We have had 37 patients with cerebral arteriovenous malformation and subarachnoid hemorrhage, who were admitted to the Department of Neurosurgery, Yonsei Medical Center from 1964 to 1976. All of the cerebral arteriovenous malformations were proved by cerebral angiography. Since the site of the lesions were considered to have a close relation to the neurologic deficit and the results of surgery, various analysis of clinical manifestations and of the cerebral angiographic findings were attempted. Out of 37 patients, surgery was performed in 28 and the results were analysed according to the various type of surgical procedure.
Adolescent ; Adult ; Cerebral Angiography ; Child ; Child, Preschool ; Female ; Human ; Infant ; Infant, Newborn ; Intracranial Arteriovenous Malformations/radiography ; Intracranial Arteriovenous Malformations/surgery* ; Male ; Methods ; Middle Age ; Subarachnoid Hemorrhage/radiography ; Subarachnoid Hemorrhage/surgery

OBJECTIVE: Although three-dimensional time-of-flight magnetic resonance angiography (3D TOF-MRA) is used frequently as a follow-up tool to assess the response of arteriovenous malformations (AVMs) after radiosurgery, the diagnostic accuracy of 3D TOF-MRA is not well known. We evaluated the diagnostic accuracy of contrast-enhanced 3D TOF-MRA at 3.0 Tesla for the detection of residual AVMs. MATERIALS AND METHODS:This study included 32 AVMs from 32 patients who had been treated with radiosurgery (males/females: 21/11; average patient age, 33.1 years). The time interval between radiosurgery and MRA was an average of 35.3 months (range, 12-88 months). Three-dimensional TOF-MRA was obtained at a magnetic field strength of 3.0 Tesla after infusion of contrast media, with a measured voxel size of 0.40 x 0.80 x 1.4 (0.45) mm3 and a reconstructed voxel size of 0.27 x 0.27 x 0.70 (0.05) mm3 after zero-filling. X-ray angiography was performed as the reference of standard within six months after MRA (an average of two months). To determine the presence of a residual AVM, the source images of 3D TOF-MRA were independently reviewed, focusing on the presence of abnormally hyperintense fine tangled or tubular structures with continuity as seen on consecutive slices by two observers blinded to the X-ray angiography results. RESULTS: A residual AVM was identified in 10 patients (10 of 32, 31%) on X-ray angiography. The inter-observer agreement for MRA was excellent (kappa= 0.813). For the detection of a residual AVM after radiosurgery as determined by observer 1 and observer 2, the source images of MRA had an overall sensitivity of 100%/90% (10 of 10, 9 of 10), specificity of 68%/68% (15 of 22, 15 of 22), positive predictive value of 59%/56% (10 of 17, 9 of 16), negative predictive value of 100%/94% (15 of 15, 15 of 16) and diagnostic accuracy of 78%/75% (25 of 32, 24 of 32), respectively. CONCLUSION: The sensitivity of contrast-enhanced 3D TOF-MRA at 3.0 Tesla is high but the specificity is not sufficient for the detection of a residual AVM after radiosurgery.
Adult ; Contrast Media ; Female ; Humans ; Intracranial Arteriovenous Malformations/*diagnosis/*surgery ; Magnetic Resonance Angiography/methods/*standards ; Male ; *Radiosurgery ; Sensitivity and Specificity

A 36-year-old man was diagnosed with a right temporal lobe grade II cerebral arteriovenous malformation (cAVM) and was treated with radiosurgery. At nine months after the cAVM radiosurgery, the patient began to develop bilateral focal narrowing at the M1 segments of the bilateral middle cerebral arteries. The narrowing progressively deteriorated as was demonstrated on longitudinal serial follow-up MR imaging. X-ray angiography performed at 51 months after radiosurgery confirmed that the cAVM was cured and a diagnosis of moyamoya disease. To the best of our knowledge, this is the first case of cAVM-associated moyamoya disease that developed after radiosurgery. Given the chronological sequence of disease development and radiation dose distribution of radiosurgery, it is proposed that humoral or unknown predisposing factors, rather than direct radiation effects, are the cause of moyamoya disease associated with cAVM.
Adult ; Humans ; Intracranial Arteriovenous Malformations/diagnosis/*surgery ; Magnetic Resonance Imaging ; Male ; Moyamoya Disease/*etiology ; Postoperative Complications ; Radiosurgery

Drainage ; Dura Mater ; blood supply ; Humans ; Intracranial Arteriovenous Malformations ; diagnostic imaging ; surgery ; Male ; Meninges ; blood supply ; Middle Aged ; Radiography

Most patients with strabismus are in good health. However, the incidence of strabismus is high in patients with central nervous system dysfunction and musculoskeletal abnormalities. Authors report one case of intracerebral hematoma due to bleeding from an intracranial arteriovenous malformation after a surgical correction of strabismus under general endotracheal anesthesia. The initial operation and postoperative course of this case were uneventful except for several episodes of nausea and vomiting, continuing hours after the operation. Twenty-four hours after the operation, the patient showed a stuporous mental state and right-sided hemiplegia. A brain C-T scan and carotid angiography revealed an intracerebral hematoma with small-sized vascular abnormalities in the frontoparietal region on the left side. Following an emergency evacuation of the hematoma and removal of the malformed vessels, the patient showed progressive improvement.
Cerebral Hemorrhage/etiology* ; Child ; Female ; Hematoma/etiology* ; Human ; Intracranial Arteriovenous Malformations/complications ; Postoperative Complications* ; Rupture, Spontaneous ; Strabismus/surgery*

OBJECTIVE: The authors undertook a study to compare three intraoperative guidance systems, which are intraoperative ultrasonography, stereotaxy and computer-assisted image-guided surgery (neuronavigation) in terms of time consuming during the preparation of these procedures. In this operative case-based study, we have investigated the ability and benefits of intraoperative grey-scale sonographic examination in the localizing of intracranial hemorrhage (ICH) in the brain. METHODS: We used B-mode ultrasonography (5-MHz, 1.2x2.5 mm sized probe) during 23 procedures (craniotomy or craniectomy ; 17, hematoma aspiration : 6) performed in the acute stage after head injury, hypertensive ICH, ruptured cerebral aneurysm. Seventeen patients who suffered from spontaneous ICH underwent stereotactic hematoma aspiration and fourteen patients underwent hematoma removal using neuronavigation system (spontaneous ICH ; 11, Arteriovenous malformation and aneurysm ; 3). We compared intraoperative ultrasonography-assisted hematoma removal with procedures with stererotaxy or neuronavigation system in respect of detection of the pathology and time consuming for preparation. RESULTS: Mean preparation time for stereotactic hematoma aspiration was 71.2 minutes (50-90 minutes), and mean preparation time for neuronavigation-guided surgery was 52.5 minutes (30-70 minutes). However, only 7.4 minutes (4-20 minutes) were needed for the preparation time of intraoperative ultrasonography. Moreover, intraoperative ultrasonography-guided surgery had many advantages compared to other image-guide surgery, such as capability of real-time monitoring and independency of brain shifting. However, there were several limitations too, which were relatively low resolution, artifact by air bubble during the procedure, and the lower echogenecity of liquified hematomas when a delay of several days was needed. Nevertheless, ultrasound-guided hematoma surgery could serve as minimally invasive treatment whenever hematoma evacuation seems to be advisable, at least as a first attempt. CONCLUSION: Based on this preliminary result, we concluded that intraoperative ultrasonographic examination during the surgical treatment of ICH was a non-invasive, useful, and simple diagnostic tool in the detection of the components and accompanying parts of the lesion. It was more useful than stereotaxy or neuronavigation system in the situation of emergent case such as an impending brain herniation.
Aneurysm ; Arteriovenous Malformations ; Artifacts ; Brain ; Cerebral Hemorrhage* ; Craniocerebral Trauma ; Hematoma ; Humans ; Intracranial Aneurysm ; Intracranial Hemorrhages ; Neuronavigation ; Pathology ; Surgery, Computer-Assisted* ; Ultrasonography*

OBJECTIVETo study the treatment strategies and operative principles of complex cerebral arteriovenous malformation (CAVM).

METHODSTotal 27 cases of complex CAVM were microsurgically resected from June 2004 to May 2011. These account for 67.5% of CAVMs in the same time. Of the CAVM, 25 were eloquent CAVMs and 2 were non-eloquent CAVM. Among the 27 cases, the size of CAVM was large in 12 cases, median in 8, and small in 7. According to Spetzler-Martin CAVM grading, 8 cases were grade II, 5 cases were grade III, 9 cases were grade IV, and 5 cases were grade V. Pre-operative endovascular embolizations were carried out in 2 large CAVMs. All CAVMs were resected by microsurgical techniques.

RESULTSThere were 23 cases of complex CAVMs totally removed. The total resection rate was 85.2%. The residual CAVMs were found in postoperative digital subtraction angiography (DSA) in 4 cases. Three of these residual cases were treated with gamma knife. Nineteen cases recovered very well after operation. The main complications were hemianopsia in 2 cases, moderate weakness in 4 cases. Two patients in coma before operation were still comatose after operation. The follow-up period were 2 months to 6 years. Twenty-two cases were Glasgow outcome scale (GOS) 5, 3 cases were GOS 4, and 2 comatose patients were improved a little during the follow-up.

CONCLUSIONSThe microsurgical total resection of the CAVMs is the most effective method to cure the disease. With the use of microsurgical technique skillfully, mose complex CAVMs can achieve good outcomes. Preoperative embolization and radiosurgery on the residual nidus are good supplementary methods to treat the complex CAVMs.

Adolescent ; Adult ; Child ; Female ; Follow-Up Studies ; Humans ; Intracranial Arteriovenous Malformations ; surgery ; Male ; Microsurgery ; methods ; Middle Aged ; Retrospective Studies ; Treatment Outcome ; Young Adult

BACKGROUNDStereotactic radiosurgery is an alternative to resection of intracranial cerebral arteriovenous malformations (AVMs), while it will fail in some cases. This study aimed to evaluate the changes after stereotactic radiosurgery for AVMs.

METHODSNineteen cases with cerebral AVMs had failure after stereotactic radiosurgery therapy. The symptoms and angiography were assessed. All patients underwent microsurgery. Pathologic examination was performed for all cases and electron microscopic examination was carried out in 6 patients.

RESULTSSeven cases had hemorrhage from 12 to 98 months after stereotactic radiosurgery, 5 had headache, 4 had refractory encephalon edema, 2 had epilepsy as a new symptom and 1 had a pressure cyst 5 years after radiosurgery. Angiography in 18 cases, 8 - 98 months after radiation therapy, demonstrated no significant changes in 5 cases, slight reduction in 9, near complete obliteration in 1 and complete obliteration in 3. An abnormal vessel was found on pathologic examination in 17 cases, even one case had obliterated in angiography. Electron microscopy examination showed vessel wall weakness, but the vessels remained open and blood circulated. One case died because of a moribund state before surgery. The other 18 cases had no new neurological deficiencies, seizure control and no hemorrhage occurred after microsurgery at an average follow-up of 3 years.

CONCLUSIONStereotactic radiotherapy for AVMs should have a long period follow-up. If serious complications occur, microsurgery can be performed as salvage treatment.

Adult ; Cerebral Angiography ; Cerebral Hemorrhage ; etiology ; Female ; Headache ; etiology ; Humans ; Intracranial Arteriovenous Malformations ; diagnostic imaging ; pathology ; surgery ; Male ; Middle Aged ; Postoperative Complications ; Radiosurgery ; adverse effects ; Treatment Outcome

OBJECTIVETo investigate pre- and postoperative changes of regional cerebral cortical blood flow in patients with cerebral arteriovenous malformation.

METHODTwenty-two adult patients with arteriovenous malformation (AVM) were recruited into this study at Beijing Tiantan Hospital from September 2001 to May 2002. Eight patients had giant cerebral AVM and the other 14 had a small one. Cortical cerebral blood flow (CBF) was measured by laser Doppler flowmetry (LDF) before and after AVM resections. After surgery, the probe of LDF was implanted adjacent to the area of AVM and monitored for 24 hours.

RESULTSCBF increased significantly after the resection in all patients regardless of AVM size. In patients with small AVM, CBF returned to the baseline level within 4 hours, but in patients with giant AVM, CBF remained high even after 24 hours.

CONCLUSIONSMonitoring CBF is helpful to understand pre- and postoperative changes of regional cortical CBF in patients with cerebral AVM.

Adult ; Cerebrovascular Circulation ; physiology ; Female ; Humans ; Intracranial Arteriovenous Malformations ; physiopathology ; surgery ; Laser-Doppler Flowmetry ; Male ; Middle Aged ; Regional Blood Flow ; physiology

From January to December in 1983, neurosurgical statistics of 38 training hospitals in Korea was summarized as follows. The total number of neurosurgical admission was 27,185. The total operations were 10,980. Each of 25( out of the 38) training units performed 100 to 400 operations during this one year period. Out of 10,980 operations, 3,938 cases were trauma, approximately 36% against the total. Of the trauma surgery, 88% was done for head injuries and remaining 12% for spine injuries. There were 2,233 cases(20.34% of the total) of spine surgery, which was next to trauma surgery. Surgery for lumbar disc herniation(2,047 cases) occupied 92% of spine surgery. Of 1,302 operations(11.86% of the total) for cerebrovascular diseases. 719 cases(55.23%) were spontaneous intracerebral hematomas and 441 cases(33.87%) were ruptured cerebral aneurysms. Forty-two per cent of aneurysms was found in anterior communicating artery and 25% in internal carotid-posterior communicating artery junction. It is interesting to note that only 1% of posterior circulation aneurysms was detected by the four vessel angiography. Another remarkable finding was the cerebrovascular occlusive lesion was rarely found among Korean patients, and consequently, the surgery for ischemic stroke was performed infrequently Remaining vascular surgery was done for the cerebral vascular malformations such as arteriovenous malformation and Moya Moya disease. Tumor surgery was done for 1,060 cases, which represents 9.65% of all. Of these tumor surgeries, 97.73% was done for primary brain tumors. Glial tumors were 41.2% of all primary brain tumors and 20.8% was meningiomas. The pituitary tumor was 10% of all primary brain tumors, and 56% of pituitary tumors was operated on by transsphenoidal approach. Five per cent of all primary brain tumors was pineal tumors, but most of pineal tumors were treated by shunt surgery and radiation therapy. Consequently, direct operation for pineal tumor was performed only in 13 case. Shunt operation was performed in 650 cases. Functional neurosurgery cases were 207 and 148(71.5%) of them were pain surgery. Twenty-two cases of microvascular decompression were performed for hemifacial spasm. Surgery for infection was 3.57% of the total.
Aneurysm ; Angiography ; Arteries ; Arteriovenous Malformations ; Brain Neoplasms ; Craniocerebral Trauma ; Hematoma ; Hemifacial Spasm ; Humans ; Intracranial Aneurysm ; Korea* ; Meningioma ; Microvascular Decompression Surgery ; Moyamoya Disease ; Neurosurgery ; Pinealoma ; Pituitary Neoplasms ; Spine ; Stroke ; Vascular Malformations