scholarly journals P.106 Functional approach using intraoperative brain mapping and neurophysiological monitoring for surgery of arteriovenous malformations in eloquent areas

2018 ◽  
Vol 45 (s2) ◽  
pp. S44-S44
Author(s):  
P Lopez-Ojeda ◽  
J Sanmillan ◽  
A Fernandez-Coello ◽  
I Fernandez-Conejero ◽  
Y Ali-Ciurana ◽  
...  
Keyword(s):  
Brain Mapping ◽  
Arteriovenous Malformations ◽  
Complete Recovery ◽  
Functional Approach ◽  
Neurophysiological Monitoring ◽  
Good Clinical Outcome ◽  
Surgical Morbidity ◽  
Language Functions ◽  
Eloquent Areas

Background: Surgical resection of arteriovenous malformations (AVMs) in eloquent areas is significantly associated with greater surgical morbidity. We describe a functional approach for surgical treatment of these lesions Methods: A total of 20 patients with AVMs in eloquent areas were surgically treated and retrospectively analyzed. Individualized functional approach, using brain mapping and/or neurophysiological monitoring was performed in each case according to every case specific features and location. Seventeen patients underwent surgery under assleep conditions and 3 -patients underwent awake intraoperative mapping Results: There was no mortality. Four patients had hemorrhagic complications (20%). Ten (50%) presented neurological immediate postoperative worsening. Eight of them achieved complete recovery in follow up and 2 showed a permanent deficit. At 6 months follow up all the patients (100%) had good clinical outcome (mRS less than 2). There were no intraoperative seizures but 5 patients (26.3%) developed postoperative seizures. Fifteen patients (75%) had total AVM resection. Language and/or motor function were identified in all but one patient (95%). Each case required changes in surgical strategy to preserve the motor and/or language functions during surgery. Conclusions: Intraoperative monitoring and brain mapping are valuable and safe for the treatment of eloquent AVMs by indentifying and protecting motor and language function during resection.

Functional approach using intraoperative brain mapping and neurophysiological monitoring for the surgical treatment of brain metastases in the central region

2017 ◽  
Vol 126 (3) ◽  
pp. 698-707 ◽  
Author(s):  
Jose L. Sanmillan ◽  
Alejandro Fernández-Coello ◽  
Isabel Fernández-Conejero ◽  
Gerard Plans ◽  
Andreu Gabarrós
Keyword(s):  
Brain Metastases ◽  
Central Region ◽  
Brain Mapping ◽  
Brain Parenchyma ◽  
Neurological Deficits ◽  
Neurophysiological Monitoring ◽  
Karnofsky Performance Scale ◽  
Total Recovery ◽  
Eloquent Areas

OBJECTIVE Brain metastases are the most frequent intracranial malignant tumor in adults. Surgical intervention for metastases in eloquent areas remains controversial and challenging. Even when metastases are not infiltrating intra-parenchymal tumors, eloquent areas can be affected. Therefore, this study aimed to describe the role of a functional guided approach for the resection of brain metastases in the central region. METHODS Thirty-three patients (19 men and 14 women) with perirolandic metastases who were treated at the authors' institution were reviewed. All participants underwent resection using a functional guided approach, which consisted of using intraoperative brain mapping and/or neurophysiological monitoring to aid in the resection, depending on the functionality of the brain parenchyma surrounding each metastasis. Motor and sensory functions were monitored in all patients, and supplementary motor and language area functions were assessed in 5 and 4 patients, respectively. Clinical data were analyzed at presentation, discharge, and the 6-month follow-up. RESULTS The most frequent presenting symptom was seizure, followed by paresis. Gross-total removal of the metastasis was achieved in 31 patients (93.9%). There were 6 deaths during the follow-up period. After the removal of the metastasis, 6 patients (18.2%) presented with transient neurological worsening, of whom 4 had worsening of motor function impairment and 2 had acquired new sensory disturbances. Total recovery was achieved before the 3rd month of follow-up in all cases. Excluding those patients who died due to the progression of systemic illness, 88.9% of patients had a Karnofsky Performance Scale score greater than 80% at the 6-month follow-up. The mean survival time was 24.4 months after surgery. CONCLUSIONS The implementation of intraoperative electrical brain stimulation techniques in the resection of central region metastases may improve surgical planning and resection and may spare eloquent areas. This approach also facilitates maximal resection in these and other critical functional areas, thereby helping to avoid new postoperative neurological deficits. Avoiding permanent neurological deficits is critical for a good quality of life, especially in patients with a life expectancy of over a year.

scholarly journals Intracranial Hemorrhage Secondary to a Delayed Cerebral Pseudoaneurysm Rupture 18 Years after Cranial Trauma

2019 ◽  
Vol 11 (3) ◽  
pp. 325-329
Author(s):  
Mikel Terceño ◽  
Sebastià Remollo ◽  
Yolanda Silva ◽  
Saima Bashir ◽  
Carlos Castaño ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Clinical Outcome ◽  
Previous History ◽  
Complete Recovery ◽  
Good Clinical Outcome ◽  
Intracranial Hematoma ◽  
Cranial Trauma ◽  
History Of ◽  
Etiological Study

We report the case of a 38-year-old male with a previous history of severe cranial trauma and subsequent large subdural and subarachnoid hemorrhage on whom an emergent hematoma evacuation was performed with a good outcome and follow-up. Despite a good clinical evolution, the patient experienced a further intracranial hematoma 18 years after the trauma, with severe aphasia and mild right hemiparesis. After complete etiological study, two cranial pseudoaneurysms were observed in the cerebral angiography. Endovascular treatment was successfully completed, achieving full embolization without complications. No rebleeding was detected during follow-up. The patient had a good clinical outcome at 3 months and achieved complete recovery. Cranial pseudoaneurysm rupture is a rare cause of intracerebral hemorrhage, especially if the trauma occurs years before the bleeding.

Natural course of unoperated intracranial arteriovenous malformations: study of 50 cases

1989 ◽  
Vol 71 (6) ◽  
pp. 805-809 ◽  
Author(s):  
Youichi Itoyama ◽  
Syouzaburou Uemura ◽  
Yukitaka Ushio ◽  
Jun-Ichi Kuratsu ◽  
Nobuhito Nonaka ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Poor Prognosis ◽  
Clinical Course ◽  
Initial Symptom ◽  
Intracranial Arteriovenous Malformations ◽  
Good Clinical Outcome ◽  
Content Type ◽  
Initial Rupture ◽  
High Incidence

✓ The clinical course of 50 patients with conservatively treated intracranial arteriovenous malformations (AVM's) was followed, most of them for more than 5 years. The average follow-up period was 13.4 years. The initial symptom was intracranial bleeding in 29 patients (58%) and seizure in 15 patients (30%). Small and deep-seated AVM's were associated with a high incidence of bleeding; however, repeated hemorrhages were not necessarily indicative of a poor prognosis. Children younger than 15 years had a better prognosis than adults. There was no correlation between pregnancy and bleeding. In the hemorrhage group, the incidence of rebleeding was 6.9% in the 1st year after initial rupture, 1.91% per year after 5 years, and 0.92% per year after 15 years. The overall incidence of rebleeding was 34.5% in the hemorrhage group. Of the 50 patients, 37 (74%) had a good clinical outcome, four (8%) had a fair outcome, and four (8%) had a poor outcome; five patients died.

Surgical Risks Associated with the Management of Grade I and II Brain Arteriovenous Malformations

Neurosurgery ◽  
2004 ◽  
Vol 54 (4) ◽  
pp. 832-839 ◽  
Author(s):  
Michael Kerin Morgan ◽  
Andrew Michael Rochford ◽  
Antonio Tsahtsarlis ◽  
Nicholas Little ◽  
Kenneth Charles Faulder
Keyword(s):  
Arteriovenous Malformations ◽  
Adverse Outcome ◽  
Adverse Outcomes ◽  
Morbidity Rate ◽  
Low Grade ◽  
Imaging Features ◽  
Surgical Morbidity ◽  
Martin Grade ◽  
Eloquent Cortex

Abstract OBJECTIVE Grade I and II arteriovenous malformations (AVMs) have been considered safe to resect. However, unoperated low-grade AVMs have not been considered in previously reported series. The aim of this study was to examine all cases, both operated and unoperated, to identify any characteristics of low-grade AVMs that comprise a subgroup that might pose a relatively higher risk. METHODS A prospectively enrolled AVM database included 237 patients in Spetzler-Martin Grade I or II. These patients were analyzed on the basis of demographic characteristics, angiographic and magnetic resonance imaging features, clinical presentation, method of treatment, and outcome. RESULTS Surgery was performed in 220 patients in Spetzler-Martin Grade I or II. Seventeen patients did not undergo treatment because of poor neurological condition (six patients), patient refusal (nine patients), and perceived surgical difficulty (AVM size approaching 3 cm adjacent to Broca's area) (two patients). The overall surgical morbidity rate was 0.9%, and the mortality rate was 0.5%. Adverse outcomes occurred in 1 (0.6%) of 180 patients with AVMs located away from eloquent cortex and in 2 (5%) of 40 patients with AVMs adjacent to eloquent cortex. None of 28 surgical patients with deep venous drainage had an adverse outcome. All 219 patients who survived surgery underwent postoperative angiography that confirmed cure. No postoperative hemorrhage has occurred in 1143 patient-years of follow-up (mean follow-up, 5.3 yr). CONCLUSION When considering adverse outcome in the surgical series of Grade I and II AVMs alone, no statistical difference between non-eloquently located AVMs (0.6%) and eloquently located AVMs (5% adverse outcome) can be detected. However, consideration of all Grade I and II AVMs, both surgical and nonsurgical, may prove that a difference in outcome exists between these two groups masked by case selection. Generalization of the chances of adverse outcomes to all Grade I and II AVMs (both operated and unoperated) suggests that the risk of performing surgery on noneloquent brain in our series was 0.6% and that in eloquent brain could have been as high as 9.5%, had all such patients undergone surgery.

scholarly journals Brainstem arteriovenous malformations: anatomical subtypes, assessment of “occlusion in situ” technique, and microsurgical results

2015 ◽  
Vol 122 (1) ◽  
pp. 107-117 ◽  
Author(s):  
Seunggu J. Han ◽  
Dario J. Englot ◽  
Helen Kim ◽  
Michael T. Lawton
Keyword(s):  
Arteriovenous Malformations ◽  
Multidisciplinary Treatment ◽  
Surgical Morbidity ◽  
Pia Mater ◽  
Complete Obliteration ◽  
Poor Outcomes ◽  
Definition Of ◽  
In Situ Technique

OBJECT The surgical management of brainstem arteriovenous malformations (AVMs) might benefit from the definition of anatomical subtypes and refinements of resection techniques. Many brainstem AVMs sit extrinsically on pia mater rather than intrinsically in the parenchyma, allowing treatment by occluding feeding arteries circumferentially, interrupting draining veins after arteriovenous shunting is eliminated, and leaving the obliterated nidus behind. The authors report here the largest series of brainstem AVMs to define 6 subtypes, assess this “occlusion in situ” technique, and analyze the microsurgical results. METHODS Brainstem AVMs were categorized as 1 of 6 types: anterior midbrain, posterior midbrain, anterior pontine, lateral pontine, anterior medullary, and lateral medullary AVMs. Data from a prospectively maintained AVM registry were reviewed to evaluate multidisciplinary treatment results. RESULTS During a 15-year period, the authors treated 29 patients with brainstem AVMs located in the midbrain (1 anterior and 6 posterior), pons (6 anterior and 7 lateral), and medulla (1 anterior and 8 lateral). The nidus was pial in 26 cases and parenchymal in 3 cases. Twenty-three patients (79%) presented with hemorrhage. Brainstem AVMs were either resected (18 patients, 62%) or occluded in situ (11 patients, 38%). All lateral pontine AVMs were resected, and the occlusion in situ rate was highest with anterior pontine AVMs (83%). Angiography confirmed complete obliteration in 26 patients (89.6%). The surgical mortality rate was 6.9%, and the rate of permanent neurological deterioration was 13.8%. At follow-up (mean 1.3 years), good outcomes (modified Rankin Scale [mRS] score ≤ 2) were observed in 18 patients (66.7%) and poor outcomes (mRS score of 3–5) were observed in 9 patients (33.3%). The mRS scores in 21 patients (77.8%) were unchanged or improved. The best outcomes were observed with lateral pontine (100%) and lateral medullary (75%) AVMs, and the rate of worsening/death was greatest with posterior midbrain and anterior pontine AVMs (50% each). CONCLUSIONS Brainstem AVMs can be differentiated by their location in the brainstem (midbrain, pons, or medulla) and the surface on which they are based (anterior, posterior, or lateral). Anatomical subtypes can help the neurosurgeon determine how to advise patients, with lateral subtypes being a favorable surgical indication along with extrinsic pial location and hemorrhagic presentation. Most AVMs are dissected with the intention to resect them, and occlusion in situ is reserved for those AVMs that do not separate cleanly from the brainstem, that penetrate into the parenchyma, or are more anterior in location, where it is difficult to visualize and preserve perforating arteries (anterior pontine and lateral medullary AVMs). Although surgical morbidity is considerable, surgery results in a better obliteration rate than nonoperative management and is indicated in highly selected patients with high rerupture risks.

Radiosurgery for low-grade intracranial arteriovenous malformations

2014 ◽  
Vol 121 (2) ◽  
pp. 457-467 ◽  
Author(s):  
Dale Ding ◽  
Chun-Po Yen ◽  
Zhiyuan Xu ◽  
Robert M. Starke ◽  
Jason P. Sheehan
Keyword(s):  
Arteriovenous Malformations ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Low Grade ◽  
Surgical Morbidity ◽  
Radiation Induced ◽  
Prescription Dose ◽  
Martin Grade ◽  
Induced Changes

Object Low-grade, or Spetzler-Martin (SM) Grades I and II, arteriovenous malformations (AVMs) are associated with lower surgical morbidity rates than higher-grade lesions. While radiosurgery is now widely accepted as an effective treatment approach for AVMs, the risks and benefits of the procedure for low-grade AVMs, as compared with microsurgery, remain poorly understood. The authors of this study present the outcomes for a large cohort of low-grade AVMs treated with radiosurgery. Methods From an institutional radiosurgery database comprising approximately 1450 AVM cases, all patients with SM Grade I and II lesions were identified. Patients with less than 2 years of radiological follow-up, except those with complete AVM obliteration, were excluded from analysis. Univariate and multivariate Cox proportional-hazards and logistic regression analyses were used to determine factors associated with obliteration, radiation-induced changes (RICs), and hemorrhage following radiosurgery. Results Five hundred two patients harboring low-grade AVMs were eligible for analysis. The median age was 35 years, 50% of patients were male, and the most common presentation was hemorrhage (47%). The median AVM volume and prescription dose were 2.4 cm3 and 23 Gy, respectively. The median radiological and clinical follow-up intervals were 48 and 62 months, respectively. The cumulative obliteration rate was 76%. The median time to obliteration was 40 months, and the actuarial obliteration rates were 66% and 80% at 5 and 10 years, respectively. Independent predictors of obliteration were no preradiosurgery embolization (p < 0.001), decreased AVM volume (p = 0.005), single draining vein (p = 0.013), lower radiosurgery-based AVM scale score (p = 0.016), and lower Virginia Radiosurgery AVM Scale (Virginia RAS) score (p = 0.001). The annual postradiosurgery hemorrhage rate was 1.4% with increased AVM volume (p = 0.034) and lower prescription dose (p = 0.006) as independent predictors. Symptomatic and permanent RICs were observed in 8.2% and 1.4% of patients, respectively. No preradiosurgery hemorrhage (p = 0.011), a decreased prescription dose (p = 0.038), and a higher Virginia RAS score (p = 0.001) were independently associated with postradiosurgery RICs. Conclusions Spetzler-Martin Grade I and II AVMs are very amenable to successful treatment with stereotactic radiosurgery. While patient, physician, and institutional preferences frequently dictate the final course of treatment, radiosurgery offers a favorable risk-to-benefit profile for the management of low-grade AVMs.

Outcomes of Radiosurgery for Brainstem Arteriovenous Malformations

Neurosurgery ◽  
2011 ◽  
Vol 69 (1) ◽  
pp. 45-52 ◽  
Author(s):  
Tomoyuki Koga ◽  
Masahiro Shin ◽  
Atsuro Terahara ◽  
Nobuhito Saito
Keyword(s):  
Arteriovenous Malformations ◽  
Additional Treatment ◽  
Surgical Morbidity ◽  
Factors Associated ◽  
Obliteration Rate ◽  
Early Results ◽  
Number Of Patients ◽  
The Mean ◽  
Risk Of Hemorrhage

Abstract BACKGROUND: Arteriovenous malformations (AVMs) in the brainstem yield a high risk of hemorrhage. Although stereotactic radiosurgery (SRS) is accepted, because of high surgical morbidity and mortality, outcomes are still unclear. OBJECTIVE: We previously reported the early results of SRS for brainstem AVMs. Here, we obtained data from a longer follow-up for a larger number of patients and present precise outcomes based on the latest follow-up data. METHODS: Forty-four patients with brainstem AVMs were treated by SRS. Outcomes such as the rates of obliteration, hemorrhage after treatment, and adverse effects were retrospectively analyzed. RESULTS: The annual hemorrhage rate before SRS was 17.5%. The mean follow-up period after SRS was 71 months (range, 2-168 months). The actuarial obliteration rate confirmed by angiography was 52% at 5 years. Factors associated with higher obliteration rate were previous hemorrhage (P = .048) and higher margin dose (P = .048). For patients treated with a margin dose of ≥ 18 Gy, the obliteration rate was 71% at 5 years. Persistent worsening of neurological symptoms was observed in 5%. The annual hemorrhage rate after SRS was 2.4%. Four patients died of rebleeding, and disease-specific survival rate was 86% at 10 years after treatment. CONCLUSION: Nidus obliteration must be achieved for brainstem AVMs because they possibly cause lethal hemorrhage even after SRS. Treatment with a high margin dose is desirable to obtain favorable outcomes for these lesions. Additional treatment should be considered for an incompletely obliterated nidus.

Effect of Presenting Hemorrhage on Outcome after Microsurgical Resection of Brain Arteriovenous Malformations

Neurosurgery ◽  
2005 ◽  
Vol 56 (3) ◽  
pp. 485-493 ◽  
Author(s):  
Michael T. Lawton ◽  
Rose Du ◽  
Mary Nelson Tran ◽  
Achal S. Achrol ◽  
Charles E. McCulloch ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Predictor Variable ◽  
Consecutive Series ◽  
Surgical Morbidity ◽  
Elective Resection ◽  
Neurological Outcomes ◽  
Improved Outcomes ◽  
Increased Risk ◽  
Microsurgical Resection

Abstract OBJECTIVE: We hypothesized that patients with unruptured arteriovenous malformations (AVMs) at presentation have an increased risk of deterioration compared with patients with ruptured AVMs. METHODS: A consecutive series of 224 patients treated microsurgically by a single neurosurgeon during a period of 6.4 years was analyzed. Initial hemorrhagic presentation was the primary predictor variable. Neurological outcomes were assessed by use of the Modified Rankin Scale (MRS) and Glasgow Outcome Scale (GOS), and logistic regression identified predictors of deterioration at follow-up (mean duration, 1.3 yr) relative to baseline before any intervention. RESULTS: Overall, 120 patients (54%) presented with hemorrhage, and all 224 patients underwent microsurgical resection. Complete resection was achieved in 220 patients (98%). According to GOS score, 13 patients (5.8%) deteriorated; according to MRS score, 45 patients (20.1%) deteriorated. Fifteen patients (6.7%) died. Hemorrhagic presentation was associated with improved outcomes, with a mean change in MRS score of +0.89 in patients with ruptured AVMs and −0.38 in patients with unruptured AVMs (P &lt; 0.001). The final mean MRS scores in patients with unruptured AVMs were better than those in patients with ruptured AVMs (1.44 versus 1.90; P = 0.048). Presentation with an unruptured AVM was a predictor of worsening MRS score (odds ratio, 2.33; 95% confidence interval, 1.3–4.3; P = 0.006) but not of worsening GOS score. CONCLUSION: Presentation with AVM hemorrhage is an underappreciated predictor of outcome after therapy that includes microsurgical resection. Patients with ruptured AVMs tended to have deficits at presentation and generally improved after surgery, whereas patients with unruptured AVMs tended to have normal or nearly normal neurological function at presentation and were susceptible to worsening, albeit slight, as measured by MRS scores. Sensitive outcome measures such as MRS detect subtle symptoms and impairments missed by coarser measures such as GOS. Patients should be counseled that the risks associated with elective resection of unruptured AVMs may be higher than recognized previously. Hemorrhagic brain injury and its secondary effects may mask this surgical morbidity.

Microsurgical management of glomus spinal arteriovenous malformations: pial resection technique

2012 ◽  
Vol 16 (6) ◽  
pp. 523-531 ◽  
Author(s):  
Gregory J. Velat ◽  
Steve W. Chang ◽  
Adib A. Abla ◽  
Felipe C. Albuquerque ◽  
Cameron G. McDougall ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Arteriovenous Malformations ◽  
Signs And Symptoms ◽  
Vascular Lesions ◽  
Morbidity Rate ◽  
Surgical Morbidity ◽  
Surgical Interventions ◽  
Spinal Arteriovenous Malformations

Object Intramedullary, or glomus, spinal arteriovenous malformations (AVMs) are rare vascular lesions amenable to resection with or without adjuvant embolization. The authors retrospectively reviewed the senior author's (R.F.S.'s) surgical series of intramedullary spinal AVMs to evaluate clinical and radiographic outcomes. Methods Detailed chart and radiographic reviews were performed for all patients with intramedullary spinal AVMs who underwent surgical treatment between 1994 and 2011. Presenting and follow-up neurological examination results were obtained and graded using the modified Rankin Scale (mRS) and McCormick Scale. Surgical technique, outcomes, complications, and long-term angiographic studies were reviewed. Results During the study period, 20 patients (10 males and 10 females) underwent resection of glomus spinal AVMs. The mean age at presentation was 30 ± 17 years (range 7–62 years). The location of the AVMs was as follows: cervical spine (n = 10), thoracic spine (n = 9), and cervicothoracic junction (n = 1). The most common presenting signs and symptoms included paresis or paralysis (65%), paresthesias (40%), and myelopathy (40%). Perioperative embolization was performed in the majority (60%) of patients. Pial AVM resection was performed in 17 cases (85%). Angiographically verified AVM obliteration was achieved in 15 patients (75%). At a mean follow-up duration of 45.4 ± 52.4 months (range 2–176 months), 14 patients (70%) remained functionally independent (mRS and McCormick Scale scores ≤ 2). One perioperative complication occurred, yielding a surgical morbidity rate of 5%. Three symptomatic spinal cord tetherings occurred at a mean of 5.7 years after AVM resection. No neurological decline was observed after endovascular and surgical interventions. No deaths occurred. Long-term angiographic follow-up data were available for 9 patients (40%) at a mean of 67.6 ± 60.3 months (range 5–176 months) following AVM resection. Durable AVM obliteration was documented in 5 (83%) of 6 patients. Conclusions Intramedullary AVMs may be safely resected with satisfactory clinical and angiographic results. The pial resection technique, which provides subtotal AVM nidus resection, effectively devascularized these lesions, as confirmed on postoperative angiography, without violating the spinal cord parenchyma, thereby potentially reducing iatrogenic injury.

scholarly journals A treatment paradigm for high-grade brain arteriovenous malformations: volume-staged radiosurgical downgrading followed by microsurgical resection

2015 ◽  
Vol 122 (2) ◽  
pp. 419-432 ◽  
Author(s):  
Adib A. Abla ◽  
William Caleb Rutledge ◽  
Zachary A. Seymour ◽  
Diana Guo ◽  
Helen Kim ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Primary Motor Cortex ◽  
Young Patients ◽  
High Grade ◽  
Surgical Morbidity ◽  
Treatment Paradigm ◽  
Martin Grade ◽  
The Mean ◽  
Risk Of Hemorrhage

OBJECT The surgical treatment of many large arteriovenous malformations (AVMs) is associated with substantial risks, and many are considered inoperable. Furthermore, AVMs larger than 3 cm in diameter are not usually treated with conventional single-session radiosurgery encompassing the entire AVM volume. Volume-staged stereotactic radiosurgery (VS-SRS) is an option for large AVMs, but it has mixed results. The authors report on a series of patients with high-grade AVMs who underwent multiple VS-SRS sessions with resultant downgrading of the AVMs, followed by resection. METHODS A cohort of patients was retrieved from a single-institution AVM patient registry consisting of prospectively collected data. VS-SRS was performed as a planned intentional treatment. Surgery was considered as salvage therapy in select patients. RESULTS Sixteen AVMs underwent VS-SRS followed by surgery. Four AVMs presented with rupture. The mean patient age was 25.3 years (range 13–54 years). The average initial Spetzler-Martin grade before any treatment was 4, while the average supplemented Spetzler-Martin grade (Spetzler-Martin plus Lawton-Young) was 7.1. The average AVM size in maximum dimension was 5.9 cm (range 3.3–10 cm). All AVMs were supratentorial in location and all except one were in eloquent areas of the brain, with 7 involving primary motor cortex. The mean number of VS-SRS sessions was 2.7 (range 2–5 sessions). The mean interval between first VS-SRS session and resection was 5.7 years. There were 4 hemorrhages that occurred after VS-SRS. The average Spetzler-Martin grade was reduced to 2.5 (downgrade, −1.5) and the average supplemented Spetzler-Martin grade was reduced to 5.6 (downgrade, −1.5). The maximum AVM size was reduced to an average of 3.0 cm (downsize = −2.9 cm). The mean modified Rankin Scale (mRS) scores were 1.2, 2.3, and 2.2 before VS-SRS, before surgery, and at last follow-up, respectively (mean follow-up, 6.9 years). Fifteen AVMs were cured after surgery. Ten patients had good outcomes at last follow-up (7 with mRS Score 0 or 1, and 3 with mRS Score 2). There were 2 deaths (both mRS Score 1 before treatment) and 4 patients with mRS Score 3 outcome (from mRS Scores 0, 1, and 2 [n = 2]). CONCLUSIONS Volume-staged SRS can downgrade AVMs, transforming high-grade AVMs (initially considered inoperable) into operable AVMs with acceptable surgical risks. This treatment paradigm offers an alternative to conservative observation for young patients with unruptured AVMs and long life expectancy, where the risk of hemorrhage is substantial. Difficult AVMs were cured in 15 patients. Surgical morbidity associated with downgraded AVMs is reduced to that of postradiosurgical/preoperative supplemented Spetzler-Martin grades, not their initial AVM grades.

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