title: Surgical Management of Giant Intracranial Arteriovenous Malformations: A Single Center Experience over 32 years.
abstract: OBJECTIVE
  Treatment of giant intracranial arteriovenous malformations (gAVMs) is a formidable challenge for neurosurgeons and carries significant morbidity and mortality rates for patients compared with smaller AVMs. In this study, we reviewed the treatments, angiographic results, and clinical outcomes in 64 patients with gAVMs who were treated at Henry Ford Hospital between 1980 and 2012.
  
  
  METHODS
  The arteriovenous malformation (AVM) database at our institution was queried for patients with gAVMs (≥ 6 cm) and data regarding patient demographics, presentation, AVM angioarchitecture, and treatments were collected. Functional outcomes as well as complications were analyzed.
  
  
  RESULTS
  Of the 64 patients, 33 (51.6%) were female and 31 (48.4%) were male, with an average age of 45.7 years (SD ± 15.5). The most common symptoms on presentation were headaches (50%), seizures (50%), and hemorrhage (41%). The mean AVM size was 6.65 cm (range, 6-9 cm). Only 6 AVMs (9.4%) were located in the posterior fossa. The most common Spetzler-Martin grade was V, seen in 64% of patients. Of the 64 patients, 42 (66%) underwent surgical excision, 10 (15.5%) declined any treatment, 8 (12.5%) were deemed inoperable and followed conservatively, 2 (3%) had stand-alone embolization, 1 (1.5%) had embolization before stereotactic radiosurgery, and 1 (1.5%) received stereotactic radiosurgery only. Complete obliteration was achieved in 90% of the surgical patients. Mortality rate was 19% in the surgical cohort compared with 22% in the observation cohort (P = 0.770).
  
  
  CONCLUSIONS
  Treatment of gAVMs carries significant morbidity and mortality; however, good outcomes are attainable with a multimodal treatment approach in carefully selected patients.
authors.affiliation: Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA.
authors.forename: Kevin A
authors.initials: KA
authors.lastname: Reinard
authors.affiliation: Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA. Electronic address: apabane1@hfhs.org.
authors.forename: Aqueel H
authors.initials: AH
authors.lastname: Pabaney
authors.affiliation: Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA.
authors.forename: Azam
authors.initials: A
authors.lastname: Basheer
authors.affiliation: Division of Neurological Surgery, Brooks Army Medical Center, San Antonio, Texas, USA.
authors.forename: Scott B
authors.initials: SB
authors.lastname: Phillips
authors.affiliation: Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA.
authors.forename: Max K
authors.initials: MK
authors.lastname: Kole
authors.affiliation: Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA.
authors.forename: Ghaus M
authors.initials: GM
authors.lastname: Malik
mesh_terms: D000328:Adult; D000368:Aged; D002533:Cerebral Angiography; D016208:Databases, Factual; D004621:Embolization, Therapeutic; D005260:Female; D006261:Headache / Q000209:etiology; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000150:complications / Q000000981:diagnostic imaging / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D008297:Male; D008866:Microsurgery; D008875:Middle Aged; D018908:Muscle Weakness / Q000209:etiology; D016634:Radiosurgery; D012189:Retrospective Studies; D013064:Speech Disorders / Q000209:etiology; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods*
keywords: Embolization; Giant intracranial arteriovenous malformations (gAVMs); Hemorrhage; Management; Microsurgery