title: Deep arteriovenous malformations in the basal ganglia, thalamus, and insula: multimodality management, patient selection, and results.
abstract: OBJECTIVE
  This study sought to describe a single institution's experience treating arteriovenous malformations (AVMs) of the basal ganglia, thalamus, and insula in a multimodal fashion.
  
  
  METHODS
  We conducted a retrospective review of all deep AVMs treated at our institution between 1997 and 2011 with attention to patient selection, treatment strategies, and radiographic and functional outcomes.
  
  
  RESULTS
  A total of 97 patients underwent initial treatment at our institution. 64% presented with hemorrhage with 29% located in the basal ganglia, 41% in the thalamus, and 30% in the insula. 80% were Spetzler-Martin grade III-IV. Initial treatment was microsurgical resection in 42%, stereotactic radiosurgery (SRS) in 45%, and observation in 12%. Radiographic cure was achieved in 54% after initial surgical or SRS treatment (71% and 23%, respectively) and in 63% after subsequent treatments, with good functional outcomes in 78% (median follow-up 2.2 years). Multivariate logistic regression analysis revealed treatment group and age as factors associated with radiographic cure, whereas Spetzler-Martin score and time to follow-up were significantly associated with improved/unchanged functional status at time of last follow-up. Posttreatment hemorrhage occurred in 11% (7% of surgical and 18% of SRS patients).
  
  
  CONCLUSIONS
  Modern treatment of deep AVMs includes a multidisciplinary approach utilizing microsurgery, SRS, embolization, and observation. Supplementary grading adds meaningfully to traditional Spetzler-Martin grading to guide patient selection. Surgical resection is more likely to result in obliteration compared with SRS, and is associated with satisfactory results in carefully selected patients.
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Matthew B
authors.initials: MB
authors.lastname: Potts
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Arman
authors.initials: A
authors.lastname: Jahangiri
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Maxwell
authors.initials: M
authors.lastname: Jen
authors.affiliation: Department of Radiation Oncology, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Penny K
authors.initials: PK
authors.lastname: Sneed
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Michael W
authors.initials: MW
authors.lastname: McDermott
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Nalin
authors.initials: N
authors.lastname: Gupta
authors.affiliation: Department of Radiology, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Steven W
authors.initials: SW
authors.lastname: Hetts
authors.affiliation: Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA; Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California, USA.
authors.forename: William L
authors.initials: WL
authors.lastname: Young
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA; Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California, USA. Electronic address: lawtonm@neurosurg.ucsf.edu.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Lawton
mesh_terms: D000293:Adolescent; D000328:Adult; D001479:Basal Ganglia / Q000473:pathology / Q000601:surgery*; D020785:Central Nervous System Vascular Malformations / Q000473:pathology / Q000601:surgery*; D002540:Cerebral Cortex / Q000473:pathology / Q000601:surgery*; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D008297:Male; D008866:Microsurgery / Q000379:methods; D008875:Middle Aged; D018579:Patient Selection; D016634:Radiosurgery; D013788:Thalamus / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome; D057832:Watchful Waiting; D055815:Young Adult
keywords: Arteriovenous malformations; Basal ganglia; Radiosurgery; Surgery; Thalamus; Therapeutic embolization