Treatment of brain arteriovenous malformations by embolization and radiosurgery

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✓ Embolization was used to reduce the size of brain arteriovenous malformations (AVMs) prior to radiosurgical treatment in 125 patients who were poor surgical candidates or had refused surgery. Of these patients, 81% had suffered hemorrhage, and 22.4% had undergone treatment at another institution. According to the Spetzler—Martin scale, the AVMs were Grade II in 9.6%, Grade III in 31.2%, Grade IV in 30.4%, and Grades V to VI in 28.8% of the cases. Most embolizations were performed using cyanoacrylate delivered by flow-guided microcatheters. Radiosurgery was performed using a linear accelerator in 62 patients treated by the authors, and 34 patients were treated at other institutions using various methods. Embolization produced total occlusion in 11.2% of AVMs and reduced 76% of AVMs enough to allow radiosurgery. Radiosurgery produced total occlusion in 65% of the partially embolized AVMs (79% when the residual nidus was < 2 cm in diameter). Embolizations resulted in a mortality rate of 1.6% and a morbidity rate of 12.8%. No complications were associated with radiosurgery. The hemorrhage rate for partially embolized AVMs was 3% per year. No patient with a completely occluded AVM experienced rehemorrhage. Angiographic follow-up review of AVMs embolized with cyanoacrylate demonstrated a 11.8% revascularization rate, occurring within 1 year. It is concluded that after partial embolization with cyanoacrylate, the risk of hemorrhage from the residual nidus is comparable to the natural history of AVMs and that the residual nidus can be irradiated with results almost as good as for a native AVM of the same size.

Article Information

Address reprint requests to: Y. Pierre Gobin, M.D., Department of Radiology, BL-121 CHS/172115, UCLA Medical Center, 10833 Le Conte Avenue, Los Angeles, California 90024–1721.

© AANS, except where prohibited by US copyright law.

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    Angiograms obtained in a 57-year-old woman presenting with a right frontal hematoma and left-sided deficit. The hematoma was surgically evacuated, and the patient made a good clinical recovery. a and b: Lateral and anteroposterior right carotid angiograms demonstrating a 3-cm diameter precentral arteriovenous malformation (AVM). c and d: Lateral and anteroposterior angiograms obtained after two embolizations were performed, and before radiosurgery, demonstrating a small residual nidus located in the most mesial part of the AVM (arrows). e: Lateral right carotid angiograms obtained 4 years after radiosurgery and embolization, demonstrating complete occlusion of the AVM.

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    Angiograms obtained in a 50-year-old woman presenting with a cerebellar hemorrhage; she recovered except for a mild cerebellar deficit. a–e: Right vertebral artery anteroposterior (a and b) and lateral (c) views, left vertebral artery (d) and right carotid artery (e) angiograms showing a large high-flow arteriovenous malformation (AVM) involving the right cerebellar hemisphere. f and g: Right vertebral angiograms (anteroposterior and lateral views) obtained after six embolizations performed over a 2-year period showing a significant reduction in the AVM. Radiosurgery was performed on the residual nidus. h: Follow-up angiograms performed 1 year after radiosurgery demonstrating subtotal thrombosis of the AVM. However, an early draining vein was still present (arrow). i: Two years after radiosurgery the AVM was thrombosed.

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