Multimodality treatment of deep arteriovenous malformations: thalamus, basal ganglia, and brain stem.

THE THERAPEUTIC APPROACH toward arteriovenous malformations (AVMs) located in the basal ganglia, thalamus, and brain stem has evolved from microsurgical resection as the predominant therapy to a combination of microsurgery, embolization, and radiosurgery. This multimodality treatment was used in the management of 32 patients with deep AVMs of all sizes. Twenty-two patients with surgically accessible AVMs (i.e., typically located in the brain stem and thalamus) underwent microsurgical resection. The AVMs of half of these patients were devascularized preoperatively with transfemoral embolization. Five patients with residual AVMs were then treated with radiosurgery. Ten patients had AVMs, typically located in the basal ganglia, that were surgically inaccessible. These patients underwent embolization to reduce the AVM size, and the postembolization nidus was then treated with radiosurgery. For patients treated early in the series with a predominantly surgical approach, the complete resection rate was 43%. For patients treated later in the series after radiosurgery was incorporated into the management scheme, the complete elimination rate was 72%. Overall, there were no deaths in this series, and the permanent treatment-associated morbidity rate was 9%. These results indicate that an individualized, multimodality approach can be used to eliminate both large and small deep AVMs with an acceptably low morbidity and mortality rate.