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Multimodality treatment of giant intracranial arteriovenous malformations
Steven D Chang1, Mary L Marcellus, Michael P Marks
1Department of Neurosurgery and the Stanford Stroke Center, Stanford University School of Medicine, Stanford, California 94305, USA.
Insights
Giant arteriovenous malformations (AVMs) are challenging to treat. Multimodality treatment, including embolization, surgery, and radiosurgery, offers successful outcomes for selected patients with giant AVMs.
Area of Science:
- Neurology
- Neurosurgery
- Radiology
Background:
- Giant arteriovenous malformations (AVMs), defined as >6 cm, present significant treatment challenges.
- These lesions are associated with higher morbidity and mortality rates compared to smaller AVMs.
Purpose of the Study:
- To review treatment strategies, angiographic results, and clinical outcomes in patients with giant AVMs.
- To evaluate the efficacy and safety of multimodality treatment for giant AVMs.
Main Methods:
- Retrospective review of 53 patients with giant AVMs treated between 1987 and 2001.
- Patients presented with hemorrhage, seizures, headaches, or neurological deficits.
- Treatment modalities included surgery, embolization, and radiosurgery, often in combination.
Main Results:
- Nineteen patients (36%) achieved complete cure; 55% had residual AVMs after multimodality therapy.
- Long-term cure rate was 58% in patients completing treatment or followed for >3 years post-radiosurgery.
- Mean follow-up was 37 months, with 51% excellent and 28% good clinical outcomes; 15% experienced treatment-related morbidity.
Conclusions:
- Selected symptomatic patients with giant AVMs can be treated successfully.
- Multimodality treatment is often required for achieving AVM obliteration.
- Good outcomes and acceptable risks are achievable with appropriate patient selection and treatment strategies.
Objective:
Giant arteriovenous malformations (AVMs) (i.e., those greater than 6 cm at maximum diameter) are difficult to treat and often carry higher treatment morbidity and mortality rates than do smaller AVMs. In this study, we reviewed the treatment, angiographic results, and clinical outcomes in 53 patients with giant AVMs who were treated at Stanford between 1987 and 2001.
Methods:
The patients selected included 20 males (38%) and 33 females (62%). Their presenting symptoms were hemorrhage (n = 20; 38%), seizures (n = 18; 34%), headaches (n = 8; 15%), and progressive neurological deficits (n = 7; 13%). One patient was in Spetzler-Martin Grade III, 9 were in Spetzler-Martin Grade IV, and 43 were in Spetzler-Martin Grade V. The mean AVM size was 6.8 cm (range, 6-15 cm). AVM venous drainage was superficial (n = 7), deep (n = 20), or both (n = 26). At presentation, 31 patients (58%) were graded in excellent neurological condition, 17 were graded good (32%), and 5 were graded poor (9%).
Results:
The patients were treated with surgery (n = 27; 51%), embolization (n = 52; 98%), and/or radiosurgery (n = 47; 89%). Most patients received multimodality treatment with embolization followed by surgery (n = 5), embolization followed by radiosurgery (n = 23), or embolization, radiosurgery, and surgery (n = 23). Nineteen patients (36%) were completely cured of their giant AVMs, 90% obliteration was achieved in 4 patients (8%), less than 90% obliteration was achieved in 29 patients (55%) who had residual AVMs even after multimodality therapy, and 1 patient was lost to follow-up. Of the 33 patients who either completed treatment or were alive more than 3 years after undergoing their most recent radiosurgery, 19 patients (58%) were cured of their AVMs. The long-term treatment-related morbidity rate was 15%. The clinical results after mean follow-up of 37 months were 27 excellent (51%), 15 good (28%), 3 poor (6%), and 8 dead (15%).
Conclusion:
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.