Management of supratentorial arteriovenous malformations.

Management of patients with arteriovenous malformations (AVMs) remains one of the most difficult problems in neurosurgery. Treatment of AVMs requires the efforts of a multidisciplinary team, including the vascular neurosurgeon, the interventional neuroradiologist, and the radiosurgery group. Other professionals are also essential to complete the team, such as a neurologist, psychologist, neurointensivist, and neuroanesthesiologist. The ultimate treatment goal is to achieve better results than the natural history of the pathology.4 The main therapy for most AVMs is microsurgical resection. The challenge of AVM surgery should be reserved for major referral centers to improve clinical results because only a few neurosurgeons have the most experience in treating this pathology, which requires endovascular and radiosurgery techniques. With the development of microsurgical techniques, anatomic knowledge, and advances in neuroimaging, neuroanesthesia, and neuromonitoring, the surgical treatment of these lesions became possible. The AVM-related risk of hemorrhage is generally assumed to be 2% to 4% per year, with a mortality rate of approximately 1% to 1.5% per year. Approximately 30% to 40% of these patients will bleed, and 10% to 15% of them will die in a 10-year period. This assumed risk is based largely on the work of Ondra et al.6 who followed 262 patients over a 33-year period in Finland. The treatment goal is to achieve AVM resection without morbidity. A multidisciplinary decision-making process is the best way to offer patients better results with less morbidity. In addition to the AVM grade, the patient’s occupation, age, and clinical status should be carefully considered before surgical treatment. Then, after a neuroteam decision, surgical planning should consider anatomic structures from different angles and approaches in a three-dimensional way. The fine and delicate microsurgical techniques necessary to deal with the fragile vessels of an AVM can only be obtained with diligent work with laboratory animals and surgical experience. The importance of microscopes, microsurgical instruments and an equipped intensive care unit cannot be overstated. A team of well-trained neuroanesthetists, intensive care staff, and specialized nurses is also extremely necessary.