ACUTE SURGICAL-MANAGEMENT OF INTRACRANIAL ARTERIOVENOUS-MALFORMATIONS

THE MAJORITY OF intracranial arteriovenous malformations (AVMs) do not require acute surgical intervention. Some patients, however, require emergent surgical treatment because of a profound neurological deterio ration from a mass effect. We report 10 patients who underwent emergen cy AVM surgery after experiencing neurological deterioration from an i ntracranial hemorrhage. Two patients bled spontaneously, whereas eight had an intracranial hemorrhage secondary to an embolization procedure . When the patients demonstrated neurological deterioration, they were intubated, hyperventilated, and underwent osmotic diuresis. Barbitura te anesthesia was initiated, and surgery was performed within 30 minut es in most cases. The hematomas were evacuated, and an attempt was mad e to excise the AVMs at the same time. Postoperatively, intracranial p ressure was monitored, and barbiturate coma was maintained until the i ntracranial pressure returned to normal. Cerebral perfusion pressure w as maintained above 55 mm Hg. The operation was confined to evacuating the hematoma in two patients with inoperable AVMs. The other eight pa tients underwent concomitant total AVM resection. Because of the sever ity of neurological deterioration, one patient who bled spontaneously underwent surgery based only on a computed tomographic scan of the bra in. Nine patients made a good-to-excellent recovery. One patient with a large motor-strip AVM remained hemiplegic. We conclude that in patie nts presenting with profound neurological deterioration after a sponta neous intracranial hemorrhage or one associated with an embolization p rocedure, prompt hematoma evacuation with simultaneous AVM excision as well as perioperative intracranial pressure control with mannitol and barbiturates can yield a good-to-excellent outcome.