Neurosurg. Rev. 15 (1992) 285-288
Intraoperative angiography and embolization in intracranial AVM's and aneurysms Horst Peter Molsen, Alexander Griiwe, Gunther Nisch, Hans Rost, and Wolf-Dieter Siedschlag Neurosurgical Clinic Berlin-Buch, Fed. Rep. of Germany
Abstract Intraoperative angiography allows for control procedures for exstirpation of arteriovenous malformations and clipping of problematic aneurysms during the entire operation_ During intraoperativ embotizations, it is especially helpful to see whether the occlusion of the nidus of an arteriovenous malformation is complete. The method is easy to perform; there were no complications in 19 cases.
Keywords: Aneurysm, cerebral arteriovenous malformation, intraoperative angiography, intraoperative embolization.
1 Introduction Modern diagnostic methods usually allow preoperative imaging o f patients with arteriovenous malformations (AVM) and aneurysms sufficient for planning surgery. Nevertheless, it is often desirable to have intraoperative angiograph.ic control during the operation. This allows correction of procedures during the same session. For example, in cases with extended AVM's, one can see whether the nidus is totally removed or not; if the excision was not complete, we can continue the operation in a marked region (clip) and then again control results with intraoperative angiograpy [1, 3]. During intraoperative embolizations, it is helpful to see whether occlusion is complete [2, 4, 5].
2 Material and method On the day of operation we performed a normal transfemoral angiography in the neuroradiological department. The patient is already under anesthesia and prepared for operation. A french-6catheter is placed into the involved parent vessel, 9 1992 by Walter de Gruyter & Co. Berlin - New York
Figure 1. AVM temporo-occipital (a). The intraoperative control angiogram (b) shows the complete exstirpation. Catheter in the i. c. a.
286
Molsen et al., Intraoperative angiography
for example, in the internal carotid artery (Figure 1). In a case with additional feeder arteries coming from the posterior cerebral artery we simultaneously introduce a second catheter into the vertebral artery (Figure 2). After a short angiographic control of the AVM - in one case we saw a spontaneous thrombosis which occurred after an attempted embolization - the patient is transferred to the operation room. To avoid removing of the catheter during the transport, the catheter should be fixed with a cutaneous ligature at the puncture site. During the entire operation the catheter should be continuously washed by saline
with 5000 units heparin in 500 cc. At the same time we permanently measure the blood pressure intraarterially in the catheter. The blood pressure curve shows us not only the course of the pressure during the hypotension but also the patency of the catheter during the entire operation, sometimes for several hours. Problems or complications were not seen in our 19 patients treated with this method. Fluoroscopic control is realized by an intraoperative stationary device which allows a simple form of digital subtraction including film documentation. The contrast injection is performed by hand.
Figure 2. AVM temporo-occipital pre (a) and after exstirpation (b). Catheter remains in the vertebral artery during the entire operation. Table I. Embolic agents in neuroradiology
Type of embolization
Material
1. Free
Gelfoam particles, polyvinylalcohol PVA
2. Balloon-driven
Gelfoam partMes, polyvinylalcohol PVA
3. Superselective
Silicon by calibrated-leak balloon PVA plus ethanol (LA Cocktail) Histoacryl/Lipiodol Detachable balloons Tantalum powder Neurosurg. Rev. 15 (1992)
Molsen et al., Intraoperative angiography If preoperative embolization was not successful we perform an intraoperative embolization of the AVM before exstirpation. After craniotomy, the AVM is approached by a superficial arterial feeder. We can also embolize in the same manner with percutaneously introduced microcatheters [3]. We control the effect of the embolization with the preoperatively introduced diagnostic angiographic catheter. The embolic agents used in our interventionalneuroradiologic procedures are listed in table i. The example in figure I shows that although the quality of the intraoperative images is not always optimal, it is sufficient to detect the presence of remnants of the AVM-nidus. In the case shown in figure 3 subtraction improves the quality of the image. Performance of a native image in the operative position immediately pre-contrast allows a later photographic or electronic subtraction. In one case with an aneurysm problematically situated at the division of the middle cerebral artery (Figure 4), we also used intraoperative angiography. After clipping the neck we could control the patency of all branches of the artery intraoperatively.
Figure 3. AVM parietal with a single feeder artery (A. angularis) (a). After introduction of two microcatheters into the branches of the feeder artery (b) and intraoperative embolization, the almost completely closed nidus was removed (e). Neurosurg. Rev. 15 (1992)
287 3 Discussion
Simple intraoperative angiography is an additional method to control the results of operation in patients with AVM's and problematic aneurysms. With this safe technique we can detect any remaining problems and resolve them during the same session. Only one "little" problem remains: the neuroradiologist is occupied in the operation room the entire day and is absent from his department.
288
Molsen et al., Intraoperative angiography
Figure 4. Aneurysm of the m. c. a. (a) after clipping. The intraoperative control angiogram shows the correct site of the clip without disturbance of circulation in the m. c. a.
References [1] CROMWELLLD, AB HARRIS: Treatment of cerebral artefiovenous malformations - a combined neurosurgical and neuroradiological approach. J Neurosurg 52 (1980) 705-708 [2] LASJAUNIASP, A BERENSTEIN: Surgical Neuroangiography. Springer Verlag Berlin 1990 [3] MOLSEN HP, U FRIEDRICH, D KINTZEL, G NISCH, W-D SIEDSCHLAG, H WINKELMANN: Interventionsradiologie in der Neurochirurgie: Zum Einsatz der endovaskul/iren Ballon-Okklusion Zentbl Neurochir 49 (1988) 2 6 3 - 2 6 9 [4] VAN ALPHEN H, M AUGUST:Intraoperative embolization of cerebral arteriovenous malformations. Neurosurg Rev 9 (1986) 7 7 - 8 5
[5] WOLPERT SM, STEIN BM: Catheter embolization of intracranial arteriovenous malformations as an aid to surgical excision. Neuroradiology 10 (1975) 73-75 Submitted July 1, 1991. Accepted August 14, 1991. Priv.-Doz. Dr. med. H. R Molsen Universit/itsklinikum Rudolf Virchow Standort Wedding Strahlenklinik und Poliklinik Altes R6ntgenhaus Augustenburger Platz 1 W-1000 Berlin 65 Fed. Rep. of Germany
Neurosurg. Rev. 15 (1992)
Intraoperative angiography and embolization in intracranial AVM's and aneurysms Horst Peter Molsen, Alexander Griiwe, Gunther Nisch, Hans Rost, and Wolf-Dieter Siedschlag Neurosurgical Clinic Berlin-Buch, Fed. Rep. of Germany
Abstract Intraoperative angiography allows for control procedures for exstirpation of arteriovenous malformations and clipping of problematic aneurysms during the entire operation_ During intraoperativ embotizations, it is especially helpful to see whether the occlusion of the nidus of an arteriovenous malformation is complete. The method is easy to perform; there were no complications in 19 cases.
Keywords: Aneurysm, cerebral arteriovenous malformation, intraoperative angiography, intraoperative embolization.
1 Introduction Modern diagnostic methods usually allow preoperative imaging o f patients with arteriovenous malformations (AVM) and aneurysms sufficient for planning surgery. Nevertheless, it is often desirable to have intraoperative angiograph.ic control during the operation. This allows correction of procedures during the same session. For example, in cases with extended AVM's, one can see whether the nidus is totally removed or not; if the excision was not complete, we can continue the operation in a marked region (clip) and then again control results with intraoperative angiograpy [1, 3]. During intraoperative embolizations, it is helpful to see whether occlusion is complete [2, 4, 5].
2 Material and method On the day of operation we performed a normal transfemoral angiography in the neuroradiological department. The patient is already under anesthesia and prepared for operation. A french-6catheter is placed into the involved parent vessel, 9 1992 by Walter de Gruyter & Co. Berlin - New York
Figure 1. AVM temporo-occipital (a). The intraoperative control angiogram (b) shows the complete exstirpation. Catheter in the i. c. a.
286
Molsen et al., Intraoperative angiography
for example, in the internal carotid artery (Figure 1). In a case with additional feeder arteries coming from the posterior cerebral artery we simultaneously introduce a second catheter into the vertebral artery (Figure 2). After a short angiographic control of the AVM - in one case we saw a spontaneous thrombosis which occurred after an attempted embolization - the patient is transferred to the operation room. To avoid removing of the catheter during the transport, the catheter should be fixed with a cutaneous ligature at the puncture site. During the entire operation the catheter should be continuously washed by saline
with 5000 units heparin in 500 cc. At the same time we permanently measure the blood pressure intraarterially in the catheter. The blood pressure curve shows us not only the course of the pressure during the hypotension but also the patency of the catheter during the entire operation, sometimes for several hours. Problems or complications were not seen in our 19 patients treated with this method. Fluoroscopic control is realized by an intraoperative stationary device which allows a simple form of digital subtraction including film documentation. The contrast injection is performed by hand.
Figure 2. AVM temporo-occipital pre (a) and after exstirpation (b). Catheter remains in the vertebral artery during the entire operation. Table I. Embolic agents in neuroradiology
Type of embolization
Material
1. Free
Gelfoam particles, polyvinylalcohol PVA
2. Balloon-driven
Gelfoam partMes, polyvinylalcohol PVA
3. Superselective
Silicon by calibrated-leak balloon PVA plus ethanol (LA Cocktail) Histoacryl/Lipiodol Detachable balloons Tantalum powder Neurosurg. Rev. 15 (1992)
Molsen et al., Intraoperative angiography If preoperative embolization was not successful we perform an intraoperative embolization of the AVM before exstirpation. After craniotomy, the AVM is approached by a superficial arterial feeder. We can also embolize in the same manner with percutaneously introduced microcatheters [3]. We control the effect of the embolization with the preoperatively introduced diagnostic angiographic catheter. The embolic agents used in our interventionalneuroradiologic procedures are listed in table i. The example in figure I shows that although the quality of the intraoperative images is not always optimal, it is sufficient to detect the presence of remnants of the AVM-nidus. In the case shown in figure 3 subtraction improves the quality of the image. Performance of a native image in the operative position immediately pre-contrast allows a later photographic or electronic subtraction. In one case with an aneurysm problematically situated at the division of the middle cerebral artery (Figure 4), we also used intraoperative angiography. After clipping the neck we could control the patency of all branches of the artery intraoperatively.
Figure 3. AVM parietal with a single feeder artery (A. angularis) (a). After introduction of two microcatheters into the branches of the feeder artery (b) and intraoperative embolization, the almost completely closed nidus was removed (e). Neurosurg. Rev. 15 (1992)
287 3 Discussion
Simple intraoperative angiography is an additional method to control the results of operation in patients with AVM's and problematic aneurysms. With this safe technique we can detect any remaining problems and resolve them during the same session. Only one "little" problem remains: the neuroradiologist is occupied in the operation room the entire day and is absent from his department.
288
Molsen et al., Intraoperative angiography
Figure 4. Aneurysm of the m. c. a. (a) after clipping. The intraoperative control angiogram shows the correct site of the clip without disturbance of circulation in the m. c. a.
References [1] CROMWELLLD, AB HARRIS: Treatment of cerebral artefiovenous malformations - a combined neurosurgical and neuroradiological approach. J Neurosurg 52 (1980) 705-708 [2] LASJAUNIASP, A BERENSTEIN: Surgical Neuroangiography. Springer Verlag Berlin 1990 [3] MOLSEN HP, U FRIEDRICH, D KINTZEL, G NISCH, W-D SIEDSCHLAG, H WINKELMANN: Interventionsradiologie in der Neurochirurgie: Zum Einsatz der endovaskul/iren Ballon-Okklusion Zentbl Neurochir 49 (1988) 2 6 3 - 2 6 9 [4] VAN ALPHEN H, M AUGUST:Intraoperative embolization of cerebral arteriovenous malformations. Neurosurg Rev 9 (1986) 7 7 - 8 5
[5] WOLPERT SM, STEIN BM: Catheter embolization of intracranial arteriovenous malformations as an aid to surgical excision. Neuroradiology 10 (1975) 73-75 Submitted July 1, 1991. Accepted August 14, 1991. Priv.-Doz. Dr. med. H. R Molsen Universit/itsklinikum Rudolf Virchow Standort Wedding Strahlenklinik und Poliklinik Altes R6ntgenhaus Augustenburger Platz 1 W-1000 Berlin 65 Fed. Rep. of Germany
Neurosurg. Rev. 15 (1992)
