Treatment of high-grade brain arteriovenous malformations using a hybrid operating room: A prospective single-arm study.

BACKGROUND: Optimal treatment of patients with high Spetzler-Martin (S-M) grade brain arteriovenous malformations (BAVMs) remains controversial. Few studies have investigated outcomes in such patients treated in a hybrid operating room (hOR). OBJECTIVE: To examine outcomes of one-stop hybrid BAVM treatment in patients with high-grade lesions. METHODS: We prospectively enrolled patients with high-grade BAVMs (S-M grade ≥3) aged 18-65 years who underwent one-stop hybrid BAVM treatment at our hospital between October 2016 and March 2021. High-grade BAVM patients who underwent surgery from 2010 to 2016 served as historical controls. RESULTS: Forty-one high-grade BAVM patients underwent one-stop hybrid treatment in a hOR. Sixty-one propensity score-matched patients comprised the historical control group. The groups did not significantly differ in patient and BAVM characteristics. Intraoperative angiography in four patients of the hOR group demonstrated residual nidus that required further immediate resection. Main procedural complications included hemorrhage, neurologic deficit, and seizure. In the historical control group, diffuse angioarchitecture and arteriovenous fistula were independent risk factors for incomplete resection. CONCLUSIONS: One-stop hybrid BAVM treatment is safe and effective for removal of high-grade BAVMs, especially those with diffuse or complex angioarchitecture. Preoperative embolization can effectively reduce blood flow while preserving motor and language function. The combined application of functional magnetic resonance imaging, electrophysiological monitoring, and awake craniotomy can successfully avoid causing neurological injury.