scholarly journals Combined (microsurgical and endovascular) treatment of cerebral arteriovenous malformations

2020 ◽  
Vol 29 (3) ◽  
pp. 21-26
Author(s):  
D.V. Shchehlov ◽  
M.S. Gudym ◽  
O.E. Svyrydiuk ◽  
I.M. Bortnik ◽  
M.B. Vyval
Keyword(s):  
Endovascular Treatment ◽  
Arteriovenous Malformations ◽  
Combined Treatment ◽  
Postoperative Bleeding ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
Subtotal Resection ◽  
Low Grade ◽  
Treatment Onset ◽  
Scientific Practical

Objective – to analyze the results of combined microsurgical and endovascular treatment of brain arteriovenous malformations (AVM).Materials and methods. Radiological and clinical data of 19 patients who underwent preoperative endovascular embolization and resection of the AVM at the SO «Scientific-practical Center of endovascular neuroradiology NAMS of Ukraine» in 2014–2019 were analyzed. Among patients were 11 (57.9 %) women and 8 (42.1 %) men. The average age of patient was 28.4 year (from 15 to 54 years). All AVMs were I–III grade according to the Spetzler–Martin scale.Results. The average AVM size in its maximum dimension was 3.2 cm (range 3.1–6.8 cm). 14 (73.7 %) AVMs were supratentorial and 5 (26.3 %) – subtentorial, in 9 (47.4 %) cases AVMs were located in eloquent areas of the brain, in 1 (5.3 %) – in the motor area. Cerebral or subarachnoid hemorrhage were observed in 12 (63.2 %) cases, seizures – in 4 (21.1 %), headache not associated with bleeding – in 2 (10.5 %) and neurological deficiency not related to the bleeding – in 1 (3.7 %). In 16 (84.2 %) patients total AVM resection was achieved, 3 (15.8 %) patients underwent subtotal resection. Fourteen (73.7 %) patients had good results at discharge (10 (52.6 %) patients had 0 or 1 according to modified Rankin score, and 4 (21.1%) patients had 2), 5 (26.3 %) – 3 and 4. There were no mortality cases after combined endovascular and microsurgical treatment. Onset of new neurological deficits occurred in 5 (26.3 %) patients, and in 3 (15.8 %) cases it regress at discharge and in 2 (10.5 %) cases was permanent.Conclusions. Combined treatment (endovascular embolization and microsurgical resection) of AVMs of the low grade AVM (I–III grade of the Spetzler–Martin scale) allows achieving good treatment results. The use of preoperative endovascular embolization reduces blood flow through the AVM and prevents postoperative hemodynamic overload, intraoperative and/or postoperative bleeding.

Early Outcomes and Complications of Endovascular Treatment of Cerebral Arteriovenous Malformations in Pediatric Patients

2021 ◽  
Vol 56 (2) ◽  
pp. 116-124
Author(s):  
Aaron Rodriguez-Calienes ◽  
Diego Bustamante-Paytan ◽  
Kiara Camacho ◽  
Angie Mayoria-Vargas ◽  
Giancarlo Saal-Zapata ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Arteriovenous Malformations ◽  
Endovascular Embolization ◽  
Prognostic Scores ◽  
Embolic Agent ◽  
Low Grade ◽  
Single Center ◽  
Efficient Treatment ◽  
Single Center Experience ◽  
Clinical Records

Introduction: Arteriovenous malformations (AVMs) are the commonest cause of hemorrhagic stroke in children. Endovascular embolization is a feasible treatment modality, but cure rates are heterogenous from one series to another. We aimed to describe the immediate obliteration rates and periprocedural complications of embolization of pediatric AVMs. Methods: Between 2011 and 2019, participants below 18 years of age with AVMs treated by the same neurosurgeon at a single center were included. The clinical features, immediate angiographic results, and periprocedural complications were retrospectively collected from the clinical records. Results: Thirty-four embolization sessions were performed on 20 children (12 females with a mean age of 13). Intracranial hemorrhage was the most common presentation (75%), and the majority were frontal (30%) and basal ganglia (30%) lesions. An immediate complete angiographic obliteration was achieved in 9 patients (45%) with low-grade lesions (Spetzler-Martin grade I and II). NBCA was the most common embolic agent used (52.9%). Complications were reported in 3 (8.8%) out of 34 sessions. Two of them were intraoperative perforations with clinical consequences. A slight cortical hemorrhage during the procedure was observed in 1 patient without clinical repercussions. Discussion: This single-surgeon single-center experience suggests that endovascular treatment is a safe and efficient treatment for pediatric AVMs. Pediatric prognostic scores for a suitable selection of candidates are needed. Further studies are required to validate these results.

scholarly journals Microsurgical treatment for cerebellomesencephalic fissure arteriovenous malformations after multiple sessions of endovascular treatment

2021 ◽  
Vol 12 ◽  
pp. 214
Author(s):  
Silvio Sarmento Lessa ◽  
Juan Alberto Paz-Archilla ◽  
Bruno Loof Amorim ◽  
Jose Maria Campos Filho ◽  
Christiane Monteiro de Siqueira Campos ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Therapeutic Strategy ◽  
Endovascular Embolization ◽  
Female Adolescent ◽  
Neurological Deficits ◽  
High Incidence ◽  
Microsurgical Resection

Background: Arteriovenous malformations (AVMs) are relatively uncommon congenital vascular anomalies, and only 7–15% of AVMs occur in the posterior fossa. Most posterior fossa AVMs clinically present with hemorrhage and are associated with a high risk of neurological deficits and mortality. These malformations are associated with a high incidence of flow-related aneurysms. Endovascular treatment of infratentorial AVMs is challenging in pediatric patients. Case Description: We describe an 11-year-old female adolescent with cerebellar syndrome [Video 1], who was diagnosed with a cerebellomesencephalic fissure AVM. We observed a sequential increase in the size of the AVM after multiple sessions of endovascular treatment and performed successful microsurgical resection of the lesion. Conclusion: This illustrative video highlights the role of microsurgery as a feasible therapeutic strategy for complete resection of cerebellar AVMs after endovascular embolization.

Concurrent decompression and resection versus decompression with delayed resection of acutely ruptured brain arteriovenous malformations

2021 ◽  
pp. 1-8
Author(s):  
Rajeev D. Sen ◽  
Isaac Josh Abecassis ◽  
Jason Barber ◽  
Michael R. Levitt ◽  
Louis J. Kim ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Scale Score ◽  
Arteriovenous Malformations ◽  
Endovascular Embolization ◽  
Surgical Decompression ◽  
Low Grade ◽  
Brain Arteriovenous Malformations ◽  
Significant Difference ◽  
Delayed Group

OBJECTIVE Brain arteriovenous malformations (bAVMs) most commonly present with rupture and intraparenchymal hemorrhage. In rare cases, the hemorrhage is large enough to cause clinical herniation or intractable intracranial hypertension. Patients in these cases require emergent surgical decompression as a life-saving measure. The surgeon must decide whether to perform concurrent or delayed resection of the bAVM. Theoretical benefits to concurrent resection include a favorable operative corridor created by the hematoma, avoiding a second surgery, and more rapid recovery and rehabilitation. The objective of this study was to compare the clinical and surgical outcomes of patients who had undergone concurrent emergent decompression and bAVM resection with those of patients who had undergone delayed bAVM resection. METHODS The authors conducted a 15-year retrospective review of consecutive patients who had undergone microsurgical resection of a ruptured bAVM at their institution. Patients presenting in clinical herniation or with intractable intracranial hypertension were included and grouped according to the timing of bAVM resection: concurrent with decompression (hyperacute group) or separate resection surgery after decompression (delayed group). Demographic and clinical characteristics were recorded. Groups were compared in terms of the primary outcomes of hospital and intensive care unit (ICU) lengths of stay (LOSs). Secondary outcomes included complete obliteration (CO), Glasgow Coma Scale score, and modified Rankin Scale score at discharge and at the most recent follow-up. RESULTS A total of 35/269 reviewed patients met study inclusion criteria; 18 underwent concurrent decompression and resection (hyperacute group) and 17 patients underwent emergent decompression only with later resection of the bAVM (delayed group). Hyperacute and delayed groups differed only in the proportion that underwent preresection endovascular embolization (16.7% vs 76.5%, respectively; p < 0.05). There was no significant difference between the hyperacute and delayed groups in hospital LOS (26.1 vs 33.2 days, respectively; p = 0.93) or ICU LOS (10.6 vs 16.1 days, respectively; p = 0.69). Rates of CO were also comparable (78% vs 88%, respectively; p > 0.99). Medical complications were similar in the two groups (33% hyperacute vs 41% delayed, p > 0.99). Short-term clinical outcomes were better for the delayed group based on mRS score at discharge (4.2 vs 3.2, p < 0.05); however, long-term outcomes were similar between the groups. CONCLUSIONS Ruptured bAVM rarely presents in clinical herniation requiring surgical decompression and hematoma evacuation. Concurrent surgical decompression and resection of a ruptured bAVM can be performed on low-grade lesions without compromising LOS or long-term functional outcome; however, the surgeon may encounter a more challenging surgical environment.

Curative treatment for low-grade arteriovenous malformations

2019 ◽  
Vol 12 (1) ◽  
pp. 48-54 ◽  
Author(s):  
Arthur Wang ◽  
Grace K Mandigo ◽  
Neil A Feldstein ◽  
Michael B Sisti ◽  
E Sander Connolly ◽  
...  
Keyword(s):  
Surgical Resection ◽  
Functional Outcomes ◽  
Arteriovenous Malformations ◽  
Combined Treatment ◽  
Curative Treatment ◽  
Embolic Agent ◽  
Preoperative Embolization ◽  
Low Grade ◽  
The Mean

BackgroundSpetzler-Martin (SM) grade I-II (low-grade) arteriovenous malformations (AVMs) are often considered safe for microsurgery or radiosurgery. The adjunctive use of preoperative embolization to reduce surgical risk in these AVMs remains controversial.ObjectiveTo assess the safety of combined treatment of grade I-II AVMs with preoperative embolization followed by surgical resection or radiosurgery, and determine the long-term functional outcomes.MethodsWith institutional review board approval, a retrospective analysis was carried out on patients with ruptured and unruptured SM I-II AVMs between 2002 and 2017. Details of the endovascular procedures, including number of arteries supplying the AVM, number of branches embolized, embolic agent(s) used, and complications were studied. Baseline clinical and imaging characteristics were compared. Functional status using the modified Rankin Scale (mRS) before and after endovascular and microsurgical treatments was compared.Results258 SM I-II AVMs (36% SM I, 64% SM II) were identified in patients with a mean age of 38 ± 17 years. 48% presented with hemorrhage, 21% with seizure, 16% with headache, 10% with no symptoms, and 5% with clinical deficits. 90 patients (68%) in the unruptured group and 74 patients (59%) in the ruptured group underwent presurgical embolization (p = 0.0013). The mean number of arteries supplying the AVM was 1.44 and 1.41 in the unruptured and ruptured groups, respectively (p = 0.75). The mean number of arteries embolized was 2.51 in the unruptured group and 1.82 in the ruptured group (p = 0.003). n-Butyl cyanoacrylate and Onyx were the two most commonly used embolic agents. Four complications were seen in four patients (4/164 patients embolized): two peri-/postprocedural hemorrhage, one dissection, and one infarct. All patients undergoing surgery had a complete cure on postoperative angiography. Patients were followed up for a mean of 55 months. Good long-term outcomes (mRS score ≤ 2) were seen in 92.5% of patients with unruptured AVMs and 88.0% of those with ruptured AVMs. Permanent neurological morbidity occurred in 1.2%.ConclusionsCurative treatment of SM I-II AVMs can be performed using endovascular embolization with microsurgical resection or radiosurgery in selected cases, with very low morbidity and high cure rates. Compared with other published series, these outcomes suggest that preoperative embolization is a safe and effective adjunct to definitive surgical treatment. Long-term follow-up showed that patients with low-grade AVMs undergoing surgical resection or radiosurgery have good functional outcomes.

PREOPERATIVE EMBOLIZATION OF INTRACRANIAL ARTERIOVENOUS MALFORMATIONS WITH ONYX

Neurosurgery ◽  
2007 ◽  
Vol 61 (2) ◽  
pp. 244-254 ◽  
Author(s):  
Werner Weber ◽  
Bernhard Kis ◽  
Ralf Siekmann ◽  
Paul Jans ◽  
Rudolf Laumer ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Clinical Status ◽  
Combined Treatment ◽  
Brain Regions ◽  
Neurological Deficits ◽  
Preoperative Embolization ◽  
Liquid Embolic ◽  
Delayed Hemorrhage ◽  
The Mean

Abstract OBJECTIVE Preoperative embolization in accordance with multimodal therapies for cerebral arteriovenous malformations (AVMs) is generally the first step in treatment and may result in complete obliteration. The Onyx liquid embolic system (Micro Therapeutics, Inc., Irvine, CA) may offer advantages for intranidal targeted embolization and microsurgical resection. We present our experience in the combined treatment of intracranial AVMs using Onyx embolization and neurosurgical resection. METHODS We treated a total of 47 patients for compact intracranial AVMs that were located in the frontal or frontoparietal area (16 patients); temporal, temporoparietal, or temporo-occipital regions (12 patients); parietal or parieto-occipital areas (8 patients); occipital regions (8 patients); had basal ganglia involvement (2 patients); and was cerebellar (1 patient). The Spetzler-Martin grading scale values were as follows: 25 patients were Grades I or II, 10 patients were Grade III, and 12 patients were Grades IV or V. Twenty-three AVMs were located in eloquent brain regions. RESULTS After we performed final embolizations, the mean nidus reduction was 84%. Seven patients had new, nondisabling neurological deficits, and four patients had new, disabling neurological deficits after embolization. Periprocedurally, five vessel perforations and four stuck microcatheters were encountered without clinical deficits. In two patients, delayed hemorrhage after embolization occurred with good clinical outcome. We completely resected 46 AVMs; in one patient, we detected an AVM on postoperative angiography. The mean operative time was 4.7 hours, and the mean blood loss was 455 mL. Clinical status worsened postoperatively in 14 patients. Angiographic and clinical follow-up examinations were available for 42 patients (89%); the average follow-up period was 13 months. We found no relapse of arteriovenous shunt. Fourteen patients improved clinically after discharge. Of the 42 patients followed up, 23 individuals had no neurological deficit, 16 had a nondisabling deficit, and three had a disabling deficit. CONCLUSION Preoperative use of the Onyx liquid embolic system in cerebral AVM treatment allows profound occlusion by targeted embolization and provides a basis for safe neurosurgical resection.

scholarly journals Complication Analysis of 469 Brain Arteriovenous Malformations Treated with N-Butyl Cyanoacrylate

2005 ◽  
Vol 11 (2) ◽  
pp. 141-148 ◽  
Author(s):  
T. L. Li ◽  
B. Fang ◽  
X. Y. He ◽  
C. Z. Duan ◽  
Q. J. Wang ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Endovascular Procedures ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
Embolization Therapy ◽  
Brain Arteriovenous Malformations ◽  
Ischemic Complications ◽  
Brain Avms ◽  
Special Strategy ◽  
Low Rate

We independently assessed the frequency, severity and determinants of neurological deficits after endovascular embolization with NBCA of brain arteriovenous malformations (BAVMs) to have a better basis for making treatment decisions. All the charts of 469 BAVMs patients who underwent embolization with NBCA were reviewed. We analyzed the complications and their relation to angiographic features. The 469 patients were treated with 1108 endovascular procedures. Each met one to eight times, average 2.3 times. Eleven patients showed treatment-related complications, including four haemorrhagic and seven ischemic complications. Of these 11 cases, two died, two had persistent disabling deficits, and another seven suffered transient neurological deficits. Our finding suggests a low rate of disabling treatment complications for embolization of brain AVMs with NBCA in this center. The management of AVM patients who have high risk of embolization therapy should be treated by special strategy.

scholarly journals Efficacy and Safety of Combined Endovascular Embolization and Stereotactic Radiosurgery for Patients with Intracranial Arteriovenous Malformations: A Systematic Review and Meta-Analysis

2021 ◽  
Vol 2021 ◽  
pp. 1-11
Author(s):  
Zhiqun Jiang ◽  
Xuezhi Zhang ◽  
Xichen Wan ◽  
Minjun Wei ◽  
Yue Liu ◽  
...  
Keyword(s):  
Sensitivity Analysis ◽  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Meta Analysis ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
Cochrane Library ◽  
Efficacy And Safety ◽  
Intracranial Arteriovenous Malformations ◽  
Obliteration Rate

Whether the use of endovascular embolization could provide additional benefits in patients treated with stereotactic radiosurgery (SRS) for intracranial arteriovenous malformations (IAVMs) remains controversial. The current meta-analysis was conducted to assess the efficacy and safety of SRS with and without prior endovascular embolization in patients with IAVMs. The electronic databases of PubMed, EmBase, and Cochrane Library were systematically searched for eligible studies published from inception to August 12, 2020. The pooled results for obliteration rate, rehemorrhage rate, and permanent neurological deficits were calculated by odds ratios (ORs) with 95% confidence intervals (CIs) using the random-effects model. The sensitivity analysis, subgroup analysis, and publication bias for investigated outcomes were also evaluated. Nineteen studies (two prospective and 17 retrospective studies) involving a total of 3,454 patients with IAVMs were selected for the final meta-analysis. We noted that prior embolization and SRS were associated with a lower obliteration rate compared with SRS alone (OR, 0.57; 95% CI, 0.44–0.74; P < 0.001 ). However, prior embolization and SRS were not associated with the risk of rehemorrhage (OR, 1.05; 95% CI, 0.81–1.34; P = 0.729 ) and permanent neurological deficits (OR, 0.80; 95% CI, 0.48–1.33; P = 0.385 ) compared with SRS alone. The sensitivity analysis suggested that prior embolization might reduce the risk of permanent neurological deficits in patients with IAVMs treated with SRS. The treatment effects of prior embolization in patients with IAVMs could be affected by nidus volume, margin dose, intervention, and follow-up duration. This study found that prior embolization was associated with a reduced risk of obliteration in patients with IAVMs treated with SRS. Moreover, prior embolization might reduce the risk of permanent neurological deficits in patients with IAVMs.

scholarly journals Endovascular Treatment of Chronic Subdural Hematomas through Embolization: A Pilot Study with a Non-Adhesive Liquid Embolic Agent of Minimal Viscosity (Squid)

2021 ◽  
Vol 10 (19) ◽  
pp. 4436
Author(s):  
Andrey Petrov ◽  
Arkady Ivanov ◽  
Larisa Rozhchenko ◽  
Anna Petrova ◽  
Pervinder Bhogal ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Complete Resolution ◽  
Middle Meningeal Artery ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
Embolic Agent ◽  
Ethylene Vinyl Alcohol ◽  
Arteriovenous Fistulas ◽  
Subdural Hematomas

Objective: Endovascular embolization using non-adhesive agents (e.g., ethylene vinyl alcohol copolymer with suspended micronized tantalum dissolved in dimethyl sulfoxide; Squid, Balt Extrusion) is an established treatment of brain arteriovenous malformations, dural arteriovenous fistulas, and hypervascular neoplasms. Middle meningeal artery (MMA) embolization is a relatively new concept for treating chronic subdural hematomas (CSDH). This study aimed to evaluate the safety and effectiveness of the use of Squid in the endovascular treatment of CSDH. Methods: Embolization was offered to patients with CSDH with minimal or moderate neurological deficits and patients who had previously undergone open surgery to evacuate their CSDH without a significant effect. Distal catheterization of the MMA was followed by embolization of the hematoma capsule with Squid 12 or Squid 18. Safety endpoints were ischemic or hemorrhagic stroke and any other adverse event of the endovascular procedure. Efficacy endpoints were the feasibility of the intended procedure and a ≥ 50% reduction of the maximum depth of the CSDH confirmed by follow-up computed tomography (CT) after >3 months. Results: Between November 2019 and July 2021, 10 patients (3 female and 7 male, age range 42–89 years) were enrolled. Five patients had bilateral hematomas, and five patients had previously been operated on with no significant effect and recurrent hematoma formation. The attempted embolization was technically possible in all patients. No technical or clinical complication was encountered. During a post-procedural follow-up (median 90 days), 10 patients improved clinically. A complete resolution of the CSDH was observed in 10 patients. The clinical condition of all enrolled patients during the so-far last contact was rated mRS 0 or 1. Conclusion: A distal catheterization of the MMA for the endovascular embolization of CSDH with Squid allowed for the devascularization of the MMA and the dependent vessels of the hematoma capsule. This procedure resulted in a partial or complete resolution of the CSDH. Procedural complications were not encountered.

scholarly journals Imaging Characteristics and Endovascular Treatment of Brain Arteriovenous Malformations Mainly Fed by the Posterior Cerebral Artery

2021 ◽  
Vol 11 ◽  
Author(s):  
Kun Hou ◽  
Chao Li ◽  
Han Su ◽  
Jinlu Yu
Keyword(s):  
Endovascular Treatment ◽  
Cerebral Artery ◽  
Arteriovenous Malformations ◽  
Posterior Cerebral Artery ◽  
Postoperative Bleeding ◽  
Venous Drainage ◽  
Type I ◽  
Type Ii ◽  
Brain Arteriovenous Malformations ◽  
Imaging Characteristics

Background: A BAVM that is mainly supplied by the posterior cerebral artery (PCA) lies deeply in the middle of the bilateral posterior hemispheres. Few studies have investigated the imaging characteristics and endovascular treatment (EVT) of brain arteriovenous malformations (BAVMs) in this area.Methods: A retrospective study was performed for patients who were diagnosed with PCA-BAVMs from January 2015 to December 2019. The PCA-BAVMs were divided into type I and type II according to their feeding arteries. Type I PCA-BAVMs were supplied by the posterior choroidal artery (PchA) from the PCA. They could be further subdivided into type Ia and type Ib. Type II PCA-BAVMs were supplied by the temporal or occipital branch from the PCA. They could also be further subdivided into type IIa and IIb. Targeted embolization of the risk factors was the main aim of EVT.Results: Forty-two patients were identified, with age ranging from 6 to 63 years. Twenty-four cases belonged to type I (57.1%, 24/42), including 6 Ia cases and 18 Ib cases. Eighteen cases belonged to type II (42.9%, 18/42), including 7 IIa cases and 11 IIb cases. Immediate complete or nearly complete embolization was achieved in 17 (40.5%, 17/42) cases. Partial embolization was achieved in 25 (59.5%, 25/42) cases. Two (4.8%, 2/42) patients experienced intraoperative or postoperative bleeding. The GOS scores at discharge were 3, 4, and 5 in 2 (4.8%, 2/42), 2 (4.8%, 2/42), and 38 (90.4%, 38/42) cases, respectively. There was no statistical difference between patients in type I and type II groups regarding age, BAVM rupture, SM grade, immediate extent of obliteration, and prognosis. Deep venous drainage was more common in patients of the type I group (P &lt; 0.001).Conclusions: Our classification of the PCA-BAVMs was based on the segmentation of the PCA, which is a reasonable approach and could guide the strategy of EVT. EVT is a reasonable option for the PCA-BAVMs. The main aim of EVT is to secure the weak structures. A targeted EVT aimed at the ruptured part of the BAVM can reduce the risk of early rebleeding.

Treatment of Cerebral Arteriovenous Malformations with a Combination of Preoperative Embolization and Surgery

Neurosurgery ◽  
1991 ◽  
Vol 29 (3) ◽  
pp. 358-368 ◽  
Author(s):  
Alberto Pasqualin ◽  
Renato Scienza ◽  
Fabrizia Cioffi ◽  
Giovanni Barone ◽  
Aldo Benati ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Arteriovenous Malformations ◽  
Combined Treatment ◽  
Neurological Deficits ◽  
Preoperative Embolization ◽  
Surgical Removal ◽  
Cerebral Arteriovenous Malformations ◽  
Selective Embolization ◽  
Intraoperative Bleeding ◽  
Microsurgical Approach

Abstract Forty-nine patients with cerebral arteriovenous malformations (AVMs) were treated with preoperative embolization followed by resection using a microsurgical approach. In 27 patients, the AVM was located in an eloquent area; in 32 patients, the volume of the AVM was over 20 cm3. Preoperatively, flow-directed embolization was performed in 10 patients (28 procedures), selective embolization with threads was performed in 35 patients (46 procedures), and a combination of flow-directed and selective embolization was performed in 4 patients (12 procedures). The percentage of reduction of the AVM volume averaged 36% after embolization. Five minor complications (transient neurological deficits, in 2 cases associated with ischemic areas on the CT scan) were observed after embolization. The interval between the last embolization and surgery was as follows: within 10 days in 7 patients; between 11 and 20 days in 3 patients; between 21 and 30 days in 10 patients; between 31 and 60 days in 11 patients; and 2 months later in 18 patients. The efficacy of this combined treatment (embolization plus surgery) was evaluated by the incidence of hyperemic complications and the clinical outcome. Hyperemic complications occurred more frequently in patients with an AVM volume greater than 20 cm3. When compared with flow-directed embolization, selective embolization was linked with decreased bleeding during surgery; postoperatively, the incidence of cerebral edema was also lower. Clinical outcome was better after selective embolization, with no occurrence of major deficits and no mortality. When the percentage of reduction of the AVM volume after embolization was 40% or more, the incidence of intraoperative hyperemic complications was lower; moreover, new permanent deficits were never observed in patients with this volume reduction. A retrospective clinical comparison of two groups of patients with similar AVM volumes (&gt;20 cm3)—those given combined treatment (n = 32) versus those treated by direct surgery alone (n = 27)—showed that intraoperative bleeding appeared to decrease in patients treated by embolization; the incidence of postoperative hyperemic complications was not different in the two groups. New major deficits and deaths were less frequent in patients treated by embolization (P= 0.05 for the incidence of major deficits); postoperative epilepsy was also less common in these patients. In conclusion, combined treatment with selective preoperative embolization and direct surgery may help the neurosurgeon in the treatment of large, high-flow AVMs, reducing the risks connected with their surgical removal. (Neurosurgery 29:358-368, 1991)

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