Normal Perfusion Pressure Breakthrough Following AVM Resection: A Case Report and Review of the Literature

T. E. O’Connor, K. M. Fargen, J. Mocco

College of Medicine, University of Florida, Gainesville, USA.
Department of Neurological Surgery, University of Florida, Gainesville, USA.
Department of Neurological Surgery, Vanderbilt University, Nashville, USA.

DOI: 10.4236/ojmn.2013.34015                

Abstract

Objective: To report a patient’s clinical course illustrative of the NPPB mechanism for hyperperfusion-induced injury. Methods: A 65-year-old female presented with a severe headache and was found to have a 6-cm right parietal AVM on imaging. The patient underwent staged, pre-operative embolization and the AVM was surgically resected without intra-operative complication. After the patient emerged from anesthesia she exhibited left hemiplegia and hemispatial neglect. Her systolic blood pressure (SBP) at that time was between 110-120 mmHg. SBP was reduced to 90-100 mmHg and the patient’s symptoms resolved shortly thereafter. The patient’s strict blood pressure goal was relaxed the next morning. However, with her SBP 110-120 mmHg in the ensuing hours, the patient’s left-sided neglect and hemiparesis returned. Her SBP was reduced again to 90-100 mmHg, leading to resolution of her symptoms. Results: This patient’s clinical course supports the NPPB theory of hyperperfusion-induced injury. Despite CT imaging demonstrating no residual AVM following resection, the patient developed neurological deficits in the immediate postoperative period. Aggressive systemic hypotension improved clinical symptoms repeatedly, whereas a brief period of normotension triggered a return of neurological deficits. As a result, there was a direct correlation between fluctuations of neurological status and SBP. This case suggests that the intrinsic autoregulatory capacity was altered in our patient, and that aggressive hypotension was necessary to compensate for diminished autonomic reactivity. Conclusions: This case provides further evidence that NPPB plays a role in hyperperfusion-induced injury following AVM excision and that blood pressure control is vital in managing hyperemic complications following complete resection of cerebral AVMs.

Keywords

Blood Pressure; Hemorrhage; Intracranial Arteriovenous Malformations; Normal Perfusion Pressure Breakthrough

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	W. A. Friedman, D. L. Blatt, F. J. Bova, J. M. Buatti, W. M. Mendenhall and P. S. Kubilis, “The Risk of Hemorrhage after Radiosurgery for Arteriovenous Malformations,” Journal of Neurosurgery, Vol. 84, No. 6, 1996, pp. 912-919. http://dx.doi.org/10.3171/jns.1996.84.6.0912
[2]	D. Kondziolka, J. C. Flickinger and L. Dade Lunsford, “Clinical Research in Stereotactic Radiosurgery: Lessons Learned from over 10,000 Cases,” Neurological Research, Vol. 33, No. 8, 2011, pp. 792-802. http://dx.doi.org/10.1179/1743132811Y.0000000034
[3]	S. L. Ondra, H. Troupp, E. D. George and K. Schwab, “The Natural History of Symptomatic Arteriovenous Malformations of the Brain: A 24-Year Follow-Up Assessment,” Journal of Neurosurgery, Vol. 73, No. 3, 1990, pp. 387-391. http://dx.doi.org/10.3171/jns.1990.73.3.0387
[4]	D. J. Englot, W. L. Young, S. J. Han, C. E. McCulloch, E. F. Chang and M. T. Lawton, “Seizure Predictors and Control after Microsurgical Resection of Supratentorial Arteriovenous Malformations in 440 Patients,” Neurosurgery, Vol. 71, No. 3, 2012, pp. 572-580. http://dx.doi.org/10.1227/NEU.0b013e31825ea3ba
[5]	R. F. Spetzler and N. A. Martin, “A Proposed Grading System for Arteriovenous Malformations,” Journal of Neurosurgery, Vol. 65, No. 4, 1986, pp. 476-483. http://dx.doi.org/10.3171/jns.1986.65.4.0476
[6]	M. G. Hamilton and R. F. Spetzler, “The Prospective Application of a Grading System for Arteriovenous Malformations,” Neurosurgery, Vol. 34, No. 1, 1994, pp. 2-6. http://dx.doi.org/10.1227/00006123-199401000-00002
[7]	M. K. Morgan, M. Winder, N. S. Little, S. Finfer and E. Ritson, “Delayed Hemorrhage Following Resection of an Arteriovenous Malformation in the Brain,” Journal of Neurosurgery, Vol. 99, No. 6, 2003, pp. 967-971. http://dx.doi.org/10.3171/jns.2003.99.6.0967
[8]	R. F. Spetzler, C. B. Wilson, P. Weinstein, M. Mehdorn, J. Townsend and D. Telles, “Normal Perfusion Pressure Breakthrough Theory,” Clinical Neurosurgery, Vol. 25, 1978, pp. 651-672.
[9]	N. R. Al-Rodhan, “Occlusive Hyperemia Remains the Most Logical Explanation for the Hemodynamic Complications of Resected Intracerebral Arteriovenous Malformations,” Journal of Neurosurgical Anesthesiology, Vol. 7, No. 3, 1995, pp. 208-210. http://dx.doi.org/10.1097/00008506-199507000-00019
[10]	M. D. Alexander, E. S. Connolly and P. M. Meyers, “Revisiting Normal Perfusion Pressure Breakthrough in Light of Hemorrhage-Induced Vasospasm,” World Journal of Radiology, Vol. 2, No. 6, 2010, pp. 230-232. http://dx.doi.org/10.4329/wjr.v2.i6.230
[11]	W. L. Young, I. Prohovnik, E. Ornstein, N. Ostapkovich, M. B. Sisti, R. A. Solomon and B. M. Stein, “The Effect of Arteriovenous Malformation Resection on Cerebrovascular Reactivity to Carbon Dioxide,” Neurosurgery, Vol. 27, No. 2, 1990, pp. 257-266. http://dx.doi.org/10.1227/00006123-199008000-00015
[12]	W. L. Young, A. Kader, I. Prohovnik, E. Ornstein, L. H. Fleischer, N. Ostapkovich, L. D. Jackson and B. M. Stein, “Pressure Autoregulation Is Intact after Arteriovenous Malformation Resection,” Neurosurgery, Vol. 32, No. 4, 1993, pp. 491-496. http://dx.doi.org/10.1227/00006123-199304000-00001
[13]	T. F. Massoud, G. J. Hademenos, W. L. Young, E. Gao and J. Pile-Spellman, “Can Induction of Systemic Hypotension Help Prevent Nidus Rupture Complicating Arteriovenous Malformation Embolization? Analysis of Underlying Mechanism Achieved Using a Theoretical Model,” American Journal of Neuroradiology, Vol. 21, No. 7, 2000, pp. 1255-1267.
[14]	N. R. Al-Rodhan, T. M. Sundt Jr., D. G. Piepgras, D. A. Nichols, D. Rufenacht and L. N. Stevens, “Occlusive Hyperemia: A Theory for the Hemodynamic Complications Following Resection of Intracerebral Arteriovenous Malformations,” Journal of Neurosurgery, Vol. 78, No. 2, 1993, pp. 167-175. http://dx.doi.org/10.3171/jns.1993.78.2.0167
[15]	L. H. Sekhon, M. K. Morgan and I. Spence, “Normal Perfusion Pressure Breakthrough: The Role of Capillaries,” Journal of Neurosurgery, Vol. 86, No. 3, 1997, pp. 519-524. http://dx.doi.org/10.3171/jns.1997.86.3.0519
[16]	J. Tu, M. A. Stoodley, M. K. Morgan and K. P. Storer, “Ultrastructure of Perinidal Capillaries in Cerebral Arteriovenous Malformations,” Neurosurgery, Vol. 58, No. 5, 2006, pp. 961-970. http://dx.doi.org/10.1227/01.NEU.0000210248.39504.B5
[17]	J. Z. Zhao, S. Wang, J. S. Li, D. L. Sui, Y. L. Zhao and Y. Zhang, “Combination of Intraoperative Embolisation with Surgical Resection for Treatment of Giant Cerebral Arteriovenous Malformations,” Journal of Clinical Neuroscience, Vol. 7, Suppl. 1, 2000, pp. 54-59. http://dx.doi.org/10.1054/jocn.2000.0713
[18]	H. Kinouchi, K. Mizoi, A. Takahashi, M. Ezura and T. Yoshimoto, “Combined Embolization and Microsurgery for Cerebral Arteriovenous Malformation,” Neurologia Medico-Chirurgica (Tokyo), Vol. 42, No. 9, 2002, pp. 372-378. http://dx.doi.org/10.2176/nmc.42.372
[19]	K. Ogasawara, K. Yoshida, Y. Otawara, M. Kobayashi, S. Yasuda, M. Doi and A. Ogawa, “Cerebral Blood Flow Imaging in Arteriovenous Malformation Complicated by Normal Perfusion Pressure Breakthrough,” Surgical Neurology, Vol. 56, No. 6, 2001, pp. 380-384. http://dx.doi.org/10.1016/S0090-3019(01)00655-3
[20]	G. H. Barnett, J. R. Little, Z. Y. Ebrahim, S. C. Jones and H. T. Friel, “Cerebral Circulation during Arteriovenous Malformation Operation,” Neurosurgery, Vol. 20, No. 6, 1987, pp. 836-842. http://dx.doi.org/10.1227/00006123-198706000-00003
[21]	W. L. Young, A. Kader, E. Ornstein, K. Z. Baker, N. Ostapkovich, J. Pile-Spellman, P. Fogarty-Mack and B. M. Stein, “Cerebral Hyperemia after Arteriovenous Malformation Resection Is Related to ‘Breakthrough’ Complications but Not to Feeding Artery Pressure. The Columbia University Arteriovenous Malformation Study Project,” Neurosurgery, Vol. 38, No. 6, 1996, pp. 1085-1093. http://dx.doi.org/10.1227/00006123-199606000-00005
[22]	A. Kader and W. L. Young, “The Effects of Intracranial Arteriovenous Malformations on Cerebral Hemodynamics,” Neurosurgery Clinics of North America, Vol. 7, No. 4, 1996, pp. 767-781.
[23]	B. Meyer, C. Schaller, C. Frenkel, B. Ebeling and J. Schramm, “Distributions of Local Oxygen Saturation and Its Response to Changes of Mean Arterial Blood Pressure in the Cerebral Cortex Adjacent to Arteriovenous Malformations,” Stroke, Vol. 30, No. 12, 1999, pp. 2623-2630. http://dx.doi.org/10.1161/01.STR.30.12.2623
[24]	C. Schaller, H. Urbach, J. Schramm and B. Meyer, “Role of Venous Drainage in Cerebral Arteriovenous Malformation Surgery, as Related to the Development of Post-operative Hyperperfusion Injury,” Neurosurgery, Vol. 51, No. 4, 2002, pp. 921-927.
[25]	B. E. Zacharia, S. Bruce, G. Appelboom and E. S. Connolly Jr., “Occlusive Hyperemia versus Normal Perfusion Pressure Breakthrough after Treatment of Cranial Arteriovenous Malformations,” Neurosurgery Clinics of North America, Vol. 23, No. 1, 2012, pp. 147-151. http://dx.doi.org/10.1016/j.nec.2011.09.005
[26]	W. N. van Mook, R. J. Rennenberg, G. W. Schurink, R. J. van Oostenbrugge, W. H. Mess, P. A. Hofman and P. W. de Leeuw, “Cerebral Hyperperfusion Syndrome,” Lancet Neurology, Vol. 4, No. 12, 2005, pp. 877-888. http://dx.doi.org/10.1016/S1474-4422(05)70251-9
[27]	N. Khandelwal, “CT Perfusion in Acute Stroke,” Indian Journal of Radiology and Imaging, Vol. 18, No. 4, 2008, pp. 281-286. http://dx.doi.org/10.4103/0971-3026.43837
[28]	R. A. Vasquez, M. F. Waters, C. J. Skowlund, J. Mocco and B. L. Hoh, “Computed Tomographic Perfusion Imaging of Non-Hemorrhagic Cerebral Hyperperfusion Syndrome and Reversal Following Medical Treatment after Carotid Artery Angioplasty and Stenting,” Journal of Neurointerventional Surgery, Vol. 4, No. 3, 2012, p. e2. http://dx.doi.org/10.1136/jnis.2010.003558
[29]	C. H. Chang, T. Y. Chang, Y. J. Chang, K. L. Huang, S. C. Chin, S. J. Ryu, T. C. Yang and T. H. Lee, “The Role of Perfusion Computed Tomography in the Prediction of Cerebral Hyperperfusion Syndrome,” PLoS One, Vol. 6, No. 5, 2011, p. e19886. http://dx.doi.org/10.1371/journal.pone.0019886
[30]	C. Lundqvist, G. Wikholm and P. Svendsen, “Embolization of Cerebral Arteriovenous Malformations: Part II— Aspects of Complications and Late Outcome,” Neurosurgery, Vol. 39, No. 3, 1996, pp. 460-467.
[31]	M. K. Morgan, L. H. Sekhon, S. Finfer and V. Grinnell, “Delayed Neurological Deterioration Following Resection of Arteriovenous Malformations of the Brain,” Journal of Neurosurgery, Vol. 90, No. 4, 1999, pp. 695-701. http://dx.doi.org/10.3171/jns.1999.90.4.0695
[32]	I. Nakagawa, S. Kawaguchi, J. Iida, H. Hirabayashi and T. Sakaki, “Postoperative Hyperperfusion Associated with Steal Phenomenon Caused by a Small Arteriovenous Malformation,” Neurologia Medico-Chirurgica (Tokyo), Vol. 45, No. 7, 2005, pp. 363-366. http://dx.doi.org/10.2176/nmc.45.363