| Cerebral arteriovenous malformations (cAVM) are abnormal collections of immature blood vessels within the brain, which can induce hemorrhage, headache, epilepsy, grading decline in neural function and mentality deficit, which with high disability rate and high fatality clinically. Present studies have showed that the treatments for AVMs including surgery, radiation, and intravascular embolization methods, or adopting a combination of these methods when dealing with complicated case. In this article, we discuss the different effects of different treatments chosen according to different condition of patients in 105 clinical surgical therapeutic cases of AVM.Data and methods:In 105 cases there were 70 males and 35 females. Ages fluctuated within 8-60, the average age was 28. The original symptom showed intracranial hemorrhage in 50 cases (intracerebral hematoma 35 and hemorrhage in subarachnoid space 15), epilepsy in 40 cases, neural functional disorder of limbs in 10 cases, dizziness and headache in 5 cases, moreover, 30 cases have intracranial hypertension and 12 cases get cerebral hernia. In 92 cases the positions of abnormal blood vessels above the tentorium cerebelli (30 in frontal lobe, 25 in parietal lobe, 10 in parietooccipital lobe, 4 in basal nucleus, 10 in temporal lobe, 8 in cerebral lateral sulcus, 5 in corpus callosum), while in 13 cases under the tentorium cerebelli (8 in lateral side of cerebellum, 4 in cerebellar inferior vermis, 1 beside brain stem). The diameter of tangled blood vessels of small size (<2.5cm) in 36 cases, medium size (2.5cm ~5cm) in 45 cases and large size (>5cm) in 24 cases. 85 cases received computerized tomography (CT), and 35 cases were diagnosed as intracerebral hematoma, 12 cases were mistaken as brain tumor, 38 cases were diagnosed as AVM. 45 cases received magnetic resonance imaging (MRI) and were diagnosed as AVM. Preoperational radiography of brain vessels in 55 cases has showed that 35 cases have hemorrhage (large size in 8 cases, medium size in 16 cases, small size in 11 cases, withsingle artery supply in 11 cases, double or more arteries supply in 24 cases, single draining vein in 13 cases, double or more draining vein in 22 cases), while 20 cases without hemorrhage (large size in 5 cases, medium size in 10 cases, small size in 5 cases, with single artery supply in 5 cases, double or more arteries supply in 15 cases, single draining vein in 6 cases, double or more draining vein in 14 cases). 12 cases received emergency operation and make confirmed diagnosis through post operational pathological examination. 50 cases received the microsurgical treatment, of which AVM focus were completely removed in 42 cases, partly removed in 3 cases, and in 5 cases the excision companied with hematoma cleaning. 53 cases received gamma knife stereotactic radiosurgery therapy. 8 cases received intravascular embolization therapy, of which 4 patients received microsurgery one week following the embolization therapy, another 2 AVM cases in deep brain region received gamma knife stereotactic radiosurgery after the great mass of abnormal vessels have been embolized.Result:Of 50 patients who received the microsurgical treatment, we having 1 death, 4 disability, while other 45 patients were recovered and discharged from hospital. Magnetic resonance angiography (MRA) test of 42 patients revealed that in 38 cases the malformed blood vessels havebeen completely remove while in 4 cases still existed partial remnants, showed the 90% good recovery rate (n=45), 8% disability rate (n=4), and 2% fatality rate (n=l) according to SiYuQuan grade. The effects of stereotactic radiosurgery in 53 cases is estimated by the degrees of the vessels occlusion, 30 cases follow -up from 6 months to 2 years have revealed that 23 completely occlusion (77%), 5 partly occlusion (17%) and 2 cases inefficacy (6%). The total effective rate is 94%. As to the patents received intravascular embolization therapy, in 2 cases the blood vessels be completely occlusion, 1 cases 70%~90% occlusion, 2 cases 50%~70% occlusion, while in another 3 cases less than 50%. Within the 6 incompletely embolized cases, 4 patients received microsurgery one week following the embolization therapy, MRA showed no residual AVM;2 deep AVM cases received gamma knife stereotactic radiosurgery after embolization therapy and MRI showed the abnormal conglomeration of entangled blood vessels have greatly reduced. The follow-up results showed that the therapeutic effects of the 8 cases were all graded as good recovery.Conclusion:In present time, surgery still is the most reliable treatment of AVM. We adopted microsurgery to cure 50 AVM patient, 90% have achieved eminent effects and good recovery. The small or medium-sized brainAVM which located in nonfunctional region, especially with a single draining vein should be surgical remove as early as possible to preventing hemorrhage. However, the AVM within deep, functional brain region with high blood stream and accompanied with aneurism or arteriovenous fistula can not be surgical excised because the dangers of excessive bleeding and complications which may affect the effects of surgery and threaten the life of patients.It is generally believed that the AVM focus which volume less than 10cm , located in deep brain region or functional region that is unsuitable for surgery, senile patients, incompletely excised focus and the patients who have received the partial intravascular embolization therapy can be treated by Gamma knife treatment. We took stereotactic radiosurgery treat 53 AVM patients, 30 cases follow -up results from 6 months to 2 years have revealed the total effective rate is 94%.Intravascular embolization therapy is also taken as the main method to cure and alleviate AVM, especially on the case of small AVM with less blood-supplying arteries that can be completely occlused. The high scale large AVM with lots of perforating arteries can not get complete therapeutic effects, but embolization therapy can reduce the size of AVM focus and change it into curable small focus that can be removed through surgery, which may remarkably improve the anatomic recovery rate ofAVM and decrease its mortality rate. In the case of enormous AVM, blood vessels partial embolization is used prior to surgery, which was taken as the most effective methods to remove the abnormal conglomeration of entangled blood vessels. When AVM lay in deep or important functional brain region, which is difficulty for surgical excision following extensive blood vessels embolization, Gamma knife stereotactic radiosurgery can make up the disadvantage of surgical unsuitability. In our study, alothough six cases of the eight patents received embolization therapy got incompletely occlusion, 4 patients received microsurgery one week following the embolization therapy, MRA showed no residual AVM;2 deep AVM cases received Gamma knife stereotactic radiosurgery after embolization therapy and MRI showed the abnormal conglomeration of entangled blood vessels have greatly reduced. The therapeutic effects of the 8 cases were all graded as good recovery through follow-up.Through investigation of our clinic cases, we believed that microsurgery is the main measures to cure the AVM. In the case of intracranial hypertension and cerebral hernia, the microsurgery should be taken to clean hematoma as soon as possible. The danger of hemorrhage in the patients of Spetzler-Martin I —EEI grades AVM is more serious than the danger of receive microsurgery and the difficulty of surgicalremove is relatively smaller. Since the possibilities of death and disability following surgery are slim in these cases, the microsurgical treatment is more suitable. In the case of above Spetzler-Martin IV grade AVM, the danger and difficulty of microsurgery are greater, so the intravascular embolization therapy should be taken before the microsurgery, which could be done after a period of two weeks. If the edema and hemorrhage did not take place during the microsurgical process, the recovery of the patients who have received embolization therapy would better than other patients of Spetzler-Martin IV grade AVM. The indications of embolization therapy should be the terminal types of AVM with lesser supplying arteries and smaller tangle abnormal blood vessels which cloud be cured by only taking the embolization, the large AVM with high blood flow, the AVM in deep cerebral region and important functional regions, the supplying arteries with aneurism or with the small contorted drainage veins which have the great possibilities of hemorrhage, the AVM accompanied with numerous and large artery-vein fistula. The best therapeutics for great complicated AVM that above the Spetzler-Martin III grade is the combination of the microsurgery and intravascular embolization treatment. In the cases of AVM, which volume less than 10c m3, located in deep and functional cerebral region that is unsuitable for microsurgery or difficult for surgical remove, no obvious dangerousfactors of hemorrhage and the canal for intravascular embolization is difficult to reach the aim position, the gamma knife will be the better therapeutic indication.
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