gms | German Medical Science

Objective: Nidal penetration and obliteration was the aim of endovascular pre-operative treatment for severals years, otherwise we presented here a different treatment "strategy" where endovascular embolization is directed at specific angiographic target areas.

The aim of pre-surgical endovascular targeted treatment is to reduce the cumulative risks of embolization plus surgery and do not exceed the risks of AVM treatment without embolization. We identified three patterns of embolization: type "a") to occlude AVMs deep arterial feeders, type "b") for extensive volumetric nidal reduction (in cases of diffuse AVM, high-flow or malformations with high venous recruitment), type "c") to occlude aneurysms and/or A-V fistula (with or without acute bleeding).

Method: We have analyzed 68 consecutive patients who underwent a surgical treatment for a cerebral AVMs between January 2011 and December 2013. 43 pts (63%) presented with an unruptured AVM, while 25 pts (37%) had a ruptured malformation. 37 pts (54 %) were grade I and II S&M ( 22 pts unruptured and 15 pts ruptured), 24 pts (35%) were grade III (17 and 7 pts respectively), 7 pts (11%) were grade IV and V (4 and 3 pts respectively). 33 pts (48%) underwent to pre-surgical targeted endovascular embolization (23 pts with unruptued AVM and 10 with ruptured AVM), 4 pts underwent to a double treatment type. 11 of 37 pre-surgical embolization (30%) underwent to endovascular occlusion of the deep feeders (type "a"), 16 (43%) underwent to extensive volumetric nidal reduction (type "b") and 10 pts (27 %) to type "c" (selective occlusion o f aneurysm or Fistula).

Results: All patients were evaluated with GOS scale at discharge and at 1 ys follow-up. At follow-up of all 43 pts with unruptured AVM,42 pts (99%) presented with GOS 5 and 1 pts (1%) presented with GOS 4. On the contrary out of 25 pts with ruptured AVM, 19 pts (76%) presented with GOS 4 and 5, 12 pts were classified as S-M grade I-II, 5 as S-M grade III and 2 as grade IV-V. One patient with S-M grade IV AVM death after surgical treatment.

Conclusions: Clinical control at follow-up demonstrated the excellent results for surgically treated AVM pts with a clear distinction between unruptured and ruptured AVM. These results seem to indicate a lack of need for AVM nidus obliteration and the excellent results with pre-surgical targeted endovascular treatment. We highlight also as S-M grade IV and V malformations underwent almost exclusively to type "a" treatment, instead grade I and II to type "b" and "c" with a clear propensity to pre-surgical endovascular embolization (12 pts, 32% of all grade I and II) especially for unruptured AVM (45 vs 13%).