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.