Article
Clinical benefit in the management of ruptured and unruptured arterio-venous malformations in a combined imaging and surgical suite based on flat-panel technology
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Authors
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Marc Kotowski
- Department of Neurosurgery, University of Geneva, Medical Center, Medical Faculty of the University of Geneva, Switzerland
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Bawarjan Schatlo
- Department of Neurosurgery, University of Geneva, Medical Center, Medical Faculty of the University of Geneva, Switzerland
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Max Jägersberg
- Department of Neurosurgery, University of Geneva, Medical Center, Medical Faculty of the University of Geneva, Switzerland
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Enrico Tessitore
- Department of Neurosurgery, University of Geneva, Medical Center, Medical Faculty of the University of Geneva, Switzerland
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Phillipe Bijlenga
- Department of Neurosurgery, , University of Geneva, Medical Center, Medical Faculty of the University of Geneva, Switzerland
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Vitor Pereira
- Diagnostic & Interventional Neuroradiology, University of Geneva, Medical Center, Medical Faculty of the University of Geneva, Switzerland
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Karl Schaller
- Department of Neurosurgery, University of Geneva, Medical Center, Medical Faculty of the University of Geneva, Switzerland
| Published: | September 16, 2010 |
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Outline
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Objective: We report our preliminary experience of a prospective series of 17 patients who underwent combined neurointerventional and surgical procedures for arterio-venous malformation in a new hybrid imaging, endovascular and surgical suite which allows for diagnostic and intraoperative imaging (CT and 3-D rotational angiography).
Methods: We combined recent Flat-Panel technology (Philips Allura Xper FD 20) with a sterile surgical and neurointerventional environment. It allows for combined neurointerventional and surgical approaches with intraoperative high-speed CT-like imaging and intraoperative 3-D rotational angiography (up to 620 projections along 240° in 8–10 sec, rotational speed: 30°/55°/s, 30 frames/sec), automated segmentation of vascular structures and intraoperative update of a frameless navigation system (Brainlab VectorVision II). The impact of intraoperative imaging on treatment strategy, workflow and feasibility was evaluated using a prospective database.
Results: Seventeen patients harboring AVMs, 11 of them ruptured (mean Spetzler-grade: 1.8) and 5 unruptured (mean Spetzler-grade: 2.4) underwent combined endovascular and microsurgical procedures. In all patients, intraoperative 3-D RA has been performed before surgery and for resection control. Intraoperative 3-D RA has been used for segmentation of vascular structures and intraoperative update of navigation. 2 patients have been treated by embolisation followed by surgery in the same session. In 15.7% (n=3 patients) intraoperative 3-D RA has led to additional resection of AVM remnants. One patient suffered from a post-operative infection, three patients suffered from transient focal deficit. One patient suffered from a permanent neurological deficit appeared after surgery. A complete excision rate of 100% has been achieved.
Conclusions: A combined neurointerventional suite based on flat-panel technology is of particular value for combined neurointerventional and surgical treatment of cerebral AVMs. It allows for a combination of endovascular embolisation and surgery in one session and intraoperative resection control. It improves the management of arterio-venous malformation in terms of the (peri-) interventional workflow, and by preventing the necessity for extraoperatvie angiographic control with potential revision in a second operation.
