With appropriate attention to surgical technique, a saphenous vein extracranial-to-intracranial bypass followed by acute parent vessel occlusion is a safe and effective method of treating giant intracranial aneurysms. A high rate of graft patency and adequate cerebral blood flow can be achieved. Thrombosis of perforating arteries caused by altered blood flow hemodynamics after parent vessel occlusion may be a continuing source of complications.

Endovascular therapy of cerebral arteriovenous malformations (AVM's) is an accepted adjunct to surgical therapy. However, the literature has not characterized the benefits or the liabilities of preoperative embolization. This series compares two groups of patients who underwent surgical resection of a cerebral AVM; one group (20 patients) received preoperative transfemoral selective embolization with N-butyl cyanoacrylate (NBCA) and the other group (13 patients) did not. In the group with preoperative embolization, the AVM's were larger (3.9 vs. 2.3 cm) and of a higher Spetzler-Martin grade (3.2 vs. 2.5) as compared to the nonembolized group. The NBCA embolization facilitated surgical resection. Arteries supplying the vascular malformation were readily distinguished from those supplying the normal brain parenchyma. Embolized vessels were compressible and easily cut with microscissors. No bleeding occurred from transected vessels. Operative time and intraoperative blood loss for the two groups were not statistically different, despite the significant differences in lesion size and grade. Endovascular complications included immediate and delayed hemorrhage (15%) and transient ischemia (5%); there were no embolization-related deaths. Postoperative complications for both groups included hemorrhage (15%), residual AVM (6%), and cerebrospinal fluid leak (3%); the mortality rate was 3%. There was no statistically significant difference in surgical complications between the embolized and nonembolized groups. Most patients (91%) in both groups had an excellent or good late neurological outcome, with no significant difference between the groups. This study concludes that preoperative NBCA embolization of AVM's makes lesions of larger size and higher grade the surgical equivalent of lesions of smaller size and lower grade by reducing operative time and intraoperative blood loss, with no statistically significant difference in surgical complications or long-term neurological outcome.

Staged-volume radiosurgery for AVMs larger than 15 mL is a viable treatment strategy. The long-term occlusion rate is high, whereas the radiation-related complication rate is low. Hemorrhage during the lag period remains the greatest source of morbidity and mortality.

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