Surgical management of giant arteriovenous malformations

The surgical management of giant arteriovenous malformations (AVMs) remains a significant treatment challenge. Perhaps the most important factor in surgical outcome for giant AVMs is patient selection. We treat most giant AVMs conservatively. Exceptions include patients with progressive neurological deficits from AVM hemorrhage. We prefer staged transfemoral glue embolization followed by craniotomy for microsurgical resection, often using frameless stereotactic guidance as a surgical adjunct. Somatosensory evoked potentials and electroencephalographic monitoring with barbiturate burst suppression are used to insure neural protection. Intraoperative cerebral angiography minimizes the possibility of residual AVM and postoperative hemorrhage. Strict postoperative control of blood pressure and staged embolization can prevent normal perfusion pressure breakthrough. A team approach with a neurosurgeon, endovascular neurosurgeon, and neuroanesthesiologist optimizes the outcomes associated with these challenging lesions.