Microsurgery of Cerebral Arteriovenous Malformations in a Resource-Limited Setting: The First Case-Series from Iraq.

[BACKGROUND] Cerebral arteriovenous malformations (AVMs) can lead to significant morbidity and are particularly challenging to manage in resource-limited settings where endovascular treatment modalities are unaffordable for most patients.

[OBJECTIVE] To describe the first case series of AVM from Iraq with an analysis of the related clinicoradiologic characteristics, operative features, and outcomes.

[METHODS] A single-center database from October 2018 to December 2022 was reviewed to analyze the characteristics of cerebral AVMs who underwent surgical treatment in Baghdad, Iraq. We collected patient demographics, clinical, radiologic, operative, and the follow-up combined outcome results (modified Rankin Scale score and the presence of AVM remnants).

[RESULTS] Of the 54 AVM patients treated with microsurgery, the majority of lesions have Spetzler-Martin grade of 3 (31.5%), followed by grade 1 (29.6%). The parietal lobe was the most common location of AVM in 25.9% of the cases, and the temporal location had better outcomes. The mean duration of surgery was 8.5 hours, ranging from 3 to 14 hours, with 20.3% of cases having undergone preoperative stereotactic radiosurgery, and just one patient received preoperative embolization. Good combined outcome (modified Rankin Scale 0-2 and no AVM remnant) was associated with lower SM grades (P=0.003); location in the nondominant hemisphere (P=0.036), and noneloquent regions (P=0.006); absence of deep venous drainage (P=0.042) and no intraoperative brain swelling (P=0.004). The mortality rate in our series was 5.5%.

[CONCLUSIONS] Good clinicoradiologic outcomes can be achieved through microsurgery in a setting where endovascular treatment is inaccessible to patients due to limited resources.