Multimodality treatment of arteriovenous malformations

The management of brain AVMS (BAVMs) is complex and mostly based on large case series from tertiary referral centers, which may not be applicable to a particular patient or physician experience. Surgery, stereotactic radiosurgery and endovascular embolization have long been critical tools in the treatment of arteriovenous malformations. In more complex lesions a combination of these techniques are important options in the treatment strategy. While all three treatment modalities can be curative each comes with their own risks, and limitation. Grade I and II AVMs are usually treated with either surgery or radiosurgery depending on lesion location, clinical presentation and the institutional preference along with embolization as an adjunct. However, management of Grade III and high grade AVMs (Spetzler Martin Grade IV and V) are more controversial and treatment is associated with significant morbidity. In select cases combined treatments have proven to be curative when single methodology treatments would not have worked. In this chapter we will review the literature for indications, cure rates, risks, potential complications and the results of multimodality treatment options of BAVMs. We will present the treatment algorithm and the rationale for the decision analysis in different clinical scenarios. Although it is difficult to make generalizations about specific uses of multimodality treatment, such treatment continues to be an important weapon in the arsenal for cure of brain arteriovenous malformations, and in particular should be considered for certain, large and eloquent region arteriovenous malformations.