Deep Arteriovenous Malformations in the Basal Ganglia, Thalamus, and Insula: Multimodality Management, Patient Selection, and Results

Abstract

Objective To describe a single institution’s experience treating arteriovenous malformations (AVMs) of the basal ganglia, thalamus, and insula in a multimodal fasion. Methods We conducted a retrospective review of all deep AVMs treated at our institution between 1997–2011 with attention to patient selection, treatment strategies, and radiographic and functional outcomes. Results 97 patients underwent initial treatment at our institution. 64% presented with hemorrhage. 29% were located in the basal ganglia, 41% in the thalamus, and 30% in the insula. 80% were Spetzler-Martin grade III-IV. Initial treatment was microsurgical resection in 42%, stereotactic radiosurgery (SRS) in 45%, and observation in 12%. Radiographic cure was achieved in 54% after initial surgical or SRS treatment (71% and 23%, respectively) and in 63% after subsequent treatments, with good functional outcomes in 78% (median follow-up 2.2 years). Multivariate logistic regression analysis revealed treatment group and age as factors associated with radiographic cure, while Spetzler-Martin score and time to follow-up were significantly associated with improved/unchanged functional status at time of last follow-up. Post-treatment hemorrhage occurred in 11% (7% of surgical and 18% of SRS patients). Conclusions Modern treatment of deep AVMs includes a multidisciplinary approach utilizing microsurgery, SRS, embolization, and observation. Supplementary grading adds meaningfully to traditional Spetzler-Martin grading to guide patient selection. Surgical resection is more likely to result in obliteration compared to SRS, and is associated with satisfactory results in highly selected patients.

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“…In neurosurgery, high 29 grades (≥ III) and deep brain locations 24 are associated with high complication rates. 22 Several surgical technical modifications, 18 such as excision of "non-eloquent" brain parts to obtain surgical access, 12 as well as multimodality treatments, 16 have been described in small case series as solutions for deep AVM treatment with moderate clinical results.…”

Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association

“…442,443 Management of deep lesions, including thalamic and brainstem AVMs, is higher risk but can still provide reasonable outcomes in selected cases (54% radiographic cure). 439,441,442,444,445 Higher-grade lesions have lower rates of successful treatment (≈35%) with radiosurgery. 446 In all cases, long-term follow-up, including posttreatment DSA, is critical because recurrence rates are as high as 11%.…”

Total temporary occlusion of blood flow for several hours to treat a giant deep arteriovenous malformation: A series of multiple operations to save a young life

“…found that 18% of patients initially treated only with radiosurgery of deep AVMs have post-treatment hemorrhage and the annual rate is 3.9%. [ 13 ] Thus, in each particular case, it is necessary to weigh the risks of different options of treatment and natural history of these malformations.…”