Multidisciplinary treatment of cerebral arteriovenous malformations

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Abstract
A series of 67 patients treated for cerebral AVM with a multidisciplinary approach is reported. The malformations were classified after the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: surgical resection alone (25% of cases), embolization plus resection (25% of cases), embolization alone (21%) and radiosurgery (30%) either alone (12%), or after incomplete embolization (15%) or after incomplete resection (3%). The clinical outcome was evaluated in terms of deterioration due to treatment. The treatment was responsible for a deterioration in 28% of all patients, either minor deterioration (19%) neurological deficit (4%), or death (4%). All complications of surgical resection (17% of all operated cases) and of radiosurgery (10% of irradiated cases) remained minor. None was haemodynamic-related. After endovascular embolization, a deterioration occurred in 25% of all embolized cases (minor 13%, neurological deficit 5% and death 8%). These complications occurring after embolization were haemodynamic related: ischaemia and haemorrhage (50% for each mechanism). Haemorrhage occurred either during or some days after the embolization procedure. The angiographic eradication rate was: 80% overall, 91% after resection (with or without previous embolization), 87% after radiosurgery (alone or after other techniques), and 10% after embolization alone. The discussion reviews in the literature the general evolution of the management of cerebral AVMs, with successive application of first surgical resection, the embolization and lastly radiosurgery. The cerebral complications related to cerebral haemodynamics are recalled (normal perfusion pressure breakthrough, disturbances of the venous drainage, thrombosis of the feeding arteries), together with the effect of selective embolization on these complications. In conclusion, the authors’ attitude towards the management of cerebral AVMs is now as follows: 1. Embolization for large AVMs in order to reduce them and make them accessible for the other two techniques. This goal is not reached in every case. 2. Radiosurgery for small AVMs which are located in highly functional or deep areas. 3. For small AVMs accessible to surgery, the discussion between surgical resection and radiosurgery is more and more often in favour of radiosurgery. After the authors’ experience the gravity of the treatment of cerebral AVMs has now shifted from surgical’ resection to endovascular embolization. This endovascular technique should perhaps be reserved to those cases for which reduction of the AVM size is absolutely necessary. [Neurol Res 1995; 17: 169-177]

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