T E C H N IC A L C A SE R E P O R T S

Staged Volume Radiosurgery Followed by
Microsurgical Resection: A Novel
Treatment for Giant Cerebral
Arteriovenous Malformations: Technical
Case Report

w h ich w e r e d e te r m in e d to b e u n resectab le at that time. T h e p atient u n d e r w e n t
six a tte m p ts at e m b o liz a tio n (u sin g G elfo a m [The U p jo h n C o ., K a la m a z o o , M I]
and p o ly v in y l alco h o l particles) in the 2
y e a rs after d ia g n o sis, w h ic h resulted in
partial

n id u s obliteration, b u t

he sus­

tained a n o th e r h e m o r r h a g e , c a u s in g right
h e m ip a re s is an d m o d e r a te a p h asia. H e
m ade

an

excellen t r e c o v e ry

fro m

this

even t, p r o m p tin g tw o a d d itio n al a tte m p ts
at e m b o liz a tio n u sin g particles, w h ic h re­

Andrew D. Firlik, M.D., Elad I. Levy, M.D.,
Douglas Kondziolka, M.D., Howard Yonas, M.D.

sulted in fu rth er partial n id u s red u ction.

Department of Neurological Surgery, University of Pittsburgh Medical Center,
Pittsburgh, Pennsylvania

b ilit a t in g h e a d a c h e s , s e i z u r e s , a n d i n t e r ­

T h r e e y e a rs after his initial p resen tatio n ,
th e p a t ie n t c o n t i n u e d to e x p e r i e n c e d e ­
m itten t

r ig h t - s id e d

p a r e s t h e s ia

and

h e m ip a r e s is . In a n a t t e m p t to a m e l i o r a t e
h is s y m p t o m s a n d p r o t e c t h i m f r o m a n ­

OBJECTIVE A N D IM PO R TAN CE: W e describe the successful trea tm e n t o f
symptomatic giant a rte rio ve n o u s m alfo rm a tio n s (AVMs) using staged
volume radiosurgery fo llo w e d by m icrosurgica l resection.
CLINICAL PRESENTATION: A 57-ye a r-old man presented w ith SpetzlerMartin Grade 5 A VM s, w ith persistent headaches and seizures. He had
previously undergone eight attem pts at A V M e m b o liza tio n and a c ra n i­
otomy for attem pted A V M resection; he had suffered fo u r episodes o f
brain hem orrhaging b u t had made a good neurological recovery.
INTERVENTION: Because o f the persistent sym ptom s o f the p a tie n t and his
history of hem orrhaging, a tre a tm e n t plan based on staged radiosurgical
treatments o f d iffe re n t p o rtio n s o f the AVM s (three sessions, spaced 6 mo
apart), follow ed by delayed m icro su rg ica l rem oval o f the m uch-reduced
residual AVMs (3 years la te r), was undertaken. The patient did not suffer
any additional h em o rrh a g in g episodes, his AVM s w ere com p le te ly re­
moved, and he has made a good recovery.
CONCLUSION: Staged vo lu m e radiosurgery fo llo w e d by m icrosurgical re­
section of the residual A V M s represents a novel tre a tm e n t strategy fo r the
management o f G rade 5 A V M s th a t m ight be untreatable by any single
treatment m ethod used alone. (Neurosurgery 4 3 :1 2 2 3 -1 2 2 8 , 1998)
bywords: Arteriovenous malformations, Microsurgery, Stereotactic radiosurgery

other h em o rrh a g e, a cra n io to m y w as
p e r f o r m e d to s u r g i c a l l y lig a te a n d d i ­
r e c tly e m b o l i z e m a jo r f e e d i n g v e s s e ls .
P o s t o p e r a t i v e l y , th e p a t ie n t w a s h e m i ­
p le g ic o n th e r ig h t a n d m o d e r a t e l y g l o ­
b a l l y a p h a s ic .
In th e n e x t 2 y e a r s , th e p a t ie n t m a d e a
good

T h e s u c c e s s fu l tre a tm e n t ° ^ rrn a 1 co m p le x, a rte rio v e n o u s
iQ c a tio n S
fo rts (A V M s ) in c r itic a l
.
rem ains a c h a lle n g e .
treatm ent s tra te g ie s u s in g
ot e m b o liz a tio n , m ic ro s u rg e

e li m in a t e d b y e ith e r r a d i o s u r g e r y o r m i ­
c r o s u r g e r y a lo n e .

o d a \ it y
b i n a tio n s
a n (j ra ^

8

, to, 151. ^

new a p p ro a ch o f s ta g e d v o
surgery fo llo w e d b y d e la y e ^
grcal re s e c tio n to r a p a n e

r ig h t h e m i p a r e s i s . H e c o n t i n u e d to b e
p la g u e d b y s e v e r e o c c ip ita l h e a d a c h e s ,
r ig h t a r m p a r e s t h e s ia , a n d f r e q u e n t s e i ­
zures, d esp ite ap p ro p ria te a n tic o n v u l­
s a n t tr e a tm e n t. H e s u s t a i n e d a n o t h e r i n ­
traven tricu lar

hem orrhage.

W hen

th e

p a tie n t w a s 5 7 y e a r s o f a g e , g i v e n h is
p e r s is t in g s y m p t o m s a n d r e p e a t e d h e m ­
o r r h a g i n g , a p la n

w as

fo rm u lated

to

p e r f o r m s ta g e d r a d io s u r g i c a l t r e a t m e n t
o f d if f e r e n t v o l u m e s o f th e A V M s , at

6- m o n t h in te r v a ls , u n til all p o r t i o n s o f
AVMs

had

been

ir r a d ia t e d .

We

p la n n e d

to f o llo w th e o b li t e r a t iv e r e ­

sponse

w ith

se ria l

com p u ted

tom o­

g r a p h i c i m a g i n g , h o p i n g th a t c o m p l e t e
o b lite r a tio n m i g h t b e a c h i e v e d in th e
The

A 5 2 - y e a r - o l d , r ig h t - h a n d e d m a n in i­
tia lly p r e s e n t e d to a n o t h e r in stitu tio n

f rU o -

w ith right h e m ip a re sis after in trav entric­
u lar an d left parietal h e m o rrh a g e . A n ­
giography disclosed giant left frontoparieton rrin ita l A V M s , m e a s u r in g 5 X 9 X 6 cm ,

p a tie n t

underw ent

an g io g rap h y -g u id ed
th r e e

o ccasio n s

m onths.

rad io su rg ery

d u rin g

In itia lly ,

s t e r e o t a c t ic

th e

th e

on

next

18

an teroin ferior

c o m p o n e n t ( s u p p lie d b y th e left in te r n a l
c a r o tid a r te r y ) a n d th e p o s t e r o i n f e r i o r
c o m p o n e n t ( s u p p lie d b y th e left p o s te -

l n
No
Neurosurgery, \/r*l
Vol. 4d J,
o . 5,
d , Novem ber 1998

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ad d itio n al

w o r d - f i n d i n g d iffic u ltie s a n d o n l y m ild

CASE REPORT

^

crO S u r g ia n t

an

s u b s e q u e n t 5 y e a r s (Fig. 1).

d io su rg e ry a llo w Sre a te r’UT . . c c e s s fu lly
fo n ts w ith A V M s to
e
be a
M e d C , 4, 5,

d esp ite

h e m o r r h a g e . H e e x h ib it e d o n l y s u b t le

th e
A V M s th a t c o u ld n o t b e s u c c e s s f u ll y

recovery

1223

Firlik et al.

1224

I

B

Hhik.

r i

FIG U R E 1. Axial c o n t r a s t - e n h a n c e d
c o m p u t e d t o m o g r a p h ic s c a n s b e f o r e
(A) and a fte r ( B ) staged v o lu m e g a m m a
knife rad io su rg ery . After rad iosu rgery,
t h e r e w a s partial nidus o b lite r a tio n and
a n o t a b le d e c r e a s e in th e v o lu m e and
c a l i b e r o f large d rain in g veins, a f a c t o r

FIGURE 2. Angiograms o b tain ed at the tim e o f the first radiosurgical treatment. The

th at fa c ilita te d s u b s e q u e n t m ic r o s u r g i­

total AVM volum e is outlined in the lateral (A) and a n te ro p o ste rio r ( B ) left internal

cal rem o v a l o f th e AVM s.

carotid artery in jectio n angiogram s. A r e a s e n c i r c l i n g t h e n u m e r a l 1, areas targeted in
the first radiosurgical trea tm en t. N ote the large portion o f the AVMs supplied by the

rio r c e r e b r a l a r te r y ) o f th e A V M s w e r e
ir r a d ia t e d , e a c h w ith 15 G y at th e 5 0 %
is o d o s e ( m a x i m u m , 30 G y ) (Fig- 2 ). Six
m o n t h s later, th e a n t e r o s u p e r i o r c o m p o ­
n e n t (s u p p lie d b y th e left in te r n a l c a ­
rotid

a r te r y )

an d

th e p o s t e r o s u p e r i o r

c o m p o n e n t (s u p p lie d b y th e m i d d l e an d
p o s t e r io r c e r e b r a l a r te r ie s ) w e r e ir r a d i ­
a te d , e a c h w ith 15 G y at th e 5 0 % is o d o s e
( m a x i m u m , 30 G y ) (Fig. 3). A th ird r a ­
d io s u r g ic a l s e s s io n 6 m o n t h s la te r d e l i v ­
e re d an a d d it i o n a l 15 G y at th e 5 0 %
is o d o s e m a r g in to th e r e m a i n i n g , p r e v i ­
o u s ly

n o n ir r a d ia t e d

p o r t io n

of

the

A V M s ( m a x i m u m , 30 G y ) (Fig. 4). In th e
3

years

a fte r

the

th ird

r a d io s u r g i c a l

t r e a t m e n t , the p a tie n t e x p e r i e n c e d

no

a d d itio n a l h e m o r r h a g i c e v e n t s a n d n o
n e w n e u r o l o g i c a l d e ficits. R e p e a t c o m ­
p u te d

to m o g rap h ic

im ag in g

show ed

p artial A V M o b lite r a tio n a n d a n o ta b le
d e c r e a s e in th e c a lib e r o f la r g e d r a i n i n g
v e in s that had p o s e d p r o b l e m s in p r e v i ­
o u s o p e r a t i o n s (Fig. 1).
T h e A V M s w e r e th e n th o u g h t to b e
r e s e c ta b le ,

and

r e s e c tio n

w as

recom ­

left vertebral artery (C ) . T h ere was both co rtical and d eep venous drainage (D).
w ith

t risk s o f s u r g e r y o u tw e ig h the risks of

sm aller d ra in in g veins. T h e b ra in tissue

t h e n a tu ra l h is to r y fo r each lesion (1,16).

less

engorged

th a n

p rev iou sly ,

s u r r o u n d in g the A V M s a p p e a re d

firm

n f r a d in § s c a ,e
Sp etzler and Martin
l a s pro\ e n u s e fu l ( 6 ) fo r preopera-

and gliotic. A resection p la n e w a s easily
d e v e lo p ed b e tw e e n the A V M s and the
gliotic brain tissue, facilitating c o m p le te

AwVa S S e S S m e n t o f t h e su rgical risk of
A V M r e s e c t i o n . T h e G r a d e 5 A VM s de-

rem ov al. A p o s to p e r a tiv e a n g io g r a m c o n ­

>td in this r e p o r t w o u ld h av e a 19%

firm ed c o m p le te A V M re m o v a l (Fig. 5).
In h istop ath o lo g ical sections, the A V M s

i o c g R a I n S k ° f a m i n o r d e ficit and a
c s u r g i c a l ris k o f a m a jo r deficit. The

sh o w e d m a r k e d h y a lin iz a tio n an d th ick ­

p M ic n ^ w o u l d

e n in g of blood vessel w a lls a n d o cclu sio n

i

to have a

or partial o cclu sio n o f s o m e v e ssels w ith

'[ o v e r a l l risk o f neurological
su rg e ry to re-

e m b o lic m aterial from p r e v io u s e m b o l iz a ­

A V M s a n d a n approximately

tions, w ith a s u r r o u n d in g rim o f gliotic

c h a n c e o f a p e r s i s t e n t late deficit

brain tissue (Fig. 6). P o sto p e ra tiv e ly , the

6 , 14). It is i m p o r t a n t to note, however,

patient d e m o n s tr a te d right h e m ip a r e s is

t la t t h e s e r is k s o t d e fic its w ere derived

and w o rs e n e d ap h asia. A fter a 6-m o n th

r o m o b s e r v a t i o n s o f p a tie n ts for whom

fo llo w -u p p eriod, h e lives in d e p e n d e n tly ,

c o m p l e t e r e s e c tio n w a s p o ssib le (a se­

exh ib its

a ted

mild

a p h a sia

an d

m ild

rig h t

*°. ^

be ex p ected

g rou p );

th e r e fo r e , the surgical

h e m ip a re sis, and has retu rn ed to his b a s e ­

ris k s for th e p a tie n t d e scrib e d in this

line level of functioning.

r e p o r t m i g h t a c t u a l l y h a v e been higher.
e r o s et al. ( 8 ) r e p o r t e d a "g o o d " or

DISCUSSION
G iv en

th e

e
co n sid erab le

treatm ent-

11lent e a r l y p o s t o p e r a t iv e outcome

for o n l y 2 8 .6 % o f 21 p a tie n ts with Grade
A V M s,

w ith

a

late

morbidity/

m e n d e d . D u r in g s u r g e r y , f r a m e le s s s t e ­

rela ted

r e o ta c tic g u i d a n c e w a s u se d . U p o n e x ­

for giant A V M s , the key to their m a n a g e ­

m o r t a l i t y r a t e o t 3 8 .4 % (5). In th ec o n te\ t

p o s u r e of th e b r a in , the A V M s a p p e a r e d

m ent in v o lv es d e te rm in a tio n of w h e th e r

ot t h e s e r e s u lts , H e r o s a n d Tu (7) urged

m o r b i d i t y»

an d

m o r ta lity
J

ra te s

Neurosurgery, Vol. 4\, No. T, Novem ber 1998

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Novel Treatment of Giant AVMs

1225

B
1 3 5 .0

B
Y = 7 1 .0
50Z

D

CRAN

<■

\
60 i

70 i
8 0 -j
T

T¥

1

130

140

150

X

v«*
GURE 3. Angiograms o b t a in e d a t th e tim e o f th e s e c o n d rad iosu rgical tre a tent. The AVMs are sh o w n in th e la te ra l (A) and a n te r o p o s t e r io r ( B ) left internal
irotid artery in jectio n a n g io g r a m s an d in th e lateral ( C ) and a n te r o p o s t e r io r

FIG U R E 4 . A n g iog ram s o b ta in e d at the
tim e o f th e third rad io su rg ical t r e a t ­
m e n t. T he residual AVM s a r e sh o w n in
th e lateral (A) and a n t e r o p o s t e r io r

)) left vertebral artery i n je c t i o n a n g io g r a m s . A r e a s e n c i r c l i n g t h e n u m e r a l 2,
eas targeted in the s e c o n d r a d io s u r g ic a l t r e a t m e n t . A r e a s e n c i r c l i n g t h e n u m e r a l
' Previously treated a re a s.

( B ) left internal c a r o tid a r te r y in je c tio n
a n g io g ra m s. A r e a e n c i r c l i n g t h e
n u m e r a l 3, a r e a ta r g e te d in th e third
rad io su rg ical t r e a t m e n t . N o te th a t th e

• iw a 1p V
p ro a c h in cg a rseufcuhl
caution in surgically
i\VMs and d is c u s s e d a
J
seleC.

d e s p i t e m u lt ip le a t t e m p t s at e m b o l i z a ­

AVM s in a r e a s tr e a te d during th e first

tion a n d p a r tia l r e s e c tio n . T h is r e p e a te d

and s e c o n d rad io su rg ical tr e a t m e n t s

decision-making p r o c e s s 1
tion of such p a tie n ts fo r s u
inginto th e d e c is io n -m a K in g t

h e m o r r h a g i n g p r o m p t e d us to d e v e l o p

( a r e a s e n c i r c l i n g t h e n u m e r a l s 1 a n d 2,

a n e w a p p r o a c h to a s u r g ic a l c u r e o f his

resp e ctiv ely ) h ave b e e n largely

A V M s.
Sin g le-stag e

o b lite r a te d .

scribed by H e ro s

an d

u

E nter^ de-

th e
^

in

suracal treatment o t s
^uprent in
addition to the r i s k f a c t o r s 1

ir r a d ia tio n

of

g ia n t

A V M s is n o t fe a sib le , e ith e r b e c a u s e o f
h ig h

r a d ia t io n - r e la te d

risk s

r e s u lt in g

1 5 -G y d o s e w a s c h o s e n for e a c h r a d i o ­
s u r g ic a l

such incalculable fa c to r s a s

^a ro e\e -

f r o m th e la r g e v o l u m e o f n o r m a l tissu e,
s u r r o u n d i n g th e A V M s , th a t is ir r a d i ­

s c r ib e d in this re p o rt. W h e n K je llb e r g et

logical reaction o f th e p a t i e n
sion, the occupation o f t h e p a ^

and
^

a te d

(at d o s e s s u f fic ie n t to o b lite r a te

al. (9) u se d p r o t o n b e a m t h e r a p y fo r th e

A V M v e s s e ls ) o r b e c a u s e o f lo w o b li ­

m a n a g e m e n t o f g ia n t A V M s , th e c o m ­

te r a tio n e f f ic a c y w ith th e u s e o f c lin i­

p le te o b lite r a tio n ra te w a s lo w ( < 20 % ),

c a lly s a f e b u t w e a k l y e ff e c tiv e d o s e s .

alth ou gh

^ er^

F l ic k i n g e r et al. (3) r e p o r te d o b lite r a tio n

som e

r a te s fo r ta r g e te d A V M tissu e b a s e d on

r h a g in g

. e

th e r a d ia t io n d o s e . A d o s e o f 15 G y to an

a lo n e , a l t h o u g h s o m e t i m e s e f f e c t iv e in

flus report d e m o n s tr a te d P r^ d a c h e s,
deterioration resu ltin g f r o m
c

A V M m a r g i n w a s a s s o c ia te d w ith a 7 0 %

r e d u c i n g a r t e r i o v e n o u s s h u n t i n g , is n o t

c h a n c e o f total o b lite r a tio n . L o w e r d o s e s

lik e ly to c u r e A V M s , as w a s th e c a s e for

seizures, and r e p e a te d h e m o r r h a g

w e r e m u c h less e ffe c tiv e ; th e r e fo r e , a

the p a tie n t d e s c r i b e d in this r e p o r t; it

the Spetzler-Martm c l a s s i i c

the prior experience o f t h e sU J
similar lesions. P r o g r e s s i v e y
referable to either h e m o r r h a g e ,
seizures, are ad d ition al r e a s o n s

totnS/
^ or

vene surgically. T h e p a t i e n t t l s c r

Neurosurgery, Vol. 43 , No. 5, Novem ber 1998

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s e s s io n

th o s e

p r o te c tio n
w as

fo r

th e

au thors
from

p a t ie n t

thou ght

de­

th at

further h e m o r ­

a c h ie v e d .

E m b o lizatio n

1226

Firlik et al.
q u a cie s in A V M im a g in g or targetin g, re­

d i o s u r g i c a l t r e a t m e n t of different por­

ca n a liz a tio n

tio n s o f th e A V M s , fo llo w e d by delayed

after

p rior

e m b o liz a tio n ,

r e o p e n in g o f v e ssels c o m p r e s s e d b y h e ­

d efin itiv e

m a to m a , or s o m e d e g r e e o f b lo o d vessel

T h e c o n c e p t u n d e r l y i n g this approach is

resistan ce to radiation. S u c c e s s w ith re­

th a t

p eat r a d io s u rg e ry in that settin g p a v e d

t e c h n i q u e s c a n b e c o m p le m e n ta ry and,

the w a y for the stra teg y u sed to treat the

w h e n c o m b i n e d in a thoughtful strat­

p atient d e scrib e d in this report.

egy,

M i c r o s u r g e r y a f te r r a d i o s u r g e r y w a s

B

t%
.f•
, .#
< I '

<

p

\

4

j

k

%

f

FIG U R E 5. P o s to p e r a tiv e a n g io g ra m s,
s h o w in g b o th th e left internal c a ro tid

t e c h n i q u e c o u ld a c h ie v e independently.

A c c e p t e d , M a y 29, 1998.

" f a c i l i t a t i n g q u i c k e r a n d s a fe r r e s e c t io n

R ep rin t

w ith less b l o o d lo s s ." O n h i s t o p a t h o l o g ­

M .D ., D e p a r t m e n t o f Neurological Surgery,

p r o lif e r a t io n , h y a l i n e d e p o s i t i o n in th e
v ascu lar

en d o th eliu m ,

and

p a r tia l

or

( B ) in je c tio n s . T h e r e is no e v id e n c e o f

all o b s e r v a t i o n s th a t s u p p o r t e d th e i n ­

residual AVM s, signifying c o m p l e t e

trao p erativ e

m ic r o s u r g ic a l re m o v a l.

th r e e

of

f in d in g s .

four

In

U n iv e r s ity o f P ittsb u rg h Medical Center, 200
L o th r o p Street, S u ite B-400, Pittsburgh, PA
15213.

r e p o r t,

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p r io r

p a t ie n t s

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Sp etzler-

"good "

the lik e lih o o d

r e su lts that neither

less v a s c u l a r a n d e a s i e r to c o a g u l a t e ,

co m p lete th ro m b o sis of A V M

in crease

ach iev e

microsurgical

R e c e i v e d , N o v e m b e r 4, 1997.

a r te r y ( 4 ) and left v e rte b ra l a rtery

(5,

can

an d

f o u n d p r e v i o u s l y ir r a d ia t e d A V M s to b e

ical a n a l y s is , th e y r e p o r t e d e n d o t h e l i a l

A

FIG U R E

rad io su rg ical

o f the remainder.

d e s c r i b e d b y S t e i n b e r g et al. (15), w h o

Vj

<

resection

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J A , C o ff e y RJ: Ste re o tactic ra d io su rge ry fb ra r

C O N C LU SIO N S

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with this m od ality. T h o s e p atien ts u n d e r ­

P a tie n ts w ith g ia n t A V M s in critica l

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had not ach iev ed c o m p le te obliteration af­

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m a tio n s fo llo w in g ra d io su rg e ry . A JN R Am

ter a single p ro ce d u re , b e c a u s e of in a d e ­

n o v e l a p p r o a c h , i.e., p la n n e d s t a g e d r a ­

N e u r o r a d io l 14:297-303, 1993.

s u r g 75:512-524, 1991*
11. M a rk s M P , L a n e B, S te in b e rg G K , Fabrikant

Neurosurgery, Vol. 44, No. 5, Novem ber 1998

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Novel Treatment of Giant AVMs

1227

LD ,

n o v a t i v e r a d io s u r g i c a l te c h n iq u e . O t h e r

rh a g e b e fo re c o m p le te o b literation o ccu rs)

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d u r in g the 4.5 y e a rs that elap sed b e tw e e n

s id e r this a p p r o a c h in s e le c te d c a se s.

the first rad io su rg ical session

p Pollock

BE,

K o n d z io lk a

D,

L u n sfo rd

radiosurgery of a rte rio v e n o u s m a lfo rm a tio n s :
Factors a s s o c ia te d w ith in c o m p le te o b lite ra tio n .
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G ary K. S tein b erg

13. Redekop GJ, E lise v ich K V , G a s p a r L E , W ie se K P ,
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Steven D. C h an g

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Long­

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an d

the

e v en tu a l surgical resection o f the stillp aten t A V M s . T h e fact that this p articu lar
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ing

that

tim e

reveals

little a b o u t

the

14. Spetzler RF, M artin N A : A p ro p o se d g r a d in g s y s ­

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1. S te in b e rg G K , C h a n g S D , L e v y R P , M a rk s M P ,
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Frankel K, M arce llu s M : S u r g ic a l re se ctio n o f

la rg e in c o m p le te ly treated in tra c ra n ia l a rte rio -

In b rie f, this is a v a l u a b l e r e p o r t that

large incom pletely treated in tr a c r a n ia l a rte rio ­

\ e n o u s m a lfo rm a tio n s fo llo w in g stereo tactic ra ­

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s iv e l y s y m p t o m a t i c a n d / o r h a v e s u f ­

16. Tamaki N , Ehara K , L in T - K , K u w a m u r a K ,

T h e a u t h o r s r e p o r t a c a s e o f a p a t ie n t

Obora Y, Kanazaw a Y , Y a m a sh ita H , M atsu m o to

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w i t h l a r g e ( G r a d e 5) A V M s w h o w a s

th o r s d e v i s e d a w e l l - p l a n n e d a p p r o a c h

S: Cerebral arteriovenous m a lfo rm a tio n s: Facto rs
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tr e a te d w ith s ta g e d (th r e e s e s s i o n s , s e p ­
arated b y 6 m o) rad io su rg ery and e v e n ­
tu al s u r g ic a l r e s e c tio n . S u r p r is in g ly , in

R o b e r t o C. H e r o s

Lylyk P, Fox A , P e lz D , D r a k e C G , G ir v in JJ,

v i e w o f th e p o s t o p e r a t i v e a n g i o g r a m s ,

M i a m i , F lo r id a

Debrun G: C o m b in e d e n d o v a s c u la r e m b o liz a ­

w h i c h s h o w e d m i n i m a l o r n o fillin g o f

arteriovenous m a lfo rm a tio n s: E x p e r ie n c e w ith
101 cases. J Neurosurg 7 5 :8 5 6 -8 6 4 , 1991.

a n y d is ta l m i d d l e c e r e b r a l b r a n c h e s , th e
p a t i e n t r e c o v e r e d to th e p o i n t o f e v e n ­
tu a lly e x h ib it i n g o n l y m ild a p h a s i a a n d
m ild r ig h t h e m ip a r e s is .
W e h av e argued , co n sid erin g

COMMENTS

sur:
0--'
$

tion a tte m p ts an d su rgery. T h e a u th o rs
treated the A V M s w ith three stag ed ra­
d io su rg ical sessions, e a ch treating a dif­

lite r a tu r e th a t in d ic a te s s im il a r l y p o o r

gery to

fro n to p arieto -

r e s u lts , th a t m o s t G r a d e 5 A V M s s h o u ld

vals. Three years later, surgical resection of

m alfo rm atio n s

b e le ft u n t r e a t e d u n le s s th e p a tie n t h a s

the reduced A V M nidus w as successful.

(AVMs). The three r a d i o s u r g i c a l t r e a t ­

p r o g r e s s i v e o r in c a p a c it a t in g s y m p t o m s

treat

large

ferent part of the A V M s , at 6- m o n th inter­

R ad io su rg ery

and/or

em b olizatio n

ments were sep arated b y 6- m o n t h i n t e r ­

and/or

T h is

m a y b e u s e d in c o m b i n a t i o n w i t h s u r ­

vals; 3 years later, the r e s i d u a l A V M s

p a t i e n t c e r t a i n ly q u a lifie s a s h a v i n g b e ­

g e r y w h e n n o s in g le t h e r a p e u t i c m e t h o d

were successfully

c o m e p r o g r e s s i v e l y in c a p a c it a te d

is lik e ly to s u c c e e d . T h e u s e o f s ta g e d

r e s e c te d .

A lth o u g h

recu rren t h em o rrh ag in g .

of

d ifferen t

fore microsurgery for A V M

treatm en t

c o m p a r t m e n t s o f la r g e A V M s , a s d e ­

have been reported p r e v i o u s l y ( 1), th e

c is io n o f th e a u t h o r s to tre a t th e p a tie n t

s c r ib e d b y th e a u t h o r s , is a n e w v a r i a ­

aPplication of staged v o l u m e r a d i o s u r ­

a g g r e s s i v e l y . O n e c o u ld a r g u e th a t p e r ­

tion o f th e c o n c e p t o f r e t r e a t i n g fa iled

gery for this patient is n o v e l a n d q u i t e

h a p s th e s a m e e v e n t u a l r e s u lts c o u ld

r a d io s u r g i c a l c a s e s w it h a n o t h e r r a d i o ­

interesting. I am s u r p r is e d a t th e l a r g e

h a v e b e e n o b t a in e d w ith m o r e a g g r e s ­

s u r g ic a l

extent of A VM

ach iev ed

s iv e e m b o l i z a t i o n a n d s u r g ic a l r e s e c tio n

g e s te d th a t d e li b e r a t e p a r tia l i r r a d ia t io n

only 1 year after the first r a d i o s u r g i c a l

in o n e s ta g e ; h o w e v e r , w i t h o u t e x a m i n ­

o f A V M s m a y i n c r e a s e th e ris k o f h e m ­

treatment and 6 m o n t h s a fte r th e s e c o n d

i n g all a n g i o g r a m s a n d w i t h o u t h a v i n g

o r r h a g e (1). A ll i n v o lv e d in th e r a d i o ­

p a r t ic ip a t e d in th e t r e a tm e n t, it is d iff i­

s u r g ic a l t r e a t m e n t o f A V M s a w a i t a d d i ­

cu lt to a r g u e this point. W h a t s e e m s clear

tio n al r e p o r ts o n this t e c h n iq u e , a p p l ie d

fro m the d escrip tion presented b y a u th o rs

to la r g e r n u m b e r s o f p a t ie n t s w h o a re

is that the e v en tu a l surgical resection w a s

m o n i t o r e d for lo n g e r p e r io d s o f tim e , to

easier than it w o u ld h a v e b e e n w ith o u t

d eterm in e

rad io su rg ery . It is also p ossible that the

s ta g e d r a d io s u r g e r y .

The

exp lan a-

tlQn for why certain A V M s a r e o b li t e r 'milarly treated r e m a in s o b s c u r e .

des

resec^ o n ^' b u t th e a p p r o a c h

altCn ^ ^
cJ

a u t b o r s r e p r e s e n t s an

atiVe strateSY w h e n a c c e s s to a c y ra<^i°slJ rgic a l facility is n o t a v a il-

res 1 e autbors a c h ie v e d g o o d c lin ic a l
s in an difficult c a se , u s i n g a n i n ­

tr e a tm e n t.

th e

Som e

e f f ic a c y

have

and

sug­

r is k s

of

rad iation, b y p r o d u c in g g ra d u a l ob litera­
tion not o n ly o f the A V M vessels b u t

W illia m A. F rie d m a n

a lso o f n o rm a l m id d le cerebral b ran ch es,

G a in e s v ille , F lo rid a

a l l o w e d t h e p a t i e n t to b e t t e r t o l e r a t e
su rg ical resectio n . T h is, of co u rse, w as
a c h ie v e d at the cost o f e x p o s in g the p a ­

1. C o lo m b o F, P o zza F, C h ie re g o G , C a se n tin i L ,

tient to a c o n tin u in g risk o f h e m o r r h a g in g

D e L u c a G , Fran cesco n P: L in e a r accelerator ra­

(it h as not b e e n arg u e d c o n v in cin g ly that

d io su rg e ry of cerebral arterio ven o u s m a lfo rm a ­

r a d io s u rg e ry d e cre a se s the risk o f h e m o r ­

Vol.

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hem or­

treatm ent

r h a g i n g ; th e r e fo r e , I a g r e e w ith th e d e ­

mdiosurgical treatm en t.

r e p e a te d

rad io su rg ical

the use and benefits o f r a d i o s u r g e r y b e ­

o b lite r a tio n

exp erien ced

and

h av in g

4

&
ft

rep eated h e m o r r h a g in g d e sp ite e m b o liz a ­

ing planned v o lu m e s t a g i n g o f r a d i o s u r ­

e ^ ave b e e n a b le to o b t a in s i m ila r
^ ^ s u r g ic a l o b lit e r a t io n a n d c u r e o f
arge A V M s u s in g s in g le - s ta g e , h e a v y ■p k arged p a rtic le r a d io s u r g e r y f o llo w e d
/ m*crosurg ic a l re s e c tio n ( o r e m b o liz a ft

w h ic h a p atient w ith A V M s e x p e rie n c e d

o w n p o o r r e s u lts a n d a r e v i e w o f th e

ated more quickly th a n o t h e r s th a t a r e
$

our

Firlik et al. p re se n t a ca se rep o rt in

This is an in te re stin g c a s e r e p o r t u s ­

fi 'I occipital arterio v en o u s

at

a n d p e r f o r m e d it s u c c e s s f u ll y .

17. Vinuela F, D io n JE , D u c k w ile r G , M a rtin N A ,

tion and surgery in the m a n a g e m e n t o f ce re b ra l

t

m a y b e c o n te m p la te d .

tions: A n update. Neurosurgery 34:14-21, 1994.

43,No. 5, Novem ber 1998