Helsinki Protocol for Postoperative Management of Arteriovenous Malformations

Patients with small, unruptured AVMs ofSpetzler-Martin grade 1 without surgical complications:

  • No need for a central venous catheter
  • Extubation in the operating room and follow-up in NICU
  • Normal blood pressure (SBP generally under 150 mmHg)
  • Strict fluid balance postoperatively
  • Antihypertensive medication if needed (vasodilating beta blocker or a calcium channel blocker) for 1 to 2 weeks postoperatively

Patients with medium to large AVMs without and small bAVMs with surgical complications or if ruptured preoperatively

  • Recovery from general anesthesia in NICU. According to the clinical evaluation, propofol dexmedetomidine sedation until the postoperative control imaging (CT-scan, DS- or CT angiogram) has been performed.
  • Head of bed elevation 15-30%
  • Restricted intravenous fluid administration postoperatively
  • Low SBP target (generally under 120-130 mmhlg) and avoidance of sudden increase in SBP
  • Labetalol, hydralazine and clonidine are used to lower blood pressure
  • Dexmedetomidine for sedation (0.2-1.5 ug/kg/h infusion)
  • Patient in NICU until stabilized, usually up to several days
  • Antihypertensive medication (a vasodilating beta blocker or a calcium channel blocker) for 1 to 2 weeks postoperatively

Patients with large AVMs

  • Placement of central venous catheter preoperatively
  • Propofol and/or dexmedetomidine sedation until the postoperative control imaging has been performed or even longer
  • Head of bed elevation 15-30%
  • Restricted intravenous fluid administration postoperatively
  • Avoidance of any sudden increase in SBP
  • Low SBP target: first under 90-110 mmhlg,then gradually increased 110 to 120 to 130 to 140 to 150 mmHg
  • Patient in NICU until stabilized, usually up to several days
  • Antihypertensive medication (a vasodilating beta blocker or a calcium channel blocker) for one to two weeks postoperatively

Figure. Delayed postoperative hemorrhage (DPH) by Spetzler Martin grade.

Reference:

Niini, T., Laakso, A., Tanskanen, P., Niemelä, M. and Luostarinen, T. (2019). Perioperative Treatment of Brain Arteriovenous Malformations Between 2006 and 2014: The Helsinki Protocol. Neurocritical Care.

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