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Original research
Curative treatment for low-grade arteriovenous malformations
  1. Arthur Wang1,
  2. Grace K Mandigo1,
  3. Neil A Feldstein2,
  4. Michael B Sisti2,
  5. E Sander Connolly2,
  6. Robert A Solomon2,
  7. Sean D Lavine1,
  8. Philip M Meyers1
  1. 1 Neurosurgery and Radiology, Columbia University Medical Center, New York City, New York, USA
  2. 2 Neurosurgery, Columbia University Medical Center, New York City, New York, USA
  1. Correspondence to Dr Arthur Wang, Neurosurgery and Radiology, Columbia University Medical Center, New York City, NY 10032, USA; aw3201{at}


Background Spetzler-Martin (SM) grade I-II (low-grade) arteriovenous malformations (AVMs) are often considered safe for microsurgery or radiosurgery. The adjunctive use of preoperative embolization to reduce surgical risk in these AVMs remains controversial.

Objective To assess the safety of combined treatment of grade I-II AVMs with preoperative embolization followed by surgical resection or radiosurgery, and determine the long-term functional outcomes.

Methods With institutional review board approval, a retrospective analysis was carried out on patients with ruptured and unruptured SM I-II AVMs between 2002 and 2017. Details of the endovascular procedures, including number of arteries supplying the AVM, number of branches embolized, embolic agent(s) used, and complications were studied. Baseline clinical and imaging characteristics were compared. Functional status using the modified Rankin Scale (mRS) before and after endovascular and microsurgical treatments was compared.

Results 258 SM I-II AVMs (36% SM I, 64% SM II) were identified in patients with a mean age of 38 ± 17 years. 48% presented with hemorrhage, 21% with seizure, 16% with headache, 10% with no symptoms, and 5% with clinical deficits. 90 patients (68%) in the unruptured group and 74 patients (59%) in the ruptured group underwent presurgical embolization (p = 0.0013). The mean number of arteries supplying the AVM was 1.44 and 1.41 in the unruptured and ruptured groups, respectively (p = 0.75). The mean number of arteries embolized was 2.51 in the unruptured group and 1.82 in the ruptured group (p = 0.003). n-Butyl cyanoacrylate and Onyx were the two most commonly used embolic agents. Four complications were seen in four patients (4/164 patients embolized): two peri-/postprocedural hemorrhage, one dissection, and one infarct. All patients undergoing surgery had a complete cure on postoperative angiography. Patients were followed up for a mean of 55 months. Good long-term outcomes (mRS score ≤ 2) were seen in 92.5% of patients with unruptured AVMs and 88.0% of those with ruptured AVMs. Permanent neurological morbidity occurred in 1.2%.

Conclusions Curative treatment of SM I-II AVMs can be performed using endovascular embolization with microsurgical resection or radiosurgery in selected cases, with very low morbidity and high cure rates. Compared with other published series, these outcomes suggest that preoperative embolization is a safe and effective adjunct to definitive surgical treatment. Long-term follow-up showed that patients with low-grade AVMs undergoing surgical resection or radiosurgery have good functional outcomes.

  • angiography
  • arteriovenous malformation
  • embolic
  • hemorrhage
  • liquid embolic material

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  • Contributors AW made substantial contributions to the conception and design of the work, the acquisition, analysis and interpretation of data for the work, and drafting the work for important intellectual content. GKM, NAF, MBS, and ESC provided final approval of the version to be published. RAS, SDL, and PMM revised the scientific content and appraised it critically for important intellectual content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.