The combined management of cerebral arteriovenous malformations experience with 100 cases and review of the literature
A series of 100 patients treated for a cerebral arteriovenous malformation (AVM) is presented. Patients were admitted between 1985 and April 1992. Two groups are considered: the first group including 52 patients treated before the availability of radiosurgery (1985–1988), and the second group including 48 patients treated after the availability of radiosurgery (1989–1992). AVM's were classified in five grades according to the Spetzler's Grading System.
Three techniques of treatment were used: surgical resection, intravascular embolization (with cyanoacrylate), and radiosurgery (linear accelerator). These three techniques were used either alone or in association, giving four types of management: surgical resection alone, embolization and resection, embolization alone, and radiosurgery (alone, or after embolization, or after surgical resection).
From 1989 on, the availability of radiosurgery was responsible for the decrease of the “embolization and resection” group, which until then was predominantly used as well for low-grade (I, II, III) as for high-grade AVM's (IV, V). Overall, for the low-grade AVM's, the treatment of choice was surgical resection (79% of cases), with pre-operative embolization in one-half of these cases; the other low-grade AVM's were irradiated, with various combinations. For the high-grade AVM's, the treatment of choice was intravascular embolization (95% of cases), either alone, or followed by resection (45%) or radiosurgery (9%).
Results were evaluated in terms of deterioration following treatment, in five groups: no deterioration (59%), minor deterioration (20%), long-lasting deficit (10%), major deterioration (5%), and death (6%). Overall, results improved after 1989: favourable outcome (no deterioration and minor deterioration) increased from 67% to 90%. Results were not related to the patients' age. More favourable results were obtained for low-grade AVM's (93%) than for high-grade AVM's (60%). For the low-grade AVM's the evolution from 1989 on (favourable outcomes increasing from 89% to 96%) occurred with the lowering of the mortality rate. For the highgrade AVM's, the evolution from 1989 onwards (favourable outcome increasing from 46% to 78%) occurred with the decrease of the cases with deficits.
The angiographic results were strongly related to the management: 95% of complete eradication after surgical resection and 5% only after embolization alone. Concerning the results in irradiated cases, the follow-up is not long enough.
The review of the neurosurgical literature since 1972 demonstrates progressive modifications in the therapeutic attitude as regards AVM's. The surgical management which was predominantly used at the beginning gave way progressively to a combined management, with a combination of embolization, surgery, and lately radiosurgery. The authors' present attitude is in favour of combined treatment using the three techniques. Direct surgical resection is proposed for small and readily accessible AVM's. Direct radiosurgery is proposed for small but deep AVM's or those located in highly functional areas. Intravascular embolization is proposed in every other situation. After embolization has been completed, totally eradicated AVM's are left in place; no further treatment is proposed for AVM's which are still large with high surgical risk. AVM's which are sufficiently reduced in size are either operated on (if accessible) or irradiated (if deeply situated). When the results of radiosurgery are assessed with long enough follow-up (in terms of eradication and clinical outcome) the authors' attitude may either increase the role of radiosurgery or return towards surgical resection, depending of the quality of the results.
KeywordsArteriovenous malformations embolization radiosurgery
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