Summary
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.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Consecutive Surgical Series
Albert P (1982) Personal experience in the treatment of 178 cases of AVM's of the Brain. Acta Neurochir (Wien) 61: 207–226
Amacher AL, Allock JM, Drake CG (1972) Cerebral angiomas. Sequellae of surgical treatment. J Neurosurg 37: 571–575
Auger RG, Wiebers DO (1992) Management of unruptured intracranial arteriovenous malformations: A decision analysis. Neurosurgery 30: 561–569
Davis Ch, Symon L (1985) The management of cerebral AVM's. Acta Neurochir (Wien) 74: 4–11
Drake CG (1978) Cerebral AVM's. Consideration for and experience with 166 cases. Clin Neurosurg 26: 145–207
Fisher WS III (1989) Decision analysis. A tool of the future. An application to unruptured AVM's. Neurosurgery 24: 129–135
Forster DM, Steiner L, Hakanson S (1972) AVM's of the brain. Longterm clinical study. J Neurosurg 37: 562
French LA (1976) Surgical treatment of AVM's. A history. Clin Neurosurg 24: 22–33
Guidetti B, Delitala A (1980) Intracranial AVM's. Conservative and surgical treatment. J Neurosurg 53: 149–152
Heros RC, Korosue K, Diebold PM (1990) Surgical excision of cerebral arteriovenous malformations: Late results. Neurosurgery 26: 570–578
Hernesniemi J, Keranen T (1990) Microsurgical treatment of AVM's of the brain in defined population. Surg Neurol 33: 384–390
Jomin M, Lesoin F, Lozes G (1985) Prognosis for AVM's of the brain in adults based on 150 cases. Surg Neurol 23: 362–367
Luessenhop AJ, Rosa L (1984) Cerebral AVM's. Indication and results for surgery and the role of intravascular techniques. J Neurosurg 60: 14–22
Mingrino S (1978) Supratentorial AVM's of the brain. In: Krayenbühl H (ed) Advances and technical standards in neurosurgery, Vol 5. Springer, Wien New York, pp 93–126
Nornes H, Lundar T, Wikeby P (1979) Cerebral AVM's. Results of microsurgical management. Acta Neurochir (Wien) 50: 243–258
Parkinson D, Bachers G (1980) AVM's. Summary of 100 consecutive supratentorial case J Neurosurg 53: 285–299
Patterson RH Jr, Voorhies RM (1977) Surgical approaches to intracranial and intraspinal AVM's. Clin Neurosurg 25: 412–423
Pelletieri L, Carlsson CA, Grevstens Norlen G, Uhlemann C (1980) Surgical versus conservative treatment of intracranial arteriovenous malformations. A study in surgical decision making. Acta Neurochir (Wien) [Suppl] 29: 1–86
Pertuiset B, Ancri D, Sichez JP, Chauvin M, Guilly E, Metzger J, Gardeur D, Basset JY (1983) Radical surgery in cerebral AVM's. Tactical procedure based upon haemodynamic factors. In: Krayenbühl H (ed) Advances and technical standards in neurosurgery, Vol 10. Springer, Wien New York, pp 81–146
Pertuiset B, Ancri D, Kinuia Y, Haisa T, Bordi L, Lin C, Makdi M, Arthuis F (1991) Classification of supratentorial arteriovenous malformations. A score system for evaluation of operability and surgical strategy. Based on an analysis of 66 cases. Acta Neurochir (Wien) 110: 6–16
Spetzler RF, Martin NA (1986) A proposed grading for AVM's. J Neurosurg 65: 476–483
Sundt ThM, Piepgras DG, Stevens LN (1989) Surgery for supratentorial AVM's. Clin Neurosurg 37: 49–115
Tamaki N, Ehara K, Lin Tin-Kai, Kuwamura K, Obora Y, Kanazawa Y, Yamashita H, Matsumoto S (1991) Cerebral arteriovenous malformations: Factors influencing the surgical difficulty and outcome. Neurosurgery 29: 856–863
Trumpy JH, Eldevik P (1977) Intracranial AVM's. Conservative or surgical treatment. Surg Neurol 8: 171–175
Wilson CB, U HS, Domingue J (1979) Microsurgical treatment of intracranial vascular malformations. J Neurosurg 51: 446–454
Yasargil MG (1988) Microneurosurgery, Vol IIIB. AVM of the brain. Summary of operative results. Thieme, Stuttgart, pp369–395
Yeh HS, Kashiwai S, Tew JM jr, Berger TS (1990) Surgical management of epilepsy associated with cerebral AVM's. J Neurosurg 72: 216–223
Embolization: Combined Treatments
Albert P, Salgado H, Polaina M, Trujillo F, Ponce De Leon A, Durand F (1990) A study of the venous drainage of 150 cerebral AVM's as related to haemorrhage risks and size of the lesion. Acta Neurochir (Wien) 103: 30–34
Andrew BT, Wilson CB (1987) Staged treatment of AVM's of the brain. Neurosurgery 21: 314–323
Benati A (1992) Interventional neuroradiology for the treatment of inaccessible arteriovenous malformations. Acta Neurochir (Wien) 118: 76–79
Cromwell LD, Harris AB (1980) Treatment of cerebral AVM's. A combined neurosurgical and neuroradiological approach. J Neurosurg 52: 705–708
Debrun G, Lacour P, Caron JP, Hurth M, Comoy J, Keravel Y (1978) Detachable balloon and calibrated leak balloon techniques in the treatment of cerebral vascular lesions. J Neurosurg 49: 635–649
Debrun G, Vinuela F, Fox A, Drake CG (1982) Embolization of cerebral AVM's with bucrylate. Experience in 46 cases. J Neurosurg 56: 615–627
Deruty R, Lapras C, Bret P, Taboada F, Duthel R (1981) Embolization per operatoire des MAV cerebrales inextirpables. Tentative d'oblitération par un mélange à polymérisation retardée. Neurochirurgie 27: 5–14
Deruty R, Lapras C. Pierluca P, Patet JD, Pialat J, Bascoulergues Y, Garcia C (1985) Embolization per operatoire des M.A.V. Cerebrales par le Butyl-Cyanoacrylate (18 cas). Neurochirurgie 31: 21, 29
Deruty R, Lapras C, Patet JD, Bascoulergues Y, Pialat J, Honorato D (1986) Intra-operative embolization of cerebral arteriovenous malformations by means of isobutylcyanoacrylate (experience in 20 cases). Neurol Res 8: 109–113
Drake CG (1978) Cerebral AVM's. Consideration for and experience with 166 cases. Clin Neurosurg 26: 145–207
Fleisher AS, Kricheff I, Ransohoff J (1972) Postmortem findings following the embolization of an AVM. Case report. J Neurosurg 37: 606–609
Fournier D, Terbrugge KG, Willinsky R, Lasjaunias P, Montanera W (1991) Endovascular treatment of intracerebral arteriovenous malformations. Experience in 49 cases. J Neurosurg 75: 228–233
Fox J, Al-Mefty O (1977) Embolization of an AVM of the Brain stem. Surg Neurol 8: 7–9
Friedman P, Salazar JL, Sugar O (1978) Embolization and surgical excision of giant AVM's. Surg Neurol 9: 149–152
Gentili F, Schwartz M, Terbrugge K, Wallace MC, Willinski R, Young C (1992) A multidisciplinary approach to the treatment of brain vascular malformations. In: Symon L (ed) Advances and technical standards in neurosurgery, Vol 19. Springer, Wien New York, pp 179–208
George B, Riche MC, Gaston A, Laurian C (1984) Embolization peroperatoire des MAV à partir de l'artére vertébrale. Neurochirurgie 30: 269–273.
Germano IM, Davis RL, Wilson CB, Hieshima GB (1992) Histopathological follow-up study of 66 cerebral arteriovenous malformations after therapeutic embolization with polyvinyl-alcohol. J Neurosurg 76: 607–614
Halbach VV, Higashida RT, Yang P, Barnwell S, Wilson CB, Hieshima GB (1988) Preoperative balloon occlusion of AVM's. Neurosurgery 22: 301–308
Hieshima GB, Mehringer CM, Grinnell VS, Landau B, Sage DJ, Goodman SJ, Beresini D, Pribram HF (1982) Preoperative balloon occlusion. “The intra-vascular ligature”. Surg Neurol 17: 191–195
Jones FD, Boone SC, Whaley RA (1982) Intracranial hemorrhage following attempted embolization and removal of large AVM's. Surg Neurol 18: 278–283
Klara PM, George ED, McDonnell DE, Pevsner PH (1985) Morphological studies of human AVM's. Effect of IBCA. Embolization. J Neurosurg 63: 421–425
Kusske JA, Kelly WA (1974) Embolization and reduction of the steal syndrome in cerebral AVM's. J Neurosurg 40: 313–321
Luessenhop AJ, Spence WT (1960) Artificial embolization of cerebral arteries. Report of use in a case of AVM. JAMA 172: 1153–1155
Luessenhop AJ, Kachman RJ, Shevlin W (1965) Clinical evaluation of artificial embolization in the management of large cerebral AVM's. J Neurosurg 23: 460–471
Luessenhop AJ, Presper JH (1975) Surgical embolization of cerebral AVM's through internal carotid and vertebral arteries. Longterm results. J Neurosurg 42: 443–451
Luessenhop AJ, Mujica SH (1981) Embolization of segments of circle of willis and adjacent branches for management of certain inoperable cerebral AVM's. J Neurosurg 54: 573–582
Luessenhop AJ, Rosa L (1984) Cerebral AVM's. Indication and results for surgery, and the role of intravascular techniques. J Neurosurg 60: 14–22
Mizoi K, Takahashi A, Yoshimoto T, Sugawara T, Saito K (1992) Surgical excision of giant cerebellar hemispheric arteriovenous malformations following preoperative embolization. J Neurosurg 76: 1008–1011
Morgan MK, Sundt ThM Jr (1989) The case against staged operative resection of cerebral AVM's. Neurosurgery 25: 429–435
Mullan S, Kawanaga H, Patronas NJ (1979) Microvascular embolization of cerebral AVM's. A technical variation. J Neurosurg 51: 621–627
Pasqualin A, Scienza R, Cioffi F, Barone G, Benati A, Beltramello A, Da Pian R (1991) Treatment of cerebral AVM's with a combination of preoperative embolization and surgery. Neurosurg 29: 358–368
Pevsner SH, George ED, Doppman JL (1982) Interventional radiology polymer update: Acrylic. Neurosurgery 10: 314–316
Purdy PD, Batjer HH, Samson D (1991) Management of hemorrhagic complications from preoperative embolization of arteriovenous malformations. J Neurosurg 74: 205–211
Purdy PD, Batjer HH, Risser RC, Samson D (1992) Arteriovenous malformations of the brain: Choosing embolic materials to enhance safety and ease of resection. J Neurosurg 77: 217–222
Samson D, Ditmore M, Beyer CW (1981) Intravascular use of IBCA. Part 1. Treatment of intracranial AVM's. Neurosurgery 8: 43–51
Schell G, Hodge CJ, Cacayorin E (1986) Transient neurological deficit after therapeutic embolization of the arteries supplying the medial wall of the hemisphere including the supplementary motor area. Neurosurgery 18: 353–356
Serbinenko FA (1974) Balloon catheterization and occlusion of major cerebral vessels. J Neurosurg 41: 125–145
Spetzler RF, Martin NA, Carter LP, Flom RA, Raudzens PA, Wilkinson E (1987) Surgical management of large AVM's by staged embolization and operative excision. J Neurosurg 67: 17–28
Spetzler RF, Zabramski JM (1988) Grading and stages resection of cerebral AVM's. Clin Neurosurg 36: 318–337
Spetzler RF, Zabramski JM (1988) Surgical management of large AVM's. Acta Neurochir Wien [Suppl] 42: 93–97
Stein BM, Wolpert SM (1977) Surgical and embolic treatment of cerebral AVM's. Surg Neurol 7: 359–369
Suzuki J, Takahashi A, Yoshimoto T, Mirobumi S (1985) Use of balloon occlusion and substances to protect ischemic brain during resection of posterior fossa AVM. J Neurosurg 63: 626–629
Terada T, Nakamura Y, Nakai K, Tsuura M, Nishiguchi T, Hayashi S, Kido T, Takiw Iwata H, Komai N (1991) Embolization of arterio-venous malformations with peripheral aneurysms using ethylene vinyl alcohol copolymer. Report of three cases. J Neurosurg 75: 655–660
Vinuela F, Dion JE, Duckwiler G, Martin NA, Lylyk P, Fox A, Pelz D, Drake CG, Girvin JJ, Debrun G (1991) Combined endovascular embolization and surgery in the management of cerebral arteriovenous malformations. Experience with 101 cases. J Neurosurg 75: 856–864
Vlahovitch B, Fuentes JM (1976) Embolization of cerebral angiomas by catheterization of cortical arteries. Neuroradiology 11: 243–248
Radiosurgery
Backlund EO (1979) Stereotactic radiosurgery in intracranial tumours and vascular malformations. In: Krayenbuhl H (ed) Advances and technical standards in neurosurgery, Vol 6. Springer, Wien New York, pp 3–38
Betti O, Derechinski V (1983) Irradiation stéréotaxique multifaisceaux. Neurochirurgie 29: 295–298
Betti O, Munari C, Rosler R (1989) Stereotactic radiosurgery with the linear accelerator: Treatment of arteriovenous malformations. Neurosurgery 24: 311–321
Betti O, Munari C (1992) Traitement radiochirurgical avec accélérateur linéaire des “petites” malformations artério-veineuses intracraniennes. Neurochirurgie 38: 27–34
Colombo F, Benedetti A, Pozza F, Marcetti C, Chierego G (1989) Linear accelerator radiosurgery for cerebral AVM's. Neurosurgery 24: 833–840
Levy RP, Fabrikant JI, Frankel KA, Phillips MH, Lyman JT (1989) Stereotactic heavy charged particle bragg peak. Radiosurgery for the treatment of intracranial AVM's in childhood and adolescence. Neurosurgery 24: 841–852
Lunsford LD, Kondsiolka D, Flickinger V, Bissonette DJ, Jungreis CA, Maitz AH, Horton JA, Coffey RJ (1991) Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 75: 512–524
Mehdorn HM, Grote W (1988) Noninvasive follow-up of patients with intracranial AVM after proton-beam radiation therapy. Acta Neurochir (Wien) [Suppl] 42: 98–102
Merienne L, Laurent A, Meder JF, Lefkopoulos D (1991) Irradiation stéréotaxique de 46 angiomes cérébraux. Analyse des résultats angiographiques deux ans et demi après traitement. Neurochirurgie 37: 185–195
Ogilvy C (1990) Radiation therapy for arteriovenous malformations. A review. Neurosurgery 26: 725–735
Steiner L, Leksell L, Greitz T, Forster DMC, Backlund EO (1974) Stereotactic radiosurgery in intracranial arteriovenous malformations. Acta Neurochir (Wien) [Suppl] 21: 195–209
Steiner L Lindquist C, Adler JR, Torner JC, Alves W, Steiner M (1992) Clinical outcome of radiosurgery for arteriovenous malformations. J Neurosurg 77: 1–8
Steiner L, Lindquist C, Steiner M (1992) Radiosurgery. In: Symon L (ed) Advances and technical standards in neurosurgery, Vol 19. Springer, Wien New York, pp 19–102
Tognetti F, Andreoli A, Cuscini A, Testa C (1985) Successful management of an intracranial AVM by conventional irradiation. J Neurosurg 63: 193–195
Yamamoto M, Jimbo M, Kobayaski M, Toyoda C, Ide M, Tanaka N, Lindquist C, Steiner L (1992) Long-term results of radiosurgery for arterio-venous malformation: Neurodiagnostic imaging and histological studies of angiographically confirmed nidus obliteration. Surg Neurol 37: 219–230
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Deruty, R., Pelissou-Guyotat, I., Mottolese, C. et al. The combined management of cerebral arteriovenous malformations experience with 100 cases and review of the literature. Acta neurochir 123, 101–112 (1993). https://doi.org/10.1007/BF01401864
Issue Date:
DOI: https://doi.org/10.1007/BF01401864