I'm going to invite Martin Sámez to come while Francisco González fixes these slides. Martin is going to talk to us about their series in Czech Republic on unraptured AVMs for almost, I think, a 15-year review. Thank you for coming, Martin. Thank you. How can I skip out of this? He's going to load your talk. Do you need him to click something? It's coming up. Excellent. There you go. Thank you very much for the invitation. I would like to speak shortly about our results of unraptured AVM. And the aim of our study is the outcomes of our surgery. And second, compare our results with Aruba. Aruba, where the morbidity mortality was very high, 30%, which is unacceptable for us. Our department is in Europe, in Czech Republic, and we did, within 18 years, 77 AVMs, 50 raptured and 27 unraptured. Very important is age distribution. You see that AVM, this is for young people, and we need studies with follow-up 20s, 30s, not 3rd or 5 years like Aruba. Our setting for patients, we have a majority of male. We do operate, especially Martin, grade 1 and 2, exceptionally for easier grade 3. And the presentation shortly, majority of patients epileptic seizures, localization. We have all lobes and even in the posterior fossa. And most common fields are from MCA, ACA, and PCA. What about embolization preoperative? We did, within these years, and we recognize it is no beneficial. So since 2010, we doesn't use the preoperative embolization. And shortly, results. Our special Martin grade 1, before surgery, modified ranking score, and after surgery, all patients better or same. Special Martin grade 2, we have one patient with better results. I will analyze later. Grade 3, before and after, good results. And one case, 4, before and after, also good results. So summary of our results, we have good results, but one patient is worse with modified ranking score, 5. So we have morbidity mortality 3.7, which is in accordance with literature. And four nice cases with good results. AVM grade 3 in the primary motoric area with aneurysm in venous area. So we do like tumors. So we identify motoric, primary motoric area, and then DTI. And we use also preoperative stimulation. And if we are not sure when the artery goes inside the AVM or it's artery for primary motoric area, so we do temporary clip. We measure MEP, and if it's okay, then we coagulate this vessel. Good eradication and good follow-up. Relatively easy AVM in posterior fossa. Feeders are from all SCA, ICA, PICA. Good result of the surgery. Very difficult case with the nidus going to the kaput nuclei caudate. MEP decreased 50%. We tolerate 50%, so we did radical surgery, and the patient recovered good. And last case in eloquent area in occipital lobe, feeders from MCA, PCA, interhemispherical approach, and good result. This is our only case with bad result. It was low-flow AVM with very small vessels. It was not able to coagulate this vessel, so we had hemorrhage. And after revision, we had also problem with the coagulation, and this is our bad case. And last case, how important grade specimen 2, how important it is to study the preoperative AVM. It looks like very easy. So we plan to clip this main feeder and then eradicate the AVM, and we can cut the venous to the temporal lobe because this is one compartment, and we have the second veins to the sigmoid sinus. So shortly the surgery, we clipped the main feeder from MCA, big, very dilated. There is no problem, very nice border of the nidus. No difficulties, grade 2. Circumferential dissection according to Yasargil, of course. Then we cut the first vein because we have the second one, and it is only one compartment, so no problem with the venous drainage. And after eradication, we cut and remove the AVM. But after this, we had problem because in the bed of the resection, we have severe bleeding, and this bleeding was from the... Could we go to the next slide? So it's very important to understand the DSA. You can see the small vessel here feeding that goes to the deep part of the AVM, so it was necessary to coagulate also this vessel, not only the main feeder because it not goes to the healthy gyrus, but it's involved in the AVM. So after coagulating this small artery was successful removing of the AVM. Nice postoperative DSA and nice MRI. So this is our series with comparable results of all surgical series. And now short criticism of the ARUBA in five points. We have good literature about natural history of the AVMs. We know about superficial, deep AVM, and the drainage, deep drainage or not, between 1% and 8% of the natural history. And we have good material for discussing with patients about natural history and surgery. But still ARUBA appears, but the aim of the study was only five years of follow-up. Five years of follow-up, which is unmeaningful for us. There was 104 centers in the U.S. and Europe. It was originally designed, and the plan was medical management group risk of 12% and for international therapy 22%. But the primary hypothesis was that medical management improved the long-term outcome compared to international therapy, irrespective of whether it is a microsurgery, radiosurgery, and endovascular, which is also very unmeaningful for us. Exclusion criteria, and this is most important slide about results. They collect only 200 patients, and the enrollment was halted because the interim analysis showed threshold for safety was met, and the international group had 30% of the complications, which is very high, and it's very unacceptable for us. We can now criticize in five points. First point, that is 87% was excluded, so the generalizability of the study is very low. The second, the event drain in the international group is extremely high, but only one picture analyzed these problems. It's very, very shallow. And in discussion, they argue that this paper has a very similar complications rate, but it's not true because it's bled and unbled together. And when we look in the literature, the unbled AVM in this paper, it's very, very lower than they argue. Number three, very different therapeutic modalities are together lumped because 80% of the patients are treated by stereotactic radiosurgery or embolization. And this favor medical treatment because after treatment, the embolization and radiosurgery has a 10-time more bleeding after treatment because obliteration after embolization and after radiosurgery, it's very, very low comparing with surgery. And point number four, 70% of the patients in the study is grade one and two, for which is gold standard, it's radiosurgery. So neurosurgery in this study is only 5%, and ARUBA, therefore, is inadequate to draw any conclusions for us. And last point, number five, the five-year follow-up, it's not long-term and unusable for us because we need clinical decision-making for 20, 30, 40 years because this is illness for young patients. So we can conclude that this study where 70% is grade one, two, it's inadequate, and microsurgery, as monotherapy, it's represented only in 5% of patients. The second, only long-term follow-up, it's meaningful for us, and ARUBA is not designed for this. One positive impact could be for France because we know that all AVM and autism, they treat endovascularly. So maybe ARUBA is good point that France should change this policy because the small AVM should be treated by microsurgery, not embolization. Problem of evidence-based in very shallow analysis, many people say, oh, it's the end of the AVM surgery, but not. After thorough analysis, we see that special material one and two should be operated, and medical treatment conservative, it's better than radiosurgery or embolization, according to this study. We know natural history. We know very high morbidity, mortality after radiosurgery, embolization. So microsurgery is solution for this small AVMs. And according to ARUBA, the CROSS will come after 15 years, which is very long time, but if we use our results or results from literature, we can see that CROSS is after two years. So when we speak with the patients with uninterrupted aneurysm, we can say that after two years, we have less risk of the complication than natural history. And we can summarize that ARUBA after three years follow-up, and when we summarize it together with studies or our department or many, many papers from these institutions, so we can conclude that AVM special material one and two should be indicated for microsurgery with risk about 4%. If we choose medical management for a small AVM, we bring problems in about 10% after three years, and if we choose radiosurgery or embolization, we treat with risk of the 30%. Thank you for your attention. Thank you. Kiko, why don't we help him set up while we're asking questions. Any questions from the audience? Thank you very much for the beautiful presentation, which is, in my opinion, is a curveball in AVM surgery. We, for years, have lost the technique and lost the drive to do the AVMs primarily, and we all relied on endovascular treatment, which many times has caused complications which have not been reported. And also death to the patients when the low-flow AVMs are converted to high-flow AVMs. And these kind of articles or presentations will give us a new thinking, which was established 40 years back by Ben Stein. So I think you are very bold to present this paper in this direction in this age when endovascular has taken over these treatment protocols. Thank you. Okay. You had a question. Have you noticed difficulty since you stopped using embolization? Has it changed? You have an opportunity to compare two phases after 2010 and before. What do you think your gut feeling of the results? No difference in the results, but our feeling was that it was not beneficial for us because we saw some big vessels was embolized, but for the surgery it was not an advantage. So we stopped it because you still have many, many small vessels which you should coagulate, and that this helps with endovascular embolization brings only more morbid mortality, because each embolization brings about 1 percent of risk. Nirav, please, you have a question, and you also give us your perspective. You did your fellowship with Michael Morgan and so forth. Thank you very much. I agree that Aruba gave us the opportunity to understand that endovascular intervention on AVMs is counterproductive, and that is definitely proven in that RCT. And I myself like to operate AVMs without embolization because I think, as Professor Morgan has shown, that surgical risk plus embolization risk is higher than surgical risk alone. You can't change the eloquence or the deep venous system by embolizing it. You cannot change that. The opportunity for us going forward is to, as one gentleman said, practice surgical embolization and utilize our surgical techniques to remove arteriovenous malformations. Maybe I would just add that Morgan suggests that we go to the bottom of the AVM first. Like you showed that case, the deep arterial feeder was what caused the issue. If we could get there early in the operation before the venous outflow is obstructed, that would be a challenge, but I think that's the way to go forward. Okay.

arteriovenous malformations

Czech Republic

surgical outcomes

epileptic seizures

microsurgery