiosurgery.. J Neurosurg 1998; 88: 641-646
• 14 Pollock BE, Lunsford LD, Kondziolka D, Maitz A, Flickinger JC. Patient outcomes after stereotactic radiosurgery for “operable” arteriovenous malformations.. Neurosurgery 1994; 35: 1-7
• 15 Muacevic A, Steiger HJ. Computer-assisted resection of cerebral arteriovenous malformations.. Neurosurgery 1999; 45: 1164-1170
• 16 Nakajima S, Atsumi H, Bhalerao AH, Jolesz FA, Kikinis R, Yoshimine T, Moriarty TM, Stieg PE. Computer-assisted surgical planning for cerebrovascular neurosurgery.. Neurosurgery 1997; 41: 403-409
• 17 Sisti MB, Solomon RA, Stein BM. Stereotactic craniotomy in the resection of small arteriovenous malformations.. J Neurosurg 1991; 75: 40-44
• 18 Zamorano L, Planells ML, Jiang Z, Nolte L, Kadi AM, Diaz F. Vascular malformations of the brain. Surgical management using interactive image guidance.. Neurosurg Clin N Am 1996; 7: 201-214
• 19 Russell SM, Woo HH, Joseffer SS, Jafar JJ. Role of frameless stereotaxy in the surgical treatment of cerebral arteriovenous malformations: technique and outcomes in a controlled study of 44 consecutive patients.. Neurosurgery 2002; 51: 1108-1116
• 20 Coenen VA, Dammert S, Reinges MH, Mull M, Gilsbach JM, Rohde V. Image-guided microneurosurgical management of small cerebral arteriovenous malformations: the value of navigated computed tomographic angiography.. Neuroradiology 2005; 47: 66-72