Case Report: Microsurgical clipping of a multilobular fenestrated anterior communicating artery aneurysm: technical challenges with video analysis

BackgroundThe anterior communicating artery (AComA) is a common site for intracranial aneurysms due to its complex vascular architecture. Fenestrations in the AComA, observed in 7.5%–40% of cases, can disrupt normal blood flow, which increases turbulence and shear stress and heightens the risk of aneurysm formation.Case descriptionWe report the case of a 67-year-old female who presented with headaches. Imaging revealing a 10 mm unruptured multilobular aneurysm arising from the AComA. Microsurgical clipping was performed via a right pterional craniotomy. The fenestrated nature of the AComA only became apparent after intraoperative full dissection of the AComA complex. Intraoperative Doppler ultrasound and indocyanine green angiography were used to evaluate the vascular anatomy, which was followed by the successful clipping of the aneurysm. Postoperative angiography verified complete obliteration, and the patient recovered without neurological deficit.ConclusionThe complexity of the AComA anatomy in this case prompted reflection on the limitations of preoperative imaging and the need for careful intraoperative planning. Although advanced imaging modalities, particularly three-dimensional rotational angiography, are crucial for detecting vascular anomalies, ultra-thin bridging vessels may remain undetected, as occurred in this case. Intraoperative recognition of these structures required real-time adaptation to ensure safe dissection and successful aneurysm clipping To our knowledge, this is the first operative video documenting microsurgical clipping of an unruptured aneurysm within a fenestrated AComA. This case underscores the importance of anticipating anatomical variations and adapting surgical strategies to optimize outcomes in complex cerebrovascular procedures

Spetzler-Martin Grade I and II Cerebral Arteriovenous Malformations: A Propensity-Score Matched Analysis of Resection and Stereotactic Radiosurgery in Adult Patients

Cerebral arteriovenous malformations (AVMs) are congenital vascular anomalies that can lead to severe complications, including hemorrhage and neurological deficits. This study compares the outcomes of microsurgical resection and stereotactic radiosurgery (SRS) for SM grade I and II AVMs. Out of a large multicenter registry, we identified 180 matched patients with SM grade I and II AVMs treated with either microsurgical resection or SRS between 2010 and 2023. The primary outcomes were AVM obliteration rates and complications; secondary outcomes included neurological status and functional outcomes measured by the modified Rankin Scale (mRS). Propensity score matching (PSM) was utilized to ensure comparability between treatment groups. After PSM, 90 patients were allocated to each treatment group. Significant differences were observed in complete obliteration rates, with resection achieving higher rates compared to SRS in overall cases (97.8% vs. 60.0%, p \u3c 0.001), unruptured AVMs (100% vs. 58.3%, p \u3c 0.001), and ruptured AVMs (95.2% vs. 61.9%, p \u3c 0.001). Functional improvement rates were similar between the groups for overall cases (67.2% in resection vs. 66.7% in SRS, p = 0.95), unruptured AVMs (55.2% in resection vs. 55.6% in SRS, p \u3e 0.9), and ruptured AVMs (78.1% in resection vs. 74.1% in SRS, p = 0.7). Symptomatic complication rates were identical between the groups (11.1% each, p \u3e 0.9), while permanent complication rates were comparable (6.7% in resection vs. 5.6% in SRS, p = 0.8). Resection demonstrated significantly higher complete obliteration rates compared to SRS across all cases, including unruptured and ruptured AVMs. Functional improvement rates were similar between the two treatment groups, with no significant differences in symptomatic or permanent complication rates

Spetzler-Martin Grade IV Cerebral Arteriovenous Malformations in Adult Patients: A Propensity-Score Matched Analysis of Resection and Stereotactic Radiosurgery

Spetzler-Martin Grade IV arteriovenous malformations (AVMs) are challenging due to high risks associated with both treatment and natural progression. This study compares the outcomes of microsurgical resection and stereotactic radiosurgery (SRS) in high-grade AVMs, analyzing obliteration rates, complications, and functional outcomes. A retrospective cohort of 96 patients treated with either microsurgical resection (33 patients) or SRS (63 patients) was analyzed. Propensity-score matching was employed to account for baseline variables such as AVM size (cm), preoperative embolization and rupture status. Primary endpoints included AVM obliteration, complication rates, and modified Rankin Scale (mRS) scores. After matching, 31 patients per group were analyzed. Microsurgical resection achieved significantly higher obliteration rates (87.1%) compared to SRS (32.3%, p \u3c 0.001). In the matched SRS cohort (n = 31), the actuarial obliteration rates were 11% (95% CI: 0-22%) at 1 year, 17% (95% CI: 0-31%) at 3 years, and 43% (95% CI: 13-63%) at 5 years post-treatment. Complication rates were similar (32.3% resection, 38.7% SRS, p = 0.6). Functional outcomes in terms of improvement in modified Rankin Scale (mRS) scores were observed in 50.0% of microsurgery patients and 41.4% of SRS patients. However, the absolute number of patients improving was similar (13 vs. 12), and the microsurgery group had more cases of worsening mRS scores compared to the SRS group (4 vs. 2). The difference was not statistically significant (p = 0.4). Microsurgical resection offers superior obliteration rates for high-grade AVMs with comparable complication risks to SRS. SRS remains a valuable alternative for select patients, particularly those ineligible for resection. Future research should focus on optimizing multimodal treatment approaches

A unique variant of abducens nerve duplication in a case of a large vestibular schwannoma

Vestibular schwannomas (VS) are slow-growing benign tumors commonly found in the cerebellopontine angle, potentially compressing brain structures and cranial nerves, including the abducens nerve (AN), responsible for lateral gaze. Although large VSs may compress the AN, postsurgical AN palsy is rare, and the clinical significance of AN variations, particularly in VS cases, remains unclear. We report a unique case of a 29-year-old female with a large left vestibular schwannoma. The patient underwent a left-sided microsurgical two-stage excision with an uneventful recovery (House-Brackmann facial grade I). During surgery, a rare variant of the AN was identified. This AN originated as two separate trunks and merged 3 mm distal to its origin in the same segment. To the best of our knowledge, arising and merging in the cisternal segment of AN variation has not been reported previously. Recognizing AN variations is vital for successful skull base surgeries, especially in preserving both branches during vestibular schwannoma surgery and ensuring ocular function

A comparative analysis of microsurgical resection versus stereotactic radiosurgery for Spetzler-Martin grade III arteriovenous malformations: A multicenter propensity score matched study

Spetzler-Martin (SM) Grade III brain arteriovenous malformations (BAVMs) represent a transitional risk zone between low- and high-grade BAVMs, characterized by diverse angioarchitecture. The primary treatment options are endovascular embolization, microsurgical resection (MS), and stereotactic radiosurgery (SRS). This study compares the efficacy and outcomes of MS and SRS. We conducted a multicenter, retrospective study involving patients from the MISTA database with SM Grade III BAVMs treated with MS or SRS between 2010 and 2023. Propensity matching was based on age, favorable modified Rankin Score (mRS) at presentation, nidus size, rupture status, location depth, and eloquence. After matching, 60 patients were equally divided between MS and SRS groups. Median age (MS: 45.0 vs. SRS: 42.5 years, p = 0.3) and AVM size (MS: 3.2 vs. SRS: 2.9 cm3, p = 0.6) were similar. MS showed higher obliteration rates (93.3 %) compared to SRS (46.7 %) at the last follow-up (p  0.9) were similar. Hemorrhage occurred once in the MS group and none in the SRS (p > 0.9). Favorable outcomes (mRS 0–2) were higher with SRS than MS (93.3 % vs 80.0 %, p = 0.3), with one AVM-related mortality in the MS group. MS and SRS are viable treatments for SM Grade III BAVMs. Treatment choice should be individualized by a multidisciplinary team, considering patient goals. [Display omitted] •MS shows superior obliteration (93.3 %) vs SRS (46.7 %) for SM Grade III AVMs (p < 0.001).•Complete obliteration with MS is immediate vs 31.5 months median time with SRS.•SRS achieves better functional outcomes (mRS 0–2: 93.3 %) compared to MS (80.0 %).•Similar complication rates between treatments (MS: 30 %, SRS: 20 %, p = 0.4)

Spetzler-Martin grade I and II cerebral arteriovenous malformations: a propensity-score matched analysis of resection and stereotactic radiosurgery in adult patients

Cerebral arteriovenous malformations (AVMs) are congenital vascular anomalies that can lead to severe complications, including hemorrhage and neurological deficits. This study compares the outcomes of microsurgical resection and stereotactic radiosurgery (SRS) for SM grade I and II AVMs. Out of a large multicenter registry, we identified 180 matched patients with SM grade I and II AVMs treated with either microsurgical resection or SRS between 2010 and 2023. The primary outcomes were AVM obliteration rates and complications; secondary outcomes included neurological status and functional outcomes measured by the modified Rankin Scale (mRS). Propensity score matching (PSM) was utilized to ensure comparability between treatment groups. After PSM, 90 patients were allocated to each treatment group. Significant differences were observed in complete obliteration rates, with resection achieving higher rates compared to SRS in overall cases (97.8% vs. 60.0%, p  0.9), and ruptured AVMs (78.1% in resection vs. 74.1% in SRS, p = 0.7). Symptomatic complication rates were identical between the groups (11.1% each, p > 0.9), while permanent complication rates were comparable (6.7% in resection vs. 5.6% in SRS, p = 0.8). Resection demonstrated significantly higher complete obliteration rates compared to SRS across all cases, including unruptured and ruptured AVMs. Functional improvement rates were similar between the two treatment groups, with no significant differences in symptomatic or permanent complication rates

Comparing stand-alone endovascular embolization versus stereotactic radiosurgery in the treatment of arteriovenous malformations with Spetzler-Martin grades I–III: a propensity score matched study

BackgroundArteriovenous malformations (AVMs) are uncommon cerebral lesions that can cause significant neurological complications. Surgical resection is the gold standard for treatment, but endovascular embolization and stereotactic radiosurgery (SRS) are viable alternatives.ObjectiveTo compare the outcomes of endovascular embolization versus SRS in the treatment of AVMs with Spetzler-Martin grades I–III.MethodsThis study combined retrospective data from 10 academic institutions in North America and Europe. Patients aged 1 to 90 years who underwent endovascular embolization or SRS for AVMs with Spetzler-Martin grades I–III between January 2010 and December 2023 were included.ResultsThe study included 244 patients, including 84 who had endovascular embolization and 160 who had SRS. Before propensity score matching (PSM), complete obliteration at the last follow-up was achieved in 74.5% of the SRS group compared with 57.8% of the embolization group (OR=0.47; 95% CI 0.26 to 0.48; P=0.01). After propensity score matching, SRS still achieved significantly higher occlusion rates at last follow-up (78.9% vs 55.3%; OR=0.32; 95% CI 0.12 to 0.90; P=0.03).Hemorrhagic complications were higher in the embolization group than in the SRS group, although this difference did not reach statistical significance after PSM (13.2% vs 2.6%; OR=5.6; 95% CI 0.62 to 50.47; P=0.12). Similarly, re-treatment rate was higher in the embolization group (10.5% vs 5.3%; OR=2.11; 95% CI 0.36 to 12.31; P=0.40) compared with the SRS group.ConclusionOur findings indicate that SRS has a significantly higher obliteration rate at last follow-up compared with endovascular embolization. Also, SRS has a higher tendency for fewer hemorrhagic complications and lower re-treatment rate. Further prospective studies are needed

Seizure presentation and incidence-associated factors in treated cerebral arteriovenous malformations: a secondary analysis of the MISTA consortium

Seizures occur in 20-45% of patients with cerebral arteriovenous malformations (AVMs) and can potentially influence their quality of life. Some studies have suggested risk factors influencing their development, but the evidence is limited to small cohorts. To analyze seizure presentation and factors influencing seizure development in patients with cerebral AVMs using a multi-institutional consortium. Retrospective multicenter registry from multiple centers in North America and Europe of patients aged 1 to 89 years who had undergone any intervention for brain AVMs between January 2010 and December 2023. Demographics, functional assessment (modified Rankin Scale; mRS), and AVM characteristics, were evaluated to assess for relationship with seizures using a multivariate generalized linear mixed-effects model. 1,005 AVM patients were analyzed; the median age was 42, 73% had a baseline mRS ≤ 2. The median nidus size was 2.2 cm, and most AVMs were Spetzler-Martin grade II (37%). Seizure was the presenting symptom in 237 patients (24%). After adjusting for significant variables, patient-specific factors associated with seizures were younger age (OR 0.99, CI95% 0.98-1), male sex (OR 1.65, CI95% 1.18-2.30), and smoking history (OR 1.69, CI95% 1.17-2.44). AVM-specific factors associated with seizures included rupture status (OR 0.42, CI95% 0.30-0.61); eloquent cortex (OR 1.61, CI95% 1.13-2.29); frontal (OR 1.54, CI95% 1.01-2.35), temporal (OR 1.93, CI95% 1.26-2.96) and parietal (OR 1.71 CI95% 1.08-2.71) location; larger nidal size (OR = 1.23, CI95% 1.08-1.39), and superficial draining vein location (OR 1.86, CI95% 1.15-3.01). In this multicenter consortium, after controlling for significant variables, the incidence of AVM-related seizures was associated with younger age, male sex, smoking history, larger AVMs, eloquent locations, and AVMs in the frontal, temporal, and parietal cortices. Conversely, rupture status, deep venous drainage, and cerebellar locations were negatively associated with seizures

Comparing stand-alone endovascular embolization versus stereotactic radiosurgery in the treatment of arteriovenous malformations with Spetzler-Martin grades I-III: a propensity score matched study.

BACKGROUND: Arteriovenous malformations (AVMs) are uncommon cerebral lesions that can cause significant neurological complications. Surgical resection is the gold standard for treatment, but endovascular embolization and stereotactic radiosurgery (SRS) are viable alternatives. OBJECTIVE: To compare the outcomes of endovascular embolization versus SRS in the treatment of AVMs with Spetzler-Martin grades I-III. METHODS: This study combined retrospective data from 10 academic institutions in North America and Europe. Patients aged 1 to 90 years who underwent endovascular embolization or SRS for AVMs with Spetzler-Martin grades I-III between January 2010 and December 2023 were included. RESULTS: The study included 244 patients, including 84 who had endovascular embolization and 160 who had SRS. Before propensity score matching (PSM), complete obliteration at the last follow-up was achieved in 74.5% of the SRS group compared with 57.8% of the embolization group (OR=0.47; 95% CI 0.26 to 0.48; P=0.01). After propensity score matching, SRS still achieved significantly higher occlusion rates at last follow-up (78.9% vs 55.3%; OR=0.32; 95% CI 0.12 to 0.90; P=0.03).Hemorrhagic complications were higher in the embolization group than in the SRS group, although this difference did not reach statistical significance after PSM (13.2% vs 2.6%; OR=5.6; 95% CI 0.62 to 50.47; P=0.12). Similarly, re-treatment rate was higher in the embolization group (10.5% vs 5.3%; OR=2.11; 95% CI 0.36 to 12.31; P=0.40) compared with the SRS group. CONCLUSION: Our findings indicate that SRS has a significantly higher obliteration rate at last follow-up compared with endovascular embolization. Also, SRS has a higher tendency for fewer hemorrhagic complications and lower re-treatment rate. Further prospective studies are needed

Efficacy and safety of preoperative embolization in surgical treatment of brain arteriovenous malformations: a multicentre study with propensity score matching

Brain arteriovenous malformations (AVMs) are abnormal connections between feeding arteries and draining veins, associated with significant risks of haemorrhage, seizures and other neurological deficits. Preoperative embolization is commonly used as an adjunct to microsurgical resection, with the aim of reducing intraoperative complications and improving outcomes. However, the efficacy and safety of this approach remain controversial. This study is a subanalysis of the Multicenter International Study for Treatment of Brain AVMs consortium. We retrospectively analysed 486 patients with brain AVMs treated with microsurgical resection between January 2010 and December 2023. Patients were divided into two groups: those who underwent microsurgery alone (n=245) and those who received preoperative embolization, followed by microsurgery (n=241). Propensity score matching was employed, resulting in 288 matched patients (144 in each group). The primary outcomes were rates of complete AVM obliteration and functional outcomes (measured by the modified Rankin Scale (mRS)). Secondary outcomes included complication rates, mortality, hospital length of stay and postsurgical rupture. After matching, the complete obliteration rate was 97% with no significant difference between the microsurgery-only group and the preoperative embolization group (p=0.12). The proportion of patients with an mRS score of 0-2 at the last follow-up was similar in both groups (83% vs 84%; p=0.67). The median hospital stay was significantly longer for the embolisation group (9 days vs 7 days; p=0.017). Complication rates (24% vs 22%; p=0.57) and mortality rates (4.9% vs 2.1%; p=0.20) were comparable between the two groups. No significant differences were observed in postsurgical rupture, recurrence or retreatment rates. In this large multicentre study, preoperative embolization did not significantly improve AVM obliteration rates, functional outcomes or reduce complications compared with microsurgery alone