Nuances in AVM Resection

Technical Principles of AVM Surgery 

Arteriovenous malformations (AVMs) are an important cause of morbidity and mortality among neurosurgical patients, usually due to hemorrhage, but also because of refractory seizures and focal neurologic deficits.

Management options for AVMs vary from microsurgery alone or in conjunction with or without adjunctive embolization and/or radiosurgery. Alternative options include radiosurgery as a standalone option. Large and complex lesions may be best managed via observation.

The specific technical nuances for excision of each AVM subtype will be discussed in the following chapters.  The current chapter will review the general principles applicable to all AVMs and should be consulted before reviewing the subsequent chapters.

Patient Positioning

As previously discussed in the Cranial Approaches Volume, thoughtful positioning of the patient during surgery can facilitate resection by allowing the use of gravity retraction.

Head position is planned with the cranial venous return in mind, keeping the patient’s head just above the level of the heart, and the neck slightly extended while avoiding extreme rotation of the head to one side. These considerations prevent intracranial venous hypertension, which can be problematic for cranial surgery in general and in AVM surgery in particular.

Common mistakes during patient positioning include failure to use free surfaces to access the lesion and maximize gravity retraction. As a result, fixed ret...