Multimodality management of Spetzler-Martin Grade III arteriovenous malformations

Clinical article

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Grade III arteriovenous malformations (AVMs) are diverse because of their variations in size (S), location in eloquent cortex (E), and presence of central venous drainage (V). Because they may have implications for management and outcome, the authors evaluated these variations in the present study.


Between 1984 and 2010, 100 patients with Grade III AVMs were treated. The AVMs were categorized by Spetzler-Martin characteristics as follows: Type 1 = S1E1V1, Type 2 = S2E1V0, Type 3 = S2E0V1, and Type 4 = S3E0V0. The occurrence of a new neurological deficit, functional status (based on modified Rankin Scale [mRS] score) at discharge and follow-up, and radiological obliteration were correlated with demographic and morphological characteristics.


One hundred patients (49 female and 51 male; age range 5–68 years, mean 35.8 years) were evaluated. The size of AVMs was less than 3 cm in 28 patients, 3–6 cm in 71, and greater than 6 cm in 1; 86 AVMs were located in eloquent cortex and 38 had central drainage. The AVMs were Type 1 in 28 cases, Type 2 in 60, Type 3 in 11, and Type 4 in 1. The authors performed embolization in 77 patients (175 procedures), surgery in 64 patients (74 surgeries), and radiosurgery in 49 patients (44 primary and 5 postoperative).

The mortality rate following the management of these AVMs was 1%. Fourteen patients (14%) had new neurological deficits, with 5 (5%) being disabling (mRS score > 2) and 9 (9%) being nondisabling (mRS score ≤ 2) events. Patients with Type 1 AVMs (small size) had the best outcome, with 1 (3.6%) in 28 having a new neurological deficit, compared with 72 patients with larger AVMs, of whom 13 (18.1%) had a new neurological deficit (p < 0.002). Older age (> 40 years), malformation size > 3 cm, and nonhemorrhagic presentation predicted the occurrence of new deficits (p < 0.002). Sex, eloquent cortex, and venous drainage did not confer any benefit.

In 89 cases follow-up was adequate for data to be included in the obliteration analysis. The AVM was obliterated in 78 patients (87.6%), 69 of them (88.5%) demonstrated on angiography and 9 on MRI /MR angiography. There was no difference between obliteration rates between different types of AVMs, size, eloquence, and drainage. Age, sex, and clinical presentation also did not predict obliteration.


Multimodality management of Grade III AVMs results in a high rate of obliteration, which was not influenced by size, venous drainage, or eloquent location. However, the development of new neurological deficits did correlate with size, whereas eloquence and venous drainage did not affect the neurological complication rate. The authors propose subclassifying the Grade III AVMs according to their size (< 3 and ≥ 3 cm) to account for treatment risk.

Abbreviations used in this paper:AVM = arteriovenous malformation; MRA = MR angiography; mRS = modified Rankin Scale.

Article Information

Address correspondence to: Gary K. Steinberg, M.D., Ph.D., R281, Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, California 94305-5327. email:

Please include this information when citing this paper: published online April 6, 2012; DOI: 10.3171/2012.3.JNS111575.

© AANS, except where prohibited by US copyright law.



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    Angiograms acquired in a 27-year-old woman who presented with right hemiparesis. She did not have any evidence of hemorrhage. A: Anteroposterior digital subtraction angiogram showing a Spetzler-Martin Grade III (S1E1V1), Type 1 cerebellar and brainstem AVM fed from the left superior cerebellar artery and multiple posterior cerebral artery feeders. B: Postembolization angiogram demonstrating a 20% reduction of AVM. C: Angiogram obtained after stereotactic radiosurgery revealing no residual AVM. At the 3-year follow-up, the patient was asymptomatic and did not have any neurological deficits.

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    A: Axial noncontrast CT scan demonstrating a left temporoparietal Type 3 AVM with evidence of acute hemorrhage. B: Preembolization anteroposterior digital subtraction angiography (DSA) image showing a prominent left posterior cerebral artery feeder. C: Postembolization anteroposterior DSA image demonstrating a 30% reduction of the AVM. D: Postoperative anteroposterior DSA image showing no residual AVM.

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    Studies obtained in a 37-year-old man presenting with headache. A: Axial postcontrast T1-weighted MR image demonstrating a right parietotemporooccipital Spetzler-Martin Grade III, Type 2 (S2E1V0) AVM. B: Preembolization anteroposterior DSA image showing a prominent right posterior cerebral artery feeder. C: Postembolization anteroposterior DSA image revealing a 30% reduction of AVM. D: Postoperative anteroposterior DSA image showing no residual AVM. Postoperatively, the patient developed left homonymous hemianopsia, which persisted at the 1-year follow-up.



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