Treatment of high-grade brain arteriovenous malformations using a hybrid operating room: A prospective single-arm study

The annual risk of intracerebral hemorrhage (ICH) from a previously unruptured brain arteriovenous malformation (BAVM) ranges between 0.9 % and 4 % [1], [2], [3]. Ruptured BAVMs have a higher risk of subsequent hemorrhage, especially within the first year of initial rupture [4], [5]. On the basis of the results of A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA), most unruptured high Spetzler–Martin (S–M) grade BAVMs are treated with medical management alone [3], [6], [7]. However, several studies with the same inclusion criteria as ARUBA have evaluated long-term outcomes of BAVMs treated with microsurgery and found higher obliteration rates and lower disability rates than those reported in ARUBA [7], [8]. In patients with a high-grade BAVM, the annual hemorrhage rate may be much higher in those whose lesion has already ruptured [9], which suggests that this patient subgroup may benefit from more aggressive treatment. Selecting medical management alone without considering other options may unnecessarily deprive these patients of potentially beneficial treatment.

The primary goal of BAVM treatment is elimination of hemorrhage risk and minimization of AVM-related epilepsy [9]. Total lesion obliteration appears to reduce the cumulative residual lifetime risk of hemorrhage. However, surgical treatment of high-grade BAVMs is extraordinarily difficult. To improve the obliteration rate and reduce neurological deficits in high-grade BAVM patients, multidisciplinary approaches have been developed. Stereotactic radiosurgery (SRS) is associated with hemorrhage risk during the latency period and long-term risk of radiation necrosis [10], [11]. Furthermore, SRS requires balancing of the risks and benefits of delivering higher radiation doses to achieve nidus occlusion. BAVM endovascular embolization followed by SRS is associated with a lower rate of SRS-induced obliteration [12] because embolization may induce hypoxia, which reduces radiosensitivity [13]. Embolization may also increase the difficulty of defining the nidus during radiosurgical planning, which affects the dose design.[14] Treatment of low-grade BAVMs is more straightforward: microsurgery is considered the gold standard given its immediate results and effectiveness. However, single-stage surgical resection is not recommended for high-grade BAVMs.

Although combined microsurgery, intraoperative angiography, and endovascular embolization in a hybrid operating room (hOR) as a one-stop hybrid procedure has shown promise as a safe and effective approach for BAVM treatment [15], [16], [17], [18], this approach has not been well studied in treating high-grade BAVMs. Therefore, this preliminary study aimed to evaluate the feasibility, safety, and effectiveness of one-stop hybrid BAVM treatment in high-grade BAVM patients. Secondary study objectives included determination of indications and identification of methodological improvements and factors affecting treatment outcome.

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