Deep arteriovenous malformations in the basal ganglia, thalamus, and insula: multimodality management, patient selection, and results

World Neurosurg. Sep-Oct 2014;82(3-4):386-94. doi: 10.1016/j.wneu.2014.03.033. Epub 2014 Mar 19.

Abstract

Objective: This study sought to describe a single institution's experience treating arteriovenous malformations (AVMs) of the basal ganglia, thalamus, and insula in a multimodal fashion.

Methods: We conducted a retrospective review of all deep AVMs treated at our institution between 1997 and 2011 with attention to patient selection, treatment strategies, and radiographic and functional outcomes.

Results: A total of 97 patients underwent initial treatment at our institution. 64% presented with hemorrhage with 29% 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, whereas Spetzler-Martin score and time to follow-up were significantly associated with improved/unchanged functional status at time of last follow-up. Posttreatment 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 with SRS, and is associated with satisfactory results in carefully selected patients.

Keywords: Arteriovenous malformations; Basal ganglia; Radiosurgery; Surgery; Thalamus; Therapeutic embolization.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Adult
  • Basal Ganglia / pathology
  • Basal Ganglia / surgery*
  • Central Nervous System Vascular Malformations / pathology
  • Central Nervous System Vascular Malformations / surgery*
  • Cerebral Cortex / pathology
  • Cerebral Cortex / surgery*
  • Combined Modality Therapy
  • Female
  • Humans
  • Male
  • Microsurgery / methods
  • Middle Aged
  • Patient Selection
  • Radiosurgery
  • Thalamus / pathology
  • Thalamus / surgery*
  • Treatment Outcome
  • Watchful Waiting
  • Young Adult