- Department of Neurosurgery, Saiseikai Shiga Hospital, Imperial Gift Foundation Inc., Ritto, Shiga, Japan.
- Department of Neurology, Saiseikai Shiga Hospital, Imperial Gift Foundation Inc., Ritto, Shiga, Japan.
Correspondence Address:
Shigeomi Yokoya, Department of Neurosurgery, Saiseikai Shiga Hospital, Imperial Gift Foundation Inc., Ritto, Shiga, Japan.
DOI:10.25259/SNI_242_2023
Copyright: © 2023 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.How to cite this article: Shigeomi Yokoya1, Hidesato Takezawa2, Yukihiro Hidaka2, Gaku Fujiwara1, Hideki Oka1. Ultrasound localization of embolic material to guide resection of brain AVM: Report of two cases. 21-Apr-2023;14:146
How to cite this URL: Shigeomi Yokoya1, Hidesato Takezawa2, Yukihiro Hidaka2, Gaku Fujiwara1, Hideki Oka1. Ultrasound localization of embolic material to guide resection of brain AVM: Report of two cases. 21-Apr-2023;14:146. Available from: https://surgicalneurologyint.com/surgicalint-articles/12271/
Abstract
Background: The Spetzler–Martin Grade (SMG) is widely used to evaluate the risk of resection of cerebral arteriovenous malformation (AVM), and direct surgery is strongly recommended for low SMG lesions. Micro-AVMs are defined as AVMs with a nidus
Case Description: (Patient 1) A 30-year-old man was brought to our hospital and diagnosed with a micro-AVM, which was classified as SMG II AVM. He underwent evacuation of the intracerebral hematoma and subsequently underwent AVM resection. However, the lesion was not identified because it was not exposed in the cerebral cortex although we searched for the lesion. Therefore, endovascular embolization was performed before subsequent surgical resection. During AVM resection following embolization with Onyx, the IUS clearly demonstrated the Onyx-embolized lesion, and it was resected uneventfully. (Patient 2) A 46-year-old man with a ruptured SMG II AVM underwent AVM resection using a microsurgical technique with IUS after embolization for AVM preoperatively. IUS clearly showed abnormal vessels embolized with Onyx and indicated the correct location of the nidus, although the lesion was not observed directly from the brain surface. After identifying some embolized AVM constructions, we excised the entire AVM with ease and safety.
Conclusion: The combined use of presurgical embolization, which focuses on marking the lesions and IUS, may contribute to improving surgical outcomes of low SMG micro-AVMs, which are not exposed on the brain surface.
Keywords: Intraoperative ultrasonography (IUS), Microarteriovenous malformation (AVM), Onyx, Presurgical embolization
INTRODUCTION
The Spetzler–Martin Grade (SMG) is widely used to evaluate the risk of arteriovenous malformation (AVM) resection,[
Herein, we present two cases in which low-SMG micro-AVMs were marked by presurgical embolization using an ethylene-vinyl alcohol co-polymer (Onyx), and intraoperative ultrasonography (IUS) from the brain surface identified the exact locations of subcortical AVM.
CASE DESCRIPTION
Patient 1
A 30-year-old man with unremarkable medical history was brought to our hospital with a sudden onset of the left hemiparesis and headache. On admission, he was in a restless state and experienced several episodes of vomiting. Although he demonstrated alert consciousness, hemiplegia and hemihypesthesia were observed on his left side. Computed tomography (CT) revealed subcortical hemorrhage in the right frontoparietal cerebrum [
Figure 1:
(a) Computed tomography scan on admission showing subcortical hematoma in the left frontal region. (b) Pre-embolization digital subtraction angiography (DSA) anteroposterior images showing a microarteriovenous malformation (AVM) fed by the central artery of the middle cerebral artery. (c) Intraoperative photograph showing that the AVM is not exposed in the cerebral cortex. We dissected the cerebral sulci to find the lesion (dotted line) but with failure. The solid line indicates the sulcus located just above the lesion according to intraoperative ultrasonography (IUS) at the second resection surgery. (d) DSA, during endovascular embolization showing that the lesion is embolized with Onyx. (e) IUS showing that the embolized compartment of the AVM presents as a highly echogenic lesion with acoustic shadow formation. (f) Intraoperative photograph after dissecting the sulcus just above the lesion, showing that an embolized vessel is confirmed (arrow).
Patient 2
A 46-year-old man presented felt listless in his right fingers and noticed facial paresis. On admission, he demonstrated motor aphasia without conscious disturbance or hemiparesis. A CT scan showed a left subcortical hemorrhage [
Figure 2:
(a) Computed tomography scan on admission demonstrating a subcortical hematoma in the left frontal region. (b) Pre-embolization digital subtraction angiography (DSA), anteroposterior images showing a microarteriovenous malformation (AVM) fed by the central artery of the middle cerebral artery. (c) DSA, during endovascular embolization, showing that part of the lesion was embolized presurgically with Onyx. (d) Intraoperative ultrasonography (IUS) showing abnormal vessels embolized with Onyx as well as intracerebral hematoma (*). (e) Intraoperative photograph showing that the AVM is not exposed in the cerebral cortex. The solid lines indicate the sulcus located just above the lesion according to the IUS. (f) Intraoperative photograph after dissecting the sulcus just above the lesion, showing that an embolized vessel is confirmed (arrow).
DISCUSSION
We present two cases of low SMG micro-AVMs marked using presurgical Onyx embolization, and IUS was useful for detecting the lesions, which could not be observed from the brain surface, correctly with ease. From our cases, the following two important points are implied. First, aggressive presurgical embolization without curative intent for lowSMG micro-AVM treatment may improve the outcomes of surgical intervention. Previously, it was reported that the main purposes of preoperative embolization are (1) to reduce the blood flow of the nidus and minimize bleeding that can occur during microsurgical removal;[
From our two cases, we realized that presurgical Onyx is highly effective as a marker for AVM sites by the embolizing substance in addition to the common purpose of embolizing the feeder and/or obstructing the nidus, although embolization for micro-AVM entails extra risks. The endovascular embolization of micro-AVM has reported a slightly high risk associated with the procedure.[
Second, IUS may improve the outcome of AVM surgery as one of the intraoperative support devices when used in combination with presurgical embolization. An intraoperative ultrasonic device, especially color-flow Doppler, has been reported to be useful for intraoperative assessment of AVM surgery.[
In conclusion, although presurgical embolization for micro-AVM may have a slightly high risk of complications associated with the procedure, presurgical embolization, which does not necessarily aim at complete obstruction of the nidus but marks the lesion site, is considered to be an effective method that can reduce complications in AVM excision and improve the overall safety of micro-AVM treatment.
CONCLUSION
The combined use of presurgical embolization, which clarifies the purpose of marking lesions, and IUS may contribute to safe surgical interventions.
Ethical approval
The publication of this case report was approved by the Ethics Committee of Saiseikai Shiga Hospital (Permission number: 526).
Declaration of patient consent
The Institutional Review Board (IRB) permission obtained for the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Disclaimer
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
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