Introduction: In this study we report a retrospective case series examining outcomes of patients who presented with a hemorrhage secondary to a cerebral AVM who were not felt to be candidates for surgical resection. All patients were Spetzler-Martin Grade III or IV and were initially treated with varying degrees of endovascular embolization prior to Gamma Knife radiosurgery.
Methods: A retrospective analysis was performed on 16 patients who presented to our institution from 2010 to 2015 with Spetzler Martin grade 3-4 AVMs. Each of these patients was treated with combination endovascular embolization and gamma knife stereotactic radiosurgery. As a measure of clinical outcome, neurological function was measured using the modified Rankin Scale (mRS). The nidus was measured and compared before and after treatment. We evaluated for clinical or radiographic evidence of re-hemorrhage, stroke within the AVM territory, or radiation necrosis.
Results: There was no subsequent re-hemorrhage in any patient with a mean follow-up period of 45 months. There was significant improvement in the mRS score in all, but 1 patient who remained stable. The one patient noted to have a stable mRS score from first presentation to last follow up was also noted to have complete obliteration of the AVM.
There were no patients with worsening of mRS score. At last known follow-up 81.25% had an mRS less than 2. 57% of the patients had complete obliteration of the nidus
Conclusions: The combination therapy of targeted endovascular embolization and gamma knife stereotactic radiosurgery is a safe and effective option for treating ruptured grade 3 and 4 brain AVMs who are not felt to be surgical candidates. In our Series, 57% of our patients were cured of their AVM and protected permanently against re-hemorrhage with no incidence of re-hemorrhage or worsening of clinical outcome.
Patient Care: By providing more evidence that combination endovascular embolization and stereotactic radiosurgery is a safe treatment option in for patients with ruptured brain AVMs who are not surgical candidates.
Learning Objectives: Understand the treatment options for ruptured brain AVMs. Understand the clinical and radiographic outcomes obtained after treatment of ruptured brain AVMs with combination stereotactic radiosurgery and endovascular embolization.