title: Multiple cerebral arterio-venous malformations: impact of multiplicity and hemodynamics on treatment strategies.
abstract: Multiple AVMs are exceptionally rare lesions and only a few larger series have been published, including other vascular pathologies, such as arterio-venous fistulae (AVF) or patients with hereditary syndromes. Our study presents clinical, angiographic, and therapeutic characteristics of patients harboring sporadic multiple AVMs.
  
  
  
  Basic demographic data, vascular architecture, clinical presentation, treatment strategies, and treatment outcome were analyzed retrospectively from patients with cerebral AVMs treated in our department between 1990 and 2015.
  
  
  
  Six out of 539 patients (1.1 %) harbored 15 multiple and distinct cerebral lesions. Nidus size was predominantly small, consequently determining a Spetzler-Martin grade °I-°II (three-tier grading system). In three patients, AVMs shared a proximal feeding artery supply, whereas each AVM displayed its own venous drainage. Five of six patients (83 %) presented with hemorrhage. Four patients received therapy of the AVMs with complete elimination in 3/4 patients (75 %) and 8/9 treated AVMs (89 %). All patients with treatment of the AVM showed good-to-excellent recovery (n = 4, mRS ≤ 2).
  
  
  
  Multiple cerebral AVMs are complex vascular lesions. The multiplicity of hemodynamic and malformation-related variables influence treatment strategy and sequence. Thus, awareness of these parameters (of various malformations before and during treatment) is important. The high number of hemorrhagic events in the present series might justify a more aggressive treatment of multiple AVMs than previously thought.
authors.affiliation: Department of Neurosurgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany. klaus-peter.stein@uk-essen.de.|Department of Neurosurgery, KRH Hospital Nordstadt, Haltenhoffstr.41, 30167, Hannover, Germany. klaus-peter.stein@uk-essen.de.
authors.forename: Klaus-Peter
authors.identifier: 0000-0003-4461-7769
authors.initials: KP
authors.lastname: Stein
authors.affiliation: Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany.
authors.forename: Isabel
authors.initials: I
authors.lastname: Wanke
authors.affiliation: Department of Neurosurgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany.
authors.forename: Neriman
authors.initials: N
authors.lastname: Oezkan
authors.affiliation: Department of Neurosurgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany.
authors.forename: Yuan
authors.initials: Y
authors.lastname: Zhu
authors.affiliation: Department of Neurosurgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany.|Department of Neurosurgery, KRH Hospital Nordstadt, Haltenhoffstr.41, 30167, Hannover, Germany.
authors.forename: I Erol
authors.initials: IE
authors.lastname: Sandalcioglu
authors.affiliation: Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Forsting
authors.affiliation: Department of Neurosurgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany.
authors.forename: Ulrich
authors.initials: U
authors.lastname: Sure
mesh_terms: D000328:Adult; D000368:Aged; D002533:Cerebral Angiography; D002648:Child; D004621:Embolization, Therapeutic / Q000009:adverse effects*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000000981:diagnostic imaging* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D016634:Radiosurgery / Q000009:adverse effects*; D012189:Retrospective Studies
keywords: AVM hemodynamics; AVM multiplicity; Cerebral arterio-venous malformation; Intracranial hemorrhage