Indications for Procedure
The operative goal is complete removal of the lesion. Operative indications are controversial and center on assessing the balance between operative risk vs. risk of hemorrhage. The decision to resect an AVM is based on several factors (38, 39):
- Eloquence of region: The eloquence of cortical location (speech, motor function, and sensation)
- Pattern of venous drainage
- Associated aneurysms
- Recent hemorrhage
- Clinical deterioration
- Risk of other treatment options: Risk of complication from other modalities of therapy (such as radiation injury to the developing brain)
Several of these factors are combined in the Spetzler-Martin grade that incorporates eloquence of location, pattern of venous drainage, and size and is considered predictive of outcome from surgical management (40).
- Anticipation of large blood loss: Anesthesia should be consulted and appropriate measures made to ensure that multiple large bore IV access is present and adequate blood products are in the room.
Devices to Be Implanted
- Vascular clips: An array of AVM/aneurysm clips should be available.
- Operating microscope
- Multiple suctions
- Retraction system
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