title: A treatment paradigm for high-grade brain arteriovenous malformations: volume-staged radiosurgical downgrading followed by microsurgical resection.
abstract: OBJECTIVE
  The surgical treatment of many large arteriovenous malformations (AVMs) is associated with substantial risks, and many are considered inoperable. Furthermore, AVMs larger than 3 cm in diameter are not usually treated with conventional single-session radiosurgery encompassing the entire AVM volume. Volume-staged stereotactic radiosurgery (VS-SRS) is an option for large AVMs, but it has mixed results. The authors report on a series of patients with high-grade AVMs who underwent multiple VS-SRS sessions with resultant downgrading of the AVMs, followed by resection.
  
  
  METHODS
  A cohort of patients was retrieved from a single-institution AVM patient registry consisting of prospectively collected data. VS-SRS was performed as a planned intentional treatment. Surgery was considered as salvage therapy in select patients.
  
  
  RESULTS
  Sixteen AVMs underwent VS-SRS followed by surgery. Four AVMs presented with rupture. The mean patient age was 25.3 years (range 13-54 years). The average initial Spetzler-Martin grade before any treatment was 4, while the average supplemented Spetzler-Martin grade (Spetzler-Martin plus Lawton-Young) was 7.1. The average AVM size in maximum dimension was 5.9 cm (range 3.3-10 cm). All AVMs were supratentorial in location and all except one were in eloquent areas of the brain, with 7 involving primary motor cortex. The mean number of VS-SRS sessions was 2.7 (range 2-5 sessions). The mean interval between first VS-SRS session and resection was 5.7 years. There were 4 hemorrhages that occurred after VS-SRS. The average Spetzler-Martin grade was reduced to 2.5 (downgrade, -1.5) and the average supplemented Spetzler-Martin grade was reduced to 5.6 (downgrade, -1.5). The maximum AVM size was reduced to an average of 3.0 cm (downsize=-2.9 cm). The mean modified Rankin Scale (mRS) scores were 1.2, 2.3, and 2.2 before VS-SRS, before surgery, and at last follow-up, respectively (mean follow-up, 6.9 years). Fifteen AVMs were cured after surgery. Ten patients had good outcomes at last follow-up (7 with mRS Score 0 or 1, and 3 with mRS Score 2). There were 2 deaths (both mRS Score 1 before treatment) and 4 patients with mRS Score 3 outcome (from mRS Scores 0, 1, and 2 [n=2]).
  
  
  CONCLUSIONS
  Volume-staged SRS can downgrade AVMs, transforming high-grade AVMs (initially considered inoperable) into operable AVMs with acceptable surgical risks. This treatment paradigm offers an alternative to conservative observation for young patients with unruptured AVMs and long life expectancy, where the risk of hemorrhage is substantial. Difficult AVMs were cured in 15 patients. Surgical morbidity associated with downgraded AVMs is reduced to that of postradiosurgical/preoperative supplemented Spetzler-Martin grades, not their initial AVM grades.
authors.affiliation: Departments of 1 Neurological Surgery and.
authors.forename: Adib A
authors.initials: AA
authors.lastname: Abla
authors.forename: William Caleb
authors.initials: WC
authors.lastname: Rutledge
authors.forename: Zachary A
authors.initials: ZA
authors.lastname: Seymour
authors.forename: Diana
authors.initials: D
authors.lastname: Guo
authors.forename: Helen
authors.initials: H
authors.lastname: Kim
authors.forename: Nalin
authors.initials: N
authors.lastname: Gupta
authors.forename: Penny K
authors.initials: PK
authors.lastname: Sneed
authors.forename: Igor J
authors.initials: IJ
authors.lastname: Barani
authors.forename: David
authors.initials: D
authors.lastname: Larson
authors.forename: Michael W
authors.initials: MW
authors.lastname: McDermott
authors.forename: Michael T
authors.initials: MT
authors.lastname: Lawton
mesh_terms: D000293:Adolescent; D000328:Adult; D002548:Cerebral Revascularization; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000145:classification / Q000175:diagnosis / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D016634:Radiosurgery / Q000379:methods*; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome; D055815:Young Adult
keywords: AVM = arteriovenous malformation; Gamma Knife; SRS = stereotactic radiosurgery; SS = single-session; Spetzler-Martin grade; VS = volume-staged; arteriovenous malformation; mRS = modified Rankin Scale; microsurgical resection; stereotactic radiosurgery; supplementary grade; vascular disorders