Role of i-CT, i-US, and Neuromonitoring in Surgical Management of Brain Cavernous Malformations and Arteriovenous Malformations: A Case Series

We retrospectively reviewed the institutional experience in patients who underwent microsurgical resection of cavernous malformations (CMs) or arteriovenous malformations (AVMs) using a multimodal intraoperative protocol including neuronavigation, intraoperative ultrasound (i-US), computed tomography (i-CT), and neuromonitoring. Twenty-four patients (14 male), with a mean age of 47.5 years (range 27−73), have been included: 20 of them suffered from CMs and 4 suffered from AVMs. Neuromonitoring was used in 18 cases, when lesions were located in eloquent areas; 2 patients underwent awake craniotomy. First, an i-CT scan with and without contrast was acquired after patient positioning. Navigated B-mode ultrasound acquisition was carried out after dural opening to identify the lesion (CMs or AVMs nidus). Following identification and resection of vascular lesions, postcontrast i-CT (or CT-angio) was performed to detect and localize any small or calcified remnant (in cases of CMs) or residual vessels feeding the nidus (in cases of AVMs). In 5 cases of CMs and in 1 case of AVM, i-CT identified small residual lesions. In these cases, new i-CT images were uploaded into the navigation system and used for further resection. i-US was useful before starting transsulcal or transcortical approach to identify the lesions and guide the trajectory of the approach. However, several artifacts were observed during subsequent steps of dissection, making image interpretation difficult. The combination of different intraoperative real-time imaging modalities (i-CT and i-US), coupled with neuromonitoring, in the surgical management of vascular lesions, particularly if located in eloquent areas, has a positive impact on clinical outcome.