Monotherapeutic Curative Endovascular Neurosurgery in the Treatment of Cerebral, Brainstem, and Cerebellar Arteriovenous Malformations 

by Michael Ghali (Author), George Ghali (Author)

Arteriovenous malformations of the intracranium carry variable morbidity and mortality depending on location, size, and angioarchitecture. In general, therapeutic options include microsurgical resection, stereotactic radiosurgical irradiation, and embolization. Lesions may be observed conservatively, treated primarily, treated following hemorrhage, utilizing one of the foregoingly described modalities individually or multimodally. Arteriovenous malformations of the basal ganglia and thalamic carry significant risk of hemorrhage, with increased risk of morbidity, mortality, and recurrent hemorrhage with an initial episode of rupture. These features thus strongly indicate a necessity for treatment. Deep location of these lesions is generally not preclusive to surgical extirpation via microsurgical resection, though stereotactic radiosurgical irradiation frequently proves useful as the preferred treatment by patients to eschew the consequent neurological deficits of craniotomy and open microsurgical dissection through eloquent parenchyma. Endovascular embolization, while shown effective as curative monotherapy for arteriovenous malformations of the intracranium in general, performed transarterially, transvenously, or via a combination thereof, has generally proved useful only insofar as effecting nidal size and flow reduction of basal ganglionic and thalamic lesions, thus facilitating surgical resection or stereotactic radiosurgical irradiation, and decreasing the morbidity ensuing thereof. We review and discuss the experience with monotherapeutic embolization of arteriovenous malformations of the basal ganglia and thalamus. Further studies and innovation in endovascular strategies and technologies are necessary to render this treatment more efficacious and safe as curative monotherapy.