Multimodal flow-assisted resection of brain AVMs

Object The authors report their personal experience with brain arteriovenous malformations (bAVMs) surgery with a multimodal flow-assisted approach. Methods Data from patients who consecutively underwent bAVM resection with the assistance of indocyanine green video-angiography (ICG-VA), micro-flow probe flowmetry, and temporary arterial clipping test under intra-operative monitoring, were retrospectively analyzed. Results Twenty seven patients were enrolled in the study. Re-operation for residual nidus was needed in one case (3%). Average mRS change 1 month after surgery was +0.02. In our experience, the multimodal flow-assisted approach enabled surgeons to shift from one technique to another, according to the stage of resection, AVM location, or specific issues to be addressed. Before resection, the value of ICG-VA and flowmetry in showing AVM angioarchitecture and guiding surgical strategy was related to AVM features. The temporary arterial clipping-test presented a 100% sensitivity to differentiate between an AVM feeder and a transit artery to the sensi-motor area. At the final stage of resection, flowmetry was more effective than ICG-VA in detecting residual nidus missed at dissection. Conclusions Multimodal flow-assisted approach in AVM surgery proved a feasible, safe, and reliable methodology to achieve AVM resection with high radicality and low morbidity rate.