MULTIDISCIPLINARY TREATMENT OF CEREBRAL ARTERIOVENOUS-MALFORMATIONS

A series of 67 patients treated for cerebral AVM with a multidisciplin ary approach is reported. The malformations were classified after the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Th ree modes of treatment were used: surgical resection, endovascular emb olization, and radiosurgery (linear accelerator technique). The actual treatment was: surgical resection alone (25% of cases), embolization plus resection (25% of cases), embolization alone (27%) and radiosurge ry (30%) either alone (12%), or after incomplete embolization (15%) or after incomplete resection (3%). The clinical outcome was evaluated i n terms of deterioration due to treatment. The treatment was responsib le for a deterioration in 28% of all patients, either minor deteriorat ion (19%) neurological deficit (4%), or death (4%). All complications of surgical resection (17% of all operated cases) and of radiosurgery (10% of irradiated cases) remained minor. None was haemodynamic-relate d. After endovascular embolization, a deterioration occurred in 25% of all embolized cases (minor 13%, neurological deficit 5% and death 8%) . These complications occurring after embolization were haemodynamic r elated: ischaemia and haemorrhage (50% for each mechanism). Haemorrhag e occurred either during or some days after the embolization procedure . The angiographic eradication rate was: 80% overall, 91% after resect ion (with or without previous embolization), 87% after radiosurgery (a lone or after other techniques), and 10% after embolization alone. The discussion reviews in the literature the general evolution of the man agement of cerebral AVMs, with successive application of first surgica l resection, the embolization and lastly radiosurgery. The cerebral co mplications related to cerebral haemodynamics are recalled (normal per fusion pressure breakthrough, disturbances of the venous drainage, thr ombosis of the feeding arteries), together with the effect of selectiv e embolization on these complications. In conclusion, the authors' att itude towards the management of cerebral AVMs is now as follows: 1. Em bolization for large AVMs in order to reduce them and make them access ible for the other two techniques. This goal is not reached in every c ase. 2. Radiosurgery for small AVMs which are located in highly functi onal or deep areas. 3. For small AVMs accessible to surgery, the discu ssion between surgical resection and radiosurgery is more and more oft en in favour of radiosurgery. After the authors' experience the gravit y of the treatment of cerebral AVMs has now shifted from surgical rese ction to endovascular embolization. This endovascular technique should perhaps be reserved to those cases for which reduction of the AVM siz e is absolutely necessary.