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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    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.

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