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Combined endovascular embolization and surgery in the management of cerebral arteriovenous malformations: experience
F Viñuela1, J E Dion, G Duckwiler
1Service of Endovascular Therapy, University of California School of Medicine, Los Angeles.
Insights
This study shows that endovascular embolization followed by surgery effectively treats cerebral arteriovenous malformations (AVMs), achieving high removal rates with manageable complication risks.
Area of Science:
- Neurosurgery
- Interventional Radiology
Background:
- Cerebral arteriovenous malformations (AVMs) are complex vascular lesions.
- Intracranial hemorrhage and seizures are common presenting symptoms.
Purpose of the Study:
- To evaluate the efficacy and safety of a combined endovascular embolization and surgical removal approach for cerebral AVMs.
- To analyze patient outcomes, including AVM obliteration rates and complication profiles.
Main Methods:
- Retrospective review of 101 patients with cerebral AVMs treated with staged endovascular embolization and surgical resection.
- Classification of AVMs using the Spetzler-Martin grading system.
- Assessment of embolization extent, surgical success, and postoperative morbidity and mortality.
Main Results:
- Complete surgical removal was achieved in 96% of patients.
- Preoperative embolization achieved 50-75% nidus obliteration in 50 cases and 75-90% in 31 cases.
- Overall morbidity rates were generally mild to moderate, with low severe morbidity and mortality associated with the combined treatment.
Conclusions:
- Combined endovascular embolization and surgical resection is a safe and effective treatment strategy for cerebral AVMs.
- The staged approach facilitates complete AVM removal and can mitigate surgical risks.
- Careful patient selection and procedural management are crucial for optimizing outcomes in AVM treatment.
Abstract:
The authors describe their experience with 101 cerebral arteriovenous malformations (AVM's) treated by endovascular embolization followed by surgical removal. Fifty-three patients presented with intracranial hemorrhage and 35 had seizures. Based on the classification of Spetzler and Martin, two AVM's were Grade I, 13 were Grade II, 26 were Grade III, 43 were Grade IV, and 17 were Grade V. Fifty-six AVM's were in the right hemisphere, 28 were in the left hemisphere, 12 were in the corpus callosum, and five involved the cerebellum. In 50 cases, presurgical obliteration of 50% to 75% of the AVM nidus was achieved by embolization, and in 31 cases this percentage increased to between 75% and 90%. In 97 (96%) patients, complete surgical removal of the AVM was obtained. Morbidity resulting from preoperative endovascular embolization was classified as mild in 3.9% of the cases, moderate in 6.9%, and severe in 1.98%. The death rate related to embolization was 0.9%. The immediate postsurgical morbidity was classified as mild in 5.9% of the cases, moderate in 10.8%, and severe in 5.9%. The overall long-term morbidity was mild in 5.9% of the cases, moderate in 6.9%, and severe in 1.98%. Two patients (1.98%) died due to intractable intraoperative hemorrhage and two (1.98%) as a result of postsurgical pulmonary complications.