A Retrospective Cohort Analysis of Hemorrhagic Arteriovenous Malformations Treated with Combined Endovascular Embolization and Gamma Knife Stereotactic Radiosurgery

Nathan Todnem, Ayobami Ward, Michael Nahhas, John R Vender, Cargill Herley Alleyne, Scott Y Rahimi

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Abstract

Background: The management of brain arteriovenous malformations (AVMs) remains a controversial topic. Given the relatively low incidence, high heterogeneity, and high morbidity and mortality of these lesions, consensus on treatment strategies is an issue of concern to organized neurosurgery. The present retrospective analysis examined and quantified the outcomes of patients with an initial presentation of intracranial hemorrhage from a Spetzler-Martin grade III or IV AVM, later ruled out as surgical candidates. Methods: A total of 16 patients (5 females; 11 males) had presented with symptomatic hemorrhage confirmed by non–contrast-enhanced computed tomography and were deemed to not be surgical candidates owing to AVM location and/or architecture. The patients underwent combined endovascular embolization and gamma knife stereotactic radiosurgery (SRS). The modified Rankin scale was used to measure the clinical outcomes, comparing the scores at presentation, gamma knife treatment, and the last known follow-up examination. A radiographic evaluation was used to determine the level of AVM nidus involution after the procedure. Results: The present study identified 16 patients with ruptured high-grade AVMs of high surgical risk. All the patients had undergone immediate embolization with delayed SRS for treatment of the hemorrhage and nidus of the AVM. A statistically significant proportion of patients showed marked improvement in the modified Rankin scale scores. No subsequent repeat hemorrhage or any associated complications after embolization occurred in any patient. Conclusion: These findings warrant consideration of endovascular embolization with adjuvant SRS as a powerful treatment option for cases with high surgical morbidity due to AVM characteristics.

Original languageEnglish (US)
Pages (from-to)e713-e722
JournalWorld Neurosurgery
Volume122
DOIs
StatePublished - Feb 1 2019

Fingerprint

Radiosurgery
Arteriovenous Malformations
Cohort Studies
Hemorrhage
Morbidity
Intracranial Hemorrhages
Neurosurgery
Therapeutics
Tomography
Outcome Assessment (Health Care)
Mortality
Incidence
Brain

Keywords

  • Arteriovenous malformation
  • Embolization
  • Endovascular
  • Gamma knife
  • Radiosurgery
  • Spetzler-Martin
  • Stereotactic

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

A Retrospective Cohort Analysis of Hemorrhagic Arteriovenous Malformations Treated with Combined Endovascular Embolization and Gamma Knife Stereotactic Radiosurgery. / Todnem, Nathan; Ward, Ayobami; Nahhas, Michael; Vender, John R; Alleyne, Cargill Herley; Rahimi, Scott Y.

In: World Neurosurgery, Vol. 122, 01.02.2019, p. e713-e722.

Research output: Contribution to journalArticle

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abstract = "Background: The management of brain arteriovenous malformations (AVMs) remains a controversial topic. Given the relatively low incidence, high heterogeneity, and high morbidity and mortality of these lesions, consensus on treatment strategies is an issue of concern to organized neurosurgery. The present retrospective analysis examined and quantified the outcomes of patients with an initial presentation of intracranial hemorrhage from a Spetzler-Martin grade III or IV AVM, later ruled out as surgical candidates. Methods: A total of 16 patients (5 females; 11 males) had presented with symptomatic hemorrhage confirmed by non–contrast-enhanced computed tomography and were deemed to not be surgical candidates owing to AVM location and/or architecture. The patients underwent combined endovascular embolization and gamma knife stereotactic radiosurgery (SRS). The modified Rankin scale was used to measure the clinical outcomes, comparing the scores at presentation, gamma knife treatment, and the last known follow-up examination. A radiographic evaluation was used to determine the level of AVM nidus involution after the procedure. Results: The present study identified 16 patients with ruptured high-grade AVMs of high surgical risk. All the patients had undergone immediate embolization with delayed SRS for treatment of the hemorrhage and nidus of the AVM. A statistically significant proportion of patients showed marked improvement in the modified Rankin scale scores. No subsequent repeat hemorrhage or any associated complications after embolization occurred in any patient. Conclusion: These findings warrant consideration of endovascular embolization with adjuvant SRS as a powerful treatment option for cases with high surgical morbidity due to AVM characteristics.",
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