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Our treatment of arteriovenous malformations (AVMs) with Gamma Knife Radiosurgery (optimal dose treatment) showed 88.4% total obliteration in small AVMs less than 10 ml after the first treatment and very low morbidity (1.7%) in long-term follow-up (5 to 12 years). These results indicate that combined treatment is a good strategy for large AVMs in eloquent areas. Therefore, we evaluated larger AVMs treated with direct surgery including feeder clipping and/or intravascular embolization prior to radiosurgery for further development of radiosurgery of large AVMs. Fifty of 171 patients had combined treatment (embolization: 27, direct surgery: 19, both: 4) and were followed more than 4 years and 6 months. Mean volume at the time of radiosurgery was smallest in the surgery group. Total obliteration was obtained in 94.4% of small AVMs less than 10 ml (surgery: 100%, embolization: 88.9%), although larger AVMs still have a lower obliteration rate. No lethal hemorrhages appeared after combination treatment up to date. We concluded that radiosurgery combined with surgery and/or embolization is a safe and effective treatment for large AVMs in eloquent areas.

Multimodality Treatment of Large AVMs in Eloquent Areas