Elsevier

Surgical Neurology

Volume 50, Issue 3, September 1998, Pages 245-256
Surgical Neurology

Original Articles
Reflections on the management of cerebral arteriovenous malformations

https://doi.org/10.1016/S0090-3019(98)00082-2Get rights and content

Abstract

BACKGROUND The authors report their personal experience in the management of cerebral arteriovenous malformations (AVMs), using the three techniques now available: surgical resection, endovascular embolization, and radiosurgery. They review the recent literature on this topic and present their current management algorithm based on this experience.

METHODS A series of 90 patients treated for cerebral AVMs is reported (68% Grade I-III and 32% Grade IV-V, Spetzler scale). The three methods of treatment were used, either individually or in combination, based on the size and the location of the malformation. The first intervention was surgical resection in 26% of cases, endovascular embolization in 57%, and radiosurgery in 17%. Surgery and embolization were followed by another technique in some cases and eventually single modality treatment was used in 58% of cases (surgical resection 21%, endovascular embolization 20%, radiosurgery 17%) and multimodality treatment in 42% (embolization + resection, 21%; embolization + radiosurgery, 17%; resection + radiosurgery, 4%). Embolization was used as reductive therapy in 38% of the overall series (65% of all embolized patients), and was followed by surgery in 56% of cases or by radiosurgery in 44%. Angiography was used to assess the cure rates.

RESULTS The following cure rates were obtained, when each technique was used as a first treatment: surgical resection, 82%; embolization, 6%; and radiosurgery, 83% (2-year angiographic follow-up). After combined treatment, embolization and resection resulted in a 100% cure rate, embolization and radiosurgery produced a 90% cure rate. The clinical outcome was evaluated in terms of deterioration attributable to treatment. Seventy-one percent of patients had no complication, minor complications were observed in 18%, and severe complications in 11%. Treatment mortality was 3%. All deaths were attributable to hemorrhage during the embolization procedure.

CONCLUSIONS In this management algorithm, AVMs submitted directly to surgery or to radiosurgery were considered “good risk” malformations, and the outcome for these cases was good in terms of clinical result and cure rate. AVMs submitted first to endovascular embolization were considered “poor risk” malformations, including a majority of Spetzler Grade IV-V lesions. Not surprisingly, the majority of severe complications occured in this group during embolization. Thus, the major risk of the treatment of AVMs has now shifted from surgery to endovascular techniques. Endovascular embolization as sole treatment gave a low rate of complete occlusion, but proved to be very useful as a reductive therapy, in preparation for further surgery or radiosurgery. Partial embolization permitted high rates of complete cure in difficult AVMs. Embolization should be used to the maximum extent possible as a reductive technique, despite the risks of the procedure. Because of its risks however, this technique of reductive embolization should be used only if absolutely necessary to allow the complete cure of the malformation. Thus, the use of embolization should be considered very cautiously in small malformations as well as in very large and complex AVMs in which partial embolization will not be sufficient to allow complete cure with either endovascular or surgical techniques.

Section snippets

Distribution of patients

From 1989 to 1995, 90 patients with cerebral arteriovenous malformations were treated in our department of Neurosurgery (7 years; average, 12.8 patients per year). Ages ranged from 11 to 69 years. The exact distribution of age is given in Table 1. The patients were one-third female and two-thirds male.

The malformations were classified according to the Spetzler scale in five groups. The distribution of these groups is given in Table 2. Overall, 68% were low-grade malformations (Grades I, II, and

Cure rate

No malformation was considered to be obliterated completely on MRI criteria alone. The cure rate was based on angiography. For irradiated patients, results were assessed on the 2-year post-treatment angiogram. Seventy-two patients (80%) underwent post-treatment angiography. The other 20% include those irradiated patients who have not yet reached this 2-year delay for angiography, and some operated patients who had no post-operative angiography. The cure rates are calculated on these 72 patients

Discussion

Since the beginning of the modern era (i.e., the advent of embolization and stereotactic radiosurgery) there has been a profusion of papers addressing the management of cerebral AVMs. However, the outcome of the various techniques of treatment is unclear. Review of the recent literature demonstrates that there are still many controversies.

Conclusion

In this series of 90 patients with cerebral AVMs, we propose management based on the three available techniques: surgical resection, endovascular embolization, and radiosurgery. Our policy was either single modality or multimodality treatment, based on the size and the location of the malformation. Direct microsurgery was recommended for small and readily accessible malformations, radiosurgery for small and deep ones, and reductive embolization for larger AVMs followed by resection or

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