Combined Microsurgery and Endovascular Intervention in One-Stop for Treatment of Cerebral Arteriovenous Malformation: The Efficacy of a Hybrid Operation

Abstract

To investigate the efficacy of a hybrid operation combining microsurgical resection and endovascular interventions in a one-stop treatment of cerebral arteriovenous malformation (AVM). Patients were divided into two groups: patients who received a hybrid operation, and patients receiving a non-hybrid operation. The hybrid operation group consisted of microsurgical resection with intraoperative angiography, or endovascular embolization. The non-hybrid operation group consisted of microsurgical resection or endovascular embolization, or microsurgery combined with embolization in multiple steps. Comprehensive clinical data was collected for all patients, including preoperative Glasgow Coma Scale score, Spetzler-Martin grade, rehemorrhagia, image follow-up, and 6-month outcomes of the modified Rankin Scale (mRS) score. This study included 22 cases in the hybrid operation group. The remnants were noted on intraoperative angiography in the four patients that were resected within the same session. The non-hybrid group consisted of 52 patients. There were no statistical differences between the two groups with GCS and Spetzler-Martin grade score. The mortality rate in the hybrid operation group was 4.5%, which was lower than the 7.6% obtained in the control group. No patients experienced post-operation rehemorrhagia in the hybrid operation group, but five cases occurred in the control group. The follow-up radiological cure rates were 100% in the hybrid group and 65.9% in the control group. The rate of good outcome was 81.8% in the hybrid operation group and 69.2% in the control group, although there was no significant difference. The hybrid operation is a safe and efficacious strategy for treating cerebral AVMs.

Keywords: cerebral arteriovenous malformation; hybrid operation; one-stop.

Fig. 1.

Radiological profiles of a 29-year-old male diagnosed with a Spetzler-Martine grade III AVM in the right temporooccipital lobe. (A and B) Preoperative computed tomography illustrates the subarachnoid hemorrhage and an AVM lesion in the right temporooccipital lobe. (C–E) Preoperative angiography shows the AVM lesion. (F) Intraoperative angiography shows a ruptured aneurysm in the P2 segment that was embolized. (G) Intraoperative angiography shows a deep feeding artery from the right vertebral artery that was embolized. (H–J) Intraoperative angiography after resection demonstrated the obliteration of the AVM. (K and L) Angiography 15 months postoperatively shows there was no recurrence.

Fig. 2.

Radiological profiles of a 25-year-old male diagnosed with a Spetzler-Martine grade IV AVM in the left parietooccipital lobe. (A and B) Preoperative magnetic resonance imaging depicts a large AVM lesion in the left parietooccipital lobe. (C–E) Preoperative angiography depicted the AVM lesion. (F–H) Intraoperative angiography shows the left internal carotid and the left vertebral arteries. (I and J) Intraoperative angiography following resection demonstrates the obliteration of the AVM. (K and L) Angiography 5 months following the operation shows there was no recurrence.