Hans-Jakob Steiger, Robert Schmid-Elsaesser, Alexander Muacevic, Hartmut Brilckmann und Berndt Wowra

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2 Hans-Jakob Steiger, Robert Schmid-Elsaesser, Alexander Muacevic, Hartmut Brilckmann und Berndt Wowra Neurosurgery of Arteriovenous Malformations and Fistulas A Multimodal Approach Springer-Verlag Wien GmbH

3 Univ.-Prof. Dr. Hans-jakob Steiger Priv.-Doz. Dr. Robert Schmid-Elsaesser Dr. Alexander Muacevic Univ.-Prof. Dr. Hartmut BrOckmann Priv.-Doz. Dr. Berndt Wowra Ludwig-Maximilians-University, Klinikum Gro&hadem and Gamma Knife Center, Munich, Germany This work is subject to copyright. AII rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machines or similar means, and storage in data banks Springer-Verlag Wien Originally published by Springer-Verlag Wien New York in 2002 Product Liability: The publisher can give no guarantee for aii the information contained in this book. This does also refer to information about drug dosage and application thereof. In every individual case the respective user must check its accuracy by consulting other pharmaceuticalliterature. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Typesetting: Asco Typesetters, Hong Kong Printed on acid-free and chlorine-free bleached paper SPIN: With 617 partly coloured Figures CIP-data applied for ISBN ISBN (ebook) DOI /

4 Preface Arteriovenous malformations (AVM) and arteriovenous fistulas (AVF) differ from all other pathology affecting the central nervous system by their highflow arteriovenous shunts. Permanent occlusion of these shunts is the essence and the challenge of therapy. Much progress has been made since the first neurosurgical efforts to deal with these problems. Endovascular therapy and radiosurgery became accepted alternatives or adjuncts to surgery. In many instances the choice of the primary therapeutic modality is not clear and arguments can be found for several options. However, microsurgery, endovascular therapy and radiosurgery differ very much with regard to invasiveness, length of stay at the hospital but also residual risk after therapy. These secondary factors are often decisive for the choice of treatment modality. The continuous interdisciplinary discussions motivated ongoing improvement of all therapeutic modalities. Each specialty tried to reduce its specific shortcomings, that is treatment morbidity for microsurgery and insufficient effect for radiosurgery and endovascular therapy. The resulting quality culture had the consequence that each specialty limited the indications to the spectrum of pathology that appeared safely amenable to the possibilities of the method. In addition, combination of the different methods enlarged the spectrum of curable malformations. The emerging treatment concepts are the object of this book. Description of the surgical method focuses therefore on lower Spetzler & Marti n grades and not on the very large and critically located lesions, which can only occasionally be cured surgitally without morbidity. The focus of the endovascular illustrations is put on the adjuvant function for surgery and on the specific pathologies than can usually be cured by the endovascular route. The radiosurgical chapter and case illustrations are concerned primarily with the therapy of small and deep seated malformations. The result is a unique structured presentation of AVM and AVF therapy. The book has been written for colleagues involved in surgery, radiosurgery and endovascular therapy of vascular malformations affecting the central nervous system. The books describes the surgical approach to the typical AVMs and AVFs and gives detailed planning information for radiosurgery. The descriptions of the endovascular techniques have been restricted to the minimum, since there are several good and detailed publications available. The authors are grateful to Uta Fischer and Barbara Ruppel for the artwork and particularly for the patience with our permanent requests for alterations and corrections. We are also indebted to Christian Vollmar and Christoph Barth for the revision of the radiographic images and for the computer graphics respectively. Finally, the book would not have been possible without the reliable help of Ilona Anders with the preparation of the manuscript. H.-j. Steiger R. Schmid-Elsaesser A. Muacevic H. Bruckmann B. Wowra

5 Contents Chapter 1: General considerations and review of the literature R. Schmid-Elsaesser Arteriovenous malformations of the brain Dural arteriovenous fistulas of the brain Spinal arteriovenous malformations References Chapter 2: Classifications H.-i. Steiger 2.1. Theoretical considerations Pathoanatomical classification Surgical classifications Angioarchitecture of cerebral arteriovenous malformations Angioarchitecture of cranial dural arteriovenous fistulas Topographical classification of cerebral arteriovenous malformations Topographical classification of cranial dural arteriovenous fistulas Classification of spinal arteriovenous malformations References Chapter 3: Results of surgery, embolization, and radiosurgery: A detailed literature review H.-i. Steiger 3.1. Results of pure surgical treatment Results of endovascular treatment Results of radiosurgical treatment Endovascular embolization combined with surgical resection Embolization combined with radiosurgery Surgery combined with radiosurgery References Chapter 4: Surgical Principles H.-i. Steiger 4.1. Introduction General principles of surgery for AVMs and davfs Peri- and intraoperative management Special principles of cerebral AVMs Specific principles of cranial davfs

6 VIII Contents 4.6. Surgical principles of spinal AVMs References Chapter 5: Endovascular interventional principles H. BrOckmann and H.-J. Steiger 5.1. Introduction General principles of endovascular embolization Peri-i nterventional management References Chapter 6: Gamma Knife radiosurgery for cerebral AVMs B. Wowra 6.1. Introduction The dose planning strategy includes a prospective risk estimation Personal experience using the LGK in Munich Discussion of the therapeutic profile of radiosurgery compared to microsurgery and embolization Conclusion References Surgical and combined endovascular and surgical case presentations (Cases S-1 to S-40) H.-}. Steiger, R. Schmid-Elsaesser, A. Muacevic, and H. BrOckmann Exclusively endovascular case presentations (Cases E-1 to E-5) R. Schmid-Elsaesser, H.-}. Steiger, and H. BrOckmann Radiosurgical case presentations (Cases R-1 to R-11) B. Wowra