Multimodal management of arteriovenous malformations of the basal ganglia and thalamus: factors affecting obliteration and outcome

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OBJECTIVE

Arteriovenous malformations (AVMs) of the basal ganglia and thalamus are particularly difficult lesions to treat, accounting for 3%–13% of all AVMs in surgical series and 23%–44% of malformations in radiosurgery series. The goal of this study was to report the results of multimodal management of basal ganglia and thalamic AVMs and investigate the factors that influence radiographic cure and good clinical outcomes.

METHODS

This study was a retrospective analysis of a prospectively maintained database of all patients treated at the authors’ institution. Clinical, radiological, follow-up, and outcome data were analyzed. Univariate and multivariate analyses were conducted to explore the influence of various factors on outcome.

RESULTS

The results and data analysis pertaining to 123 patients treated over 32 years are presented. In this cohort, radiographic cure was achieved in 50.9% of the patients. Seventy-five percent of patients had good clinical outcomes (stable or improved performance scores), whereas 25% worsened after treatment. Inclusion of surgery and radiosurgery independently predicted obliteration, whereas nidus diameter and volume predicted clinical outcomes. Nidus volume/diameter and inclusion of surgery predicted the optimal outcome, i.e., good clinical outcomes with lesion obliteration.

CONCLUSIONS

Good outcomes are possible with multimodal treatment in these complex patients. Increasing size and, by extension, higher Spetzler-Martin grade are associated with worse outcomes. Inclusion of multiple modalities of treatment as indicated could improve the chances of radiographic cure and good outcomes.

ABBREVIATIONS AVM = arteriovenous malformation; BGT = basal ganglia and thalamus; EVT = endovascular treatment; GKS = Gamma Knife surgery; LINAC = linear accelerator; mRS = modified Rankin Scale; PreTP = pretreatment period; PostTP = posttreatment period; SRS = stereotactic radiosurgery.

Article Information

Correspondence Gary K. Steinberg: Stanford University School of Medicine, Stanford, CA. gsteinberg@stanford.edu.

INCLUDE WHEN CITING Published online August 17, 2018; DOI: 10.3171/2018.2.JNS172511.

Disclosures Dr. Steinberg is a consultant for Qool Therapeutics, Peter Lazic US, Inc., and NeuroSave.

© AANS, except where prohibited by US copyright law.

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Figures

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    Thalamic AVM, Spetzler-Martin grade III. The lesion was cured with multimodal management. This patient initially presented with a massive intraventricular hemorrhage. Endovascular embolization of some feeders arising from the left posterior cerebral artery was the first stage in the treatment. Planned partial resection of the nidus was performed in the next stage. Radiation using the CyberKnife system was delivered to the residual lesion, leading to complete cure. a: Axial T2-weighted image showing an AVM in the left thalamus with hemorrhage extending into the lateral ventricles. b: Anteroposterior view of an angiogram showing the nidus, supplied predominantly by the left posterior cerebral artery and draining into the vein of Galen. c: Posttreatment angiogram, anteroposterior view. d: Posttreatment angiogram, lateral view. The posttreatment angiograms show no residual nidus or early draining veins. From chapter 17: Madhugiri VS, Teo M, Steinberg GK: Surgery of basal ganglia, thalamic, and brainstem arteriovenous malformations, in Brain Arteriovenous Malformations and Arteriovenous Fistulas, Dumont AS, Lanzino G, Sheehan JP (eds), 2017, www.thieme.com, Thieme Medical Publishers, Inc. (reprinted with permission).

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    Capsulo-ganglionic AVM, Spetzler-Martin grade III. The patient presented with sudden loss of consciousness. a: Axial CT image obtained at presentation, showing hemorrhage in the right basal ganglia. b: MR angiogram showing an AVM located just superior to the right M1 segment of the middle cerebral artery. The white arrow points to an enlarged lenticulostriate feeder. c: Anteroposterior projection of a digitally subtracted angiogram showing a nidus measuring 2 × 1.5 cm, supplied by feeders from the lenticulostriate perforators (black arrow). An early draining vein is seen on the medial aspect of the nidus (white arrow). d: Lateral view of the AVM. The venous drainage into the basal vein of Rosenthal (arrow) and then to the straight sinus (broken arrow) is seen. This lesion was cured by surgery, via a conventional pterional craniotomy and transsylvian approach. e and f: Intraoperative images. The site of corticectomy was on the inferior frontal gyrus, just abutting the sylvian fissure (black star, e). The hematoma and feeders to the nidus could be accessed via this approach. The hematoma has been evacuated, and the first of the lenticulostriate feeders is visible in the walls of the hematoma cavity (arrow, f). From chapter 17: Madhugiri VS, Teo M, Steinberg GK: Surgery of basal ganglia, thalamic, and brainstem arteriovenous malformations, in Brain Arteriovenous Malformations and Arteriovenous Fistulas, Dumont AS, Lanzino G, Sheehan JP (eds), 2017, www.thieme.com, Thieme Medical Publishers, Inc. (reprinted with permission).

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    Kaplan-Meier graphs showing the probability of angiographic obliteration of the nidus over time. The graphs indicate the probability of angiographic obliteration over time, with respect to various dichotomized variables, including high grade (A), received EVT (B), received SRS (C), and underwent surgery (D). The p values listed in the figures are from a Cox proportional hazards regression to check for the significance of the differences between the 2 Kaplan-Meier lines in each plot. embo = embolization; XRT = radiation therapy.

References

  • 1

    Andrade-Souza YMZadeh GScora DTsao MNSchwartz ML: Radiosurgery for basal ganglia, internal capsule, and thalamus arteriovenous malformation: clinical outcome. Neurosurgery 56:56642005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Bonita RBeaglehole R: Recovery of motor function after stroke. Stroke 19:149715001988

  • 3

    Brown RD JrWiebers DOForbes GO’Fallon WMPiepgras DGMarsh WR: The natural history of unruptured intracranial arteriovenous malformations. J Neurosurg 68:3523571988

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Chang SDMarcellus MLMarks MPLevy RPDo HMSteinberg GK: Multimodality treatment of giant intracranial arteriovenous malformations. Neurosurgery 53:1132003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Chang SDSteinbergLevy RPMarks MPFrankel KAShuster DL: Microsurgical resection of incompletely obliterated intracranial arteriovenous malformations following stereotactic radiosurgery. Neurol Med Chir (Tokyo) 38 Suppl:2002071998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Crawford PMWest CRChadwick DWShaw MD: Arteriovenous malformations of the brain: natural history in unoperated patients. J Neurol Neurosurg Psychiatry 49:1101986

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Davidson ASMorgan MK: How safe is arteriovenous malformation surgery? A prospective, observational study of surgery as first-line treatment for brain arteriovenous malformations. Neurosurgery 66:4985052010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    de Oliveira ETedeschi HSiqueira MGOno MRhoton AL Jr: Arteriovenous malformations of the basal ganglia region: rationale for surgical management. Acta Neurochir (Wien) 139:4875061997

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Fleetwood IGMarcellus MLLevy RPMarks MPSteinberg GK: Deep arteriovenous malformations of the basal ganglia and thalamus: natural history. J Neurosurg 98:7477502003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Friedman WABova FJMendenhall WM: Linear accelerator radiosurgery for arteriovenous malformations: the relationship of size to outcome. J Neurosurg 82:1801891995

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Graf CJPerret GETorner JC: Bleeding from cerebral arteriovenous malformations as part of their natural history. J Neurosurg 58:3313371983

  • 12

    Heros RCKorosue KDiebold PM: Surgical excision of cerebral arteriovenous malformations: late results. Neurosurgery 26:5705781990

  • 13

    Kano HKondziolka DFlickinger JCYang HCFlannery TJNiranjan A: Stereotactic radiosurgery for arteriovenous malformations, Part 4: management of basal ganglia and thalamus arteriovenous malformations. J Neurosurg 116:33432012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Kiran NAKale SSKasliwal MKVaishya SGupta ASingh Sharma M: Gamma knife radiosurgery for arteriovenous malformations of basal ganglia, thalamus and brainstem—a retrospective study comparing the results with that for AVMs at other intracranial locations. Acta Neurochir (Wien) 151:157515822009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Kobayashi TTanaka TKida YOyama HNiwa MMaesawa S: [Gamma knife treatment of AVM of the basal ganglia and thalamus.] No To Shinkei 48:3513561996 (Jpn)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Lawton MTHamilton MGSpetzler RF: Multimodality treatment of deep arteriovenous malformations: thalamus, basal ganglia, and brain stem. Neurosurgery 37:29361995

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Liu KDLee LS: Microsurgical treatment of deep arteriovenous malformations–basal ganglia and thalamus. Zhonghua Yi Xue Za Zhi (Taipei) 64:23302001

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Lunsford LDKondziolka DFlickinger JCBissonette DJJungreis CAMaitz AH: Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 75:5125241991

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Malik GMUmansky FPatel SAusman JI: Microsurgical removal of arteriovenous malformations of the basal ganglia. Neurosurgery 23:2092171988

  • 20

    Marks MPMarcellus MLSantarelli JDodd RLDo HMChang SD: Embolization followed by radiosurgery for the treatment of brain arteriovenous malformations (AVMs). World Neurosurg 99:4714762017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Mizoi KYoshimoto TNagamine YTakahashi AEzura M: Surgical removal of giant basal ganglia arteriovenous malformations through the extended transsylvian approach following preoperative embolization–two case reports. Neurol Med Chir (Tokyo) 35:8698751995

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Nagy GMajor ORowe JGRadatz MWHodgson TJColey SC: Stereotactic radiosurgery for arteriovenous malformations located in deep critical regions. Neurosurgery 70:145814712012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Nicolato AForoni RCrocco AZampieri PGAlessandrini FBricolo A: Gamma knife radiosurgery in the management of arteriovenous malformations of the basal ganglia region of the brain. Minim Invasive Neurosurg 45:2112232002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Paulsen RDSteinberg GKNorbash AMMarcellus MLMarks MP: Embolization of basal ganglia and thalamic arteriovenous malformations. Neurosurgery 44:9919971999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Pollock BEFlickinger JC: A proposed radiosurgery-based grading system for arteriovenous malformations. J Neurosurg 96:79852002

  • 26

    Pollock BEGorman DABrown PD: Radiosurgery for arteriovenous malformations of the basal ganglia, thalamus, and brainstem. J Neurosurg 100:2102142004

  • 27

    Rankin J: Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J 2:2002151957

  • 28

    Sasaki TKurita HSaito IKawamoto SNemoto STerahara A: Arteriovenous malformations in the basal ganglia and thalamus: management and results in 101 cases. J Neurosurg 88:2852921998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Sheps MC: On the person years concept in epidemiology and demography. Milbank Mem Fund Q 44:69911966

  • 30

    Steinberg GKFabrikant JIMarks MPLevy RPFrankel KAPhillips MH: Stereotactic heavy-charged-particle Bragg-peak radiation for intracranial arteriovenous malformations. N Engl J Med 323:961011990

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    U HSKerber CWTodd MM: Multimodality treatment of deep periventricular cerebral arteriovenous malformations. Surg Neurol 38:1922031992

  • 32

    Yamada KMase MMatsumoto T: Surgery for deeply seated arteriovenous malformation: with special reference to thalamic and striatal arteriovenous malformation. Neurol Med Chir (Tokyo) 38 Suppl:2272301998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Yamagata SKikuchi HIhara INagata INaruo YShishido H: [Intraoperative liquid embolization of an arteriovenous malformation in the basal ganglia and thalamic region.] No Shinkei Geka 15:7177231987 (Jpn)

    • PubMed
    • Search Google Scholar
    • Export Citation

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