Combined embolization and microsurgery for cerebral arteriovenous malformation.

Thirty-seven of 396 patients with arteriovenous malformations (AVMs) were treated by preoperative embolization and surgical excision in our medical center between 1991 and 1997. The AVMs were Spetzler-Martin grade I in six, grade II in 11, grade III in 12, grade IV in four, and Grade V in four. A total of 69 embolization procedures were performed using estrogen alcohol and polyvinyl acetate as liquid embolization materials. AVM grades improved following embolization in 10 patients. Three hemorrhages occurred several days after the final embolization, probably due to hemodynamic stress on the unoccluded perforating feeders or drainer occlusion. Surgical resection was performed under guidance of intraoperative digital subtraction angiography. Although the AVMs were excised totally in one stage with no major neurological deficits, normal perfusion pressure breakthrough occurred in a patient with prominent collateral circulation of the AVM which developed after the main feeder embolization. Preoperative staged embolization with estrogen alcohol and polyvinyl acetate is effective to expand the surgical indication and to achieve complete resection of difficult AVMs. Direct surgery should be performed as soon as possible if hemodynamic changes are observed following embolization.