title: Multimodality treatment of giant intracranial arteriovenous malformations.
abstract: OBJECTIVE
  Giant arteriovenous malformations (AVMs) (i.e., those greater than 6 cm at maximum diameter) are difficult to treat and often carry higher treatment morbidity and mortality rates than do smaller AVMs. In this study, we reviewed the treatment, angiographic results, and clinical outcomes in 53 patients with giant AVMs who were treated at Stanford between 1987 and 2001.
  
  
  METHODS
  The patients selected included 20 males (38%) and 33 females (62%). Their presenting symptoms were hemorrhage (n = 20; 38%), seizures (n = 18; 34%), headaches (n = 8; 15%), and progressive neurological deficits (n = 7; 13%). One patient was in Spetzler-Martin Grade III, 9 were in Spetzler-Martin Grade IV, and 43 were in Spetzler-Martin Grade V. The mean AVM size was 6.8 cm (range, 6-15 cm). AVM venous drainage was superficial (n = 7), deep (n = 20), or both (n = 26). At presentation, 31 patients (58%) were graded in excellent neurological condition, 17 were graded good (32%), and 5 were graded poor (9%).
  
  
  RESULTS
  The patients were treated with surgery (n = 27; 51%), embolization (n = 52; 98%), and/or radiosurgery (n = 47; 89%). Most patients received multimodality treatment with embolization followed by surgery (n = 5), embolization followed by radiosurgery (n = 23), or embolization, radiosurgery, and surgery (n = 23). Nineteen patients (36%) were completely cured of their giant AVMs, 90% obliteration was achieved in 4 patients (8%), less than 90% obliteration was achieved in 29 patients (55%) who had residual AVMs even after multimodality therapy, and 1 patient was lost to follow-up. Of the 33 patients who either completed treatment or were alive more than 3 years after undergoing their most recent radiosurgery, 19 patients (58%) were cured of their AVMs. The long-term treatment-related morbidity rate was 15%. The clinical results after mean follow-up of 37 months were 27 excellent (51%), 15 good (28%), 3 poor (6%), and 8 dead (15%).
  
  
  CONCLUSIONS
  The results in this series of patients with giant AVMs, which represents the largest series reported to date, suggest that selected symptomatic patients with giant AVMs can be treated successfully with good outcomes and acceptable risk. Multimodality treatment is usually necessary to achieve AVM obliteration.
authors.affiliation: Department of Neurosurgery and the Stanford Stroke Center, Stanford University School of Medicine, Stanford, California 94305, USA.
authors.forename: Steven D
authors.initials: SD
authors.lastname: Chang
authors.forename: Mary L
authors.initials: ML
authors.lastname: Marcellus
authors.forename: Michael P
authors.initials: MP
authors.lastname: Marks
authors.forename: Richard P
authors.initials: RP
authors.lastname: Levy
authors.forename: Huy M
authors.initials: HM
authors.lastname: Do
authors.forename: Gary K
authors.initials: GK
authors.lastname: Steinberg
mesh_terms: D000293:Adolescent; D000328:Adult; D002533:Cerebral Angiography; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D004621:Embolization, Therapeutic / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D008297:Male; D008866:Microsurgery / Q000009:adverse effects; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications; D016634:Radiosurgery / Q000009:adverse effects*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015996:Survival Rate