Rosli, Fadzlishah Johanabas
(2015)
Comparing monomodality treatments of low--‐
grade intracranial arteriovenous malformation at hospital Kuala Lumpur between 2008 and 2011:
a retrospective study.
Masters thesis, Universiti Sains Malaysia.
Abstract
Title
Comparing Monomodality Treatments of Low-Grade Intracranial AVM at Hospital Kuala
Lumpur between 2008 and 2011: A Retrospective Study
Authors
Fadzlishah Johanabas Rosli1,2, Mohammed Saffari Mohammed Haspani1, Abdul Rahman
Izaini Ghani2
1Department of Neurosurgery, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
2Department of Neurosciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
Introduction
Arteriovenous malformation (AVM) is an abnormal connection between arteries and veins,
which bypasses the capillary system. Although it can appear in any location, this vascular
anomaly is widely known due to its occurrence in the central nervous system.
AVMs are one-tenth as common as saccular aneurysms. The rate of haemorrhage in
untreated patients is between 2 to 4 percent per year, with a mortality rate of 5 to 10 percent.
There are several treatment modalities for AVMs: microsurgery, endovascular embolization
and stereotactic radiosurgery (SRS). Surgical excision remains the gold standard treatment
for accessible, low-grade AVM. However, resection of deep-seated AVMs, such as within
the thalamus and the brainstem, remains a therapeutic challenge.
Objectives
To establish an understanding whether SRS or embolization can achieve satisfactory
obliteration of AVM nidi for patients as opposed to microsurgical excision, and to look for
incidence of complications such as haemorrhage and permanent neurological deficit
following treatment, for up to 3 years.
Methods
This is a retrospective review of records study. The data is acquired from case notes of
patients with intracranial AVM of Spetzler-Martin grades I to III who underwent
monomodality treatment at Hospital Kuala Lumpur between 2008 and 2011. The patients
were followed-up with imaging for up to 3 years from the date of treatment. A total of 81
patients were recruited in this study, where 30 underwent microsurgical treatment, 27
underwent embolization, and 24 underwent SRS.
Results
Total obliteration of AVM nidus was achieved in 96.7% of patients who underwent
microsurgery, 8.7% of patients who underwent embolization and 79.2% of patients who
underwent SRS. 4 patients who underwent microsurgery passed away (3 directly related to
surgery), and 4 patients who underwent embolization passed away (3 directly related to
procedure), whereas no mortality was seen in the SRS group. The modified Rankin Scale
(mRS) for all three groups showed an improving trend, with the microsurgery group showing
the best improvement (from 70% at 3 months to 92.3% at 3 years showing favourable mRS
scores).
Conclusion
The AVM nidus obliteration for each treatment group is comparable to the meta-analysis
published in 2011, where successful AVM obliteration was achieved in 96% (range 0% -
100%) after microsurgery, 38% (range 0% - 75%) after SRS and 13% (range 0% - 94%)
after embolization. Each modality had its own set of complications; however, most of the
patients in all three groups had either static or improved modified Rankin Scale (mRS) at the
end of the 3-year follow-up. As we can achieve good AVM nidus obliteration using
microsurgery and SRS, it will be good to explore and develop these treatment options
further. Embolization, however, still plays a vital role in complicated cases (eloquent
regions, large AVM).
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