Intraoperative DSA for residual nidus detection during microsurgical resection of low-grade brain arteriovenous malformations: a single-center case series

This study evaluated the feasibility of intraoperative digital subtraction angiography (DSA)-assisted microsurgical resection for Spetzler-Martin (SM) grade I-II brain arteriovenous malformations (bAVMs) in a hybrid operating room and assessed its potential value for intraoperative residual nidus detection and immediate management. We retrospectively analyzed 12 patients with SM grade I-II bAVMs who underwent intraoperative DSA-assisted microsurgical resection in the hybrid operating room of our hospital between June 2019 and June 2023. All patients were diagnosed by preoperative DSA and had not received endovascular embolization or stereotactic radiosurgery before surgery. Intraoperative DSA was routinely incorporated into the surgical workflow, with additional angiographic assessments performed according to intraoperative findings and surgical progress. Global functional status was assessed using the modified Rankin Scale (mRS), together with review of documented neurological examinations for new or worsened focal neurological deficits. Intraoperative DSA showed no residual nidus in 10 patients and identified a residual nidus in 2 patients, both of whom underwent additional resection during the same operation. Completion DSA confirmed no definite residual nidus in any patient. The median intraoperative blood loss was 150 mL (IQR, 117.5–197.5 mL; range, 100–300 mL). No major postoperative complications were observed within 30 days after surgery. At the 6-month follow-up, mRS scores were 0 in 10 patients, 2 in 1 patient, and 3 in 1 patient, and DSA confirmed no residual nidus in all 12 patients. This single-center feasibility case series suggests that intraoperative DSA-assisted microsurgical resection of SM grade I–II bAVMs in a hybrid operating room is technically feasible and can provide angiographic information for residual nidus detection and immediate supplementary resection. Because this study was small and uncontrolled, no comparative conclusions regarding clinical outcomes or advantages over conventional microsurgery can be drawn.