Multimodality Treatment of Giant Intracranial Arteriovenous Malformations

Abstract

The results in this series of patients with giant AVMs, which represents the largest series reported to date, suggest that selected symptomatic patients with giant AVMs can be treated successfully with good outcomes and acceptable risk. Multimodality treatment is usually necessary to achieve AVM obliteration.

Microsurgery for cerebral arteriovenous malformations: postoperative outcomes and predictors of complications in 264 cases

“…Previous data highlight the favorable clinical outcomes of multimodality therapy for carefully selected patients. 3,4,6,11,19 Presurgical embolization can safely decrease the size of AVMs and decrease the apparent risk of rupture in high-risk lesions such as highflow aneurysms or remote fistulas. 28 Du and colleagues 9 have shown that diffuseness and deep perforating artery supply are subtle features of an AVM that predict worse outcomes after microsurgical resection, since deep perforators are friable, poorly visualized, and located in eloquent white matter tracts.…”

“…For these lesions, multimodality therapy may be considered an option that could provide more favorable outcomes. 3,4 Microsurgery and the ARUBA Trial Earlier this year, the ARUBA trial 17 was published and the investigators reached a conclusion that medical management is superior to any intervention (microsurgery, embolization, or radiosurgery) in terms of patient outcomes. Such a study on the topic of AVMs has been long overdue, and we acknowledge the efforts of the authors.…”

Embolization with gamma knife radiosurgery of giant intracranial arteriovenous malformations

“…'Bad' AVMs are in the sensory or motor or visual cortex AVM, large size (≥ 3 cm) in critical locations (thalamus, brainstem), affect the deep venous drainage, or are posterior cerebral artery P3, or P4 segment supplied AVMs. Chang et al (4) showed that combinations of microsurgery, embolization and SRS were often required to obliterate a giant AVM completely. Embolization reduces the volume of nidus that requires surgical resection but stereotactic radiosurgery several years prior to resection provides beneficial results also.…”

Central Nervous System Vascular Malformations

“…There are many groups who advocate against surgery for SM grade 4 & 5 AVMs because of the perceived high risk of surgery [75]. In those series where surgery was undertaken, even in carefully selected patients, complications occurred in up to 30% [76][77][78][79][80][81].…”

“…Although multi-modality treatment (incorporating combinations of surgery, embolization, and radiosurgery) appears to be an attractive option for treating these large lesions, cure rates are only in the order of 36% [76], and the cumulative effects of treatment-related morbidity may be much higher than single-or dual-modality management.…”