Deliberately Staged Combined Endovascular Embolization and Subsequent Microsurgery Resection for the Treatment of Cerebral Arteriovenous Malformations

Abstract

Complex cerebral arteriovenous malformations (AVMs) require a combined therapy of endovascular embolization and microsurgical resection to eliminate the lesion and maximize neurological protection, while a deliberate time interval might contribute to optimal clinical outcomes. The present study aimed to explore the feasibility of this paradigm. All patients who underwent deliberately planned pre-surgery embolization and microsurgery resection between 2015 and 2023 were reviewed, with baseline data, postoperative complications, and follow-up outcomes recorded. The modified Rankin scale (mRS) was used to evaluate clinical outcomes, with mRS 0-2 defined as good. A total of 30 patients were included in the study (15 were ruptured AVMs). The median Spetzler-Martin grade (SM) of baseline AVMs was 3 (interquartile range [IQR]:2-3). The median interval between the last embolization and microsurgery was 5 days (IQR:2.25-7). The complete removal rate was 100%, and the overall permanent complication rate was 16.67%. At the last follow-up, 26 patients achieved mRS 0-2, while 28 had improved or unaltered mRS. The last follow-up mRS significantly improved from baseline and discharge (P=0.0006 and P=0.006). The last follow-up mRS decreased by 0.65 for each additional day of time interval before the 4.4-day inflection point (β=-0.65, P=0.02) in the AVM ruptured cohort. The deliberately staged combined procedure of embolization and microsurgical might be a safe and efficacious strategy for SM 2-5 AVMs, 4-5 days might be an appropriate staged time interval for ruptured AVMs. although further studies are needed to substantiate these findings.