Since Yaşargil pioneered the use of the operating microscope in the 1960s, microscopes have improved dramatically with regard to optics, illumination, and ease of use. Perhaps the most significant recent advance has been the seamless incorporation of indocyanine green angiography. Killory et al73 published their review of 10 consecutive AVM surgeries during which they used indocyanine green angiography. Intraoperative indocyanine green angiography was able to detect 1 of 2 residual AVMs confirmed by intraoperative DSA. We routinely use indocyanine green angiography at various stages of resection to assess the status of arteriovenous shunting and the overall transit time through the AVM. This advance is likely the tip of the iceberg. It is possible that contrast imaging techniques will be used to give the surgeon dynamic information on brain perfusion and arteriovenous shunting through the microscope. The incorporation of image guidance and 3-D imaging will also likely merge with the microscope, giving the surgeon a heads-up display of important anatomic information. This has the potential to dramatically facilitate the surgeon's understanding of the complex 3-D architecture of an AVM. The ability of a surgeon to preserve en passant vessels could be greatly aided by such an advance. Additionally, micro-Doppler and flow probe technologies may allow the surgeon to gauge hemodynamic changes throughout the operation as well.74
Over the past decade, multiple enhancements in microinstrumentation have been geared at AVM surgery. One challenge with resecting AVMs is having the bipolar tips become adherent to fragile AVM tissue. Recent advances in coating technologies have made this less of an issue.75 Adding illumination to bipolar instrumentation has also been recently described. Additionally, AVM clips have been enhanced over the past decade.
The physical separation of high-end radiology equipment from the operating room has always been a barrier to image-guided surgery. This has been particularly true for surgeries such as AVM resection in which postoperative imaging can dictate a return to the operating room. This led to a growing need to integrate CT, MR, and DSA technologies into the operating theater, which has culminated in the creation of hybrid operating rooms. One such operating room suite is the IMRIS, which was recently developed by J.M. Keckler Medical Co (Figure 9A and 9B). Such operative rooms will enhance surgical precision and safety and reduce returns to the operating room.
Tailored cranial base approaches and endoscopic techniques may play a role in the future of AVM management.76 The orbitozygomatic approach, various transtemporal approaches, and the far lateral approach may enhance the safety of exposure of deep-seated lesions.77,78 Less reliance on retractors may also enhance outcomes.79 It is important here to distinguish brain compression by a retractor and the strategic use of a retractor to hold brain, which is already relaxed out of the way.
Despite all advances in tools and techniques, outcomes of AVM surgeries remain operator dependent. Simulation, if integrated into a curriculum with strong mentorship, may be one mechanism by which skills can be improved.80 The complexity of AVMs has made simulation difficult, but advances in 3-D printing and holographic technologies with haptic feedback may overcome challenges. Holography, which is the 3-D projection of the AVM into space, might help the surgeon understand the anatomic and hemodynamic characteristics of the AVM in all directions. Holographic projection is still in its very early developmental stage; medical applications remain restricted only to few case reports, and applications even outside medicine remain scarce.81,82 Currently, 3-D printing is used to print 3-D biological scaffolds.83 Other applications, although rare, include printing of DICOM (digital imaging and communications in medicine) files.84 Despite being a very new technology, 3-D printing might in the future provide the surgeon with the ability to practice a surgical operation as many times as deemed necessary before doing it on a patient.
Recent data suggest that neurosurgical patient outcomes can be enhanced by specialized neurological intensive care units where physicians and nurses have significant experience with neurosurgical pathologies.85 Blood pressure control is important in the postoperative period after AVM resection because surrounding brain tissue may be prone to hemorrhage until autoregulation has been restored. Postresection hyperemia is a unique complication caused by loss of autoregulation, and care should be taken to meticulously ensure hemostasis during surgery. Additionally, it is important to have a comprehensive strategy for deep venous thrombosis prophylaxis and medical complication avoidance. To reduce radiation exposure, we have recently shifted to using MRI preferentially for postoperative monitoring rather than CT. A postoperative angiogram is essential to rule out any residual AVM, which could be a risk for rehemorrhage.
AVMs are an important cause of hemorrhagic stroke in young individuals. Surgery remains the most versatile and curative option for many patients with AVMs. AVM microsurgery is a vibrant field that has seen exciting advances in the past 2 decades, with many advances yet to come. Continued innovations in the science of precision medicine, imaging, intraoperative technologies, simulation, neuroanesthesia, rehabilitation, and the science of outcomes assessment will likely enhance outcomes and refine indications. Concurrent advances in radiosurgery and endovascular techniques are creating new opportunities to treat more AVMs with microsurgery with lower morbidity and better outcomes.
The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.
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