Deep Arteriovenous Malformations in the Basal Ganglia, Thalamus, and Insula: Multimodality Management, Patient Selection, and Results

ObjectiveThis study sought to describe a single institution's experience treating arteriovenous malformations (AVMs) of the basal ganglia, thalamus, and insula in a multimodal fashion.MethodsWe conducted a retrospective review of all deep AVMs treated at our institution between 1997 and 2011 with attention to patient selection, treatment strategies, and radiographic and functional outcomes.ResultsA total of 97 patients underwent initial treatment at our institution. 64% presented with hemorrhage with 29% located in the basal ganglia, 41% in the thalamus, and 30% in the insula. 80% were Spetzler-Martin grade III-IV. Initial treatment was microsurgical resection in 42%, stereotactic radiosurgery (SRS) in 45%, and observation in 12%. Radiographic cure was achieved in 54% after initial surgical or SRS treatment (71% and 23%, respectively) and in 63% after subsequent treatments, with good functional outcomes in 78% (median follow-up 2.2 years). Multivariate logistic regression analysis revealed treatment group and age as factors associated with radiographic cure, whereas Spetzler-Martin score and time to follow-up were significantly associated with improved/unchanged functional status at time of last follow-up. Posttreatment hemorrhage occurred in 11% (7% of surgical and 18% of SRS patients).ConclusionsModern treatment of deep AVMs includes a multidisciplinary approach utilizing microsurgery, SRS, embolization, and observation. Supplementary grading adds meaningfully to traditional Spetzler-Martin grading to guide patient selection. Surgical resection is more likely to result in obliteration compared with SRS, and is associated with satisfactory results in carefully selected patients.