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Updated: Jun 30, 2026
Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
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, but multimodality therapy can lead to successful outcomes. This study shows selected patients with giant AVMs can achieve good results with acceptable risk using combined treatments.
Area of Science:
- Neurosurgery
- Interventional Neuroradiology
- Neurology
Background:
- Giant arteriovenous malformations (AVMs), defined as >6 cm, present significant treatment challenges.
- These large AVMs are associated with higher morbidity and mortality rates compared to smaller AVMs.
- Treatment outcomes for giant AVMs require careful evaluation due to their complexity.
Purpose of the Study:
- To review treatment strategies, angiographic results, and clinical outcomes in patients with giant AVMs.
- To evaluate the effectiveness of multimodality treatment for giant AVMs.
- To assess the risks and benefits of treating large AVMs.
Main Methods:
- Retrospective review of 53 patients with giant AVMs treated between 1987 and 2001.
- Analysis of presenting symptoms, Spetzler-Martin grades, AVM size, and venous drainage patterns.
- Evaluation of treatment modalities including surgery, embolization, and radiosurgery, often in combination.
Main Results:
- Multimodality treatment was frequently employed, with 55% achieving <90% obliteration after therapy.
- Complete cure was achieved in 36% of patients, with 58% cured among those with >3 years follow-up post-radiosurgery.
- Mean follow-up was 37 months, with 51% excellent, 28% good, 6% poor, and 15% mortality outcomes.
Conclusions:
- Selected symptomatic patients with giant AVMs can be treated successfully.
- Multimodality treatment is often essential for achieving AVM obliteration.
- Good outcomes and acceptable risks are achievable with careful patient selection and treatment planning.
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.
