The Utility of Superselective Rotational Angiography for Frameless Stereotactic Navigation During Craniotomy for Micro-Arteriovenous Malformation

Abstract

Background: Micro-arteriovenous malformations (AVMs) can present challenges to neurosurgeons with respect to localization during resection. We sought to describe a novel method that merges super-selective 3-dimensional angiographic images with magnetic resonance imaging (MRI) sequences to facilitate frameless stereotaxic navigation during AVM surgery.

Methods: A retrospective analysis was performed comprising cases that employed merging of angiographic and MRI images for navigation purposes. Baseline clinical and imaging features were recorded. The technique and operative experiences were analyzed descriptively and presented alongside detailed illustrative cases.

Results: During the review period, 11 cases were identified where this technique was employed. Successful image acquisition and merging was possible in all cases. Complete obliteration of the target pathology was achieved in all cases. Precise localization of the micro-AVMs minimized dissection in eloquent cortex.

Conclusions: Superselective 3-dimensional angiographic images merged to baseline MRI sequences facilitates planning and navigation during surgery for micro-AVMs.

Keywords: 3D, 3-dimensional; AVM, Arteriovenous malformation; Arteriovenous malformation; CT, Computed tomography; CTA, Computed tomography angiography; MRI, Magnetic resonance imaging; Neuronavigation; Superselective angiography.

Figure 1

(A) Lateral projection of right internal carotid injection, the arteriovenous malformation is apparent but difficult to characterize completely. (B) Microcatheter injection shows feeding artery, nidus, and draining vein more clearly. (C) Three-dimensional reconstruction of microcatheter injection. (D) Screen grab from the navigation system showing fused microcatheter injection images overlayed on magnetic resonance imaging, sagittal and axial images demonstrating the relationship of the nidus to the hemorrhage cavity, and coronal images show the draining vein within a sulcus on the inferior surface of the temporal lobe.

Figure 2

(A) Axial CT scan demonstrating a posterior frontal, peri-rolandic intracerebral hemorrhage. (B) Lateral projection of right internal carotid injection from the delayed angiographic study, distal arteriovenous malformation (AVM) is apparent. (C) Microcatheter injection showing AVM feeding artery and draining vein. (D) Three-dimensional reconstruction of microcatheter injection. (E) Fused images of microcatheter injection and sagittal magnetic resonance imaging demonstrate the relationship of the nidal vessels to the intracerebral hemorrhage. (F) Fused axial images illustrate the relationship of the feeding artery and draining vein to the superficial cortical anatomy.

Figure 3

(A) Axial computed tomography scan showing a peri-insular intracerebral hemorrhage. (B) Lateral projection, left internal carotid injection, the insular arteriovenous malformation (AVM) is visible but difficult to characterize fully. (C) Three-dimensional reconstruction of microcatheter injection showing the AVM more clearly. (D) Intraoperative view of the insular cortex before resection. (E) Postresection appearance of insular cortex illustrating that the navigation facilitated a limited and precise resection.