Embolization of cerebral arteriovenous malformations to enhance the success of subsequent radiosurgery.

SUMMARY: We studied angiographic changes in embolized arteriovenous malformations (AVMs) by comparing pre- and postembolization angiograms and angiograms preceding radiosurgery. This study sought factors determining the usefulness of embolization as a pretreatment to enhance the success of subsequent radiosurgery. Thirty patients with cerebral AVMs treated in this manner over 4 years were studied. In these cases AVMs were embolized with cyanoacrylate and were treated with Gamma-knife radiosurgery. The mean size of the AVM nidus was reduced by a fraction of seven following embolization. The subsequent angiogram for planning radiosurgery showed further nidus reduction in 10 AVMs, no change in 12, and regrowth in 8. In all size-reduction cases the nidus was sufficiently packed, and 2 AVMs had thrombosed completely before radiosurgery. All the regrowing AVMs were of diffuse type; 6 were associated with already-developed leptomeningeal channels, and the remaining 3 were fed by newly sprouted meningeal feeders. Five AVMs disappeared following radiosurgery, all representing size-reduction or nochange cases. Analysis of cases with regrowth showed increased risk of that event with feeder occlusion of a multi-axially supplied AVM, lack of reduction of shunt flow, or remaining meningeal feeders. On the other hand, when embolization as pretreatment prior to radiosurgery succeeds in producing a small, compacted, plexiform nidus with slow shunt flow, it furthers the likelihood of successful radiosurgery. Nidus embolization and occlusion of fistulous and meningeal feeders are mandatory, while proximal feeder occlusion and use of embolic materials which risk recanalization should be avoided to prevent nidus regrowth.