[The neurosurgeon's role in the treatment of cerebral arteriovenous malformations. A study of a series of 100 cases and review of the literature].

The Neurosurgeons's place in the management of cerebral A.V.M.'s is discussed in the light of a personal experience and of the review of the neurosurgical literature. A personal series of 100 treated patients is presented. Patients were admitted between 1985 and April 1992. Two groups are considered: the first group including 52 patients treated before the availability of radiosurgery (1985-1988), and the second group including 48 patients treated afterwards (1989-1992). A.V.M.'s were classified in five grades according to the Spetlzer's Grading System. Three techniques of treatment were used: Surgical Resection, Intravascular Embolization (cyanoacrylate) and Radiosurgery (linear accelerator). These three techniques were used either alone or in association, giving four types of management: surgical resection alone, embolization and resection, embolization alone, and radiosurgery (alone, or after embolization or after surgical resection). From 1989 on, the availability of radiosurgery was responsible for the diminution of the "embolization and resection" group, which until then was predominantly used, for the low-grade A.V.M.'s (I.II.III) and for the high grade A.V.M.'s (IV.V) as well. Overall, for the low grade A.V.M.'s, the treatment of choice was the surgical resection (79% of cases), with a preoperative embolization in one half of these cases; the other A.V.M.'s were irradiated, with various combinations. For the high-grade A.V.M.'s, the treatment of choice was the intravascular embolization (95% of cases), either alone, or followed by exeresis (45%) or radiosurgery (9%). Results were evaluated in terms of deterioration due to treatment, in five groups: no deterioration (59%), minor deterioration (20%), long-lasting deficit (10%), major deterioration (5%) and death (6%). Overall, results improved after 1989: favourable outcome (no deterioration and minor deterioration) increased from 67% to 90%. Results were not related to the patient's age. More favourable results were obtained for low grade A.V.M.'s (93%) than for high grade A.V.M.'s (60%). For the low grade A.V.M.S. the evolution form 1989 on (favourable outcome increasing from 89% to 96%) occurred with the suppression of death cases. For the high grade A.V.M.'s, the evolution from 1989 on (favourable outcome increasing from 46% to 78%), occurred with the decreasing of the deficit cases. The angiographic eradication was strongly related to the management: 95% of complete eradication after surgical resection and 5% only after embolization alone. Concerning the results in irradiated cases, the follow-up is not long enough. The review of the neurosurgical literature since 1972 demonstrates progressive modifications in the therapeutic attitude as regards A.V.M.'s. The surgical management which was predominantly used at the beginning gave progressively way to a combined management, with a combination of embolization, surgery, and lately radiosurgery.(ABSTRACT TRUNCATED AT 400 WORDS)