Background

A multi-modality approach with staggered endovascular embolisations, serving as an adjunct to surgery or stereotactic radiosurgery, was historically the mainstay of treatment of cerebral arteriovenous malformations (cAVMs) at our institutions. Since 2016, we have performed endovascular embolisation with curative intent as a first line treatment.

Objective

To assess the role of cAVM endovascular treatment with curative intent when using a combination of arterial and venous approaches, and new techniques such as the pressure-cooker technique.

Methods

All cAVMs that were treated with endovascular embolisation at our institutions between September 2016 and June 2022 were recorded. Any cases which did not have long-term follow-up were also excluded. All cases were detailed for patient demographics, presentation, cAVM characteristics and grading, endovascular approach, radiological and clinical follow-up. Obliteration and complication rates were calculated.

Results

In less than 6 years we performed endovascular embolisation of 74 cAVMs. Grades ranged from Spetzler Martin I-IV. 48 cAVMs (64.9%) presented due to rupture. Only 66 cAVMs had endovascular treatment as a first-line therapy, since the other 8 AVMs had some form of previous treatment (either from a different interventionalist with a staggered approach to embolisation, radiotherapy, or surgery). The approach to embolisation was arterial in 55 AVMs (74.3%), venous in 5 AVMs (6.8%), and combined in 14 AVMs (18.9%). Follow up varied from 2-60 months (mean of 19.6 months) after final embolisation, with a DSA in 71 cases, MRI/A alone in 2 cases, and 1 patient deceased. Considering all 74 cAVMs, complete obliteration was achieved in 95.9%. Analysis of just the 66 cAVMs treated with first-line endovascular embolisation shows a complete obliteration rate of 97.0%, with the other 3.0% requiring radiotherapy treatment. mRS score remained unchanged in 55 AVMs (74.3%), improved in 9 AVMs (12.2%), deteriorated in 6 AVMs (8.1%), mortality in 1 case (1.4%), and in 3 cases no pre-operative mRS was recorded (4.0%). Ultimately, it was 4.0% of cases that involved clinical deterioration or death with a final mRS outcome >2. This includes 1 patient with final mRS 6 and 2 patients with final mRS 3.

Conclusions

Our series demonstrates the safety and efficacy of endovascular intervention in treatment of cAVMs, which is on par with the internationally reported rates. Specialist centres need to consider adopting this as a first-line therapy in the management of cAVMs.