Several approaches can be used alone or in combination to obtain AVM occlusion. 

     This study investigates the use of single and multi-modality therapy for the management of arteriovenous malformations (AVMs) and analyzes demographics, presentation, intervention, complications, and outcomes.

     835 patients with AVMs were treated in our institution between 1994 and 2010, with staged endovascular embolization (with NBCA or Onyx), SRS (Gamma Knife or LINAC), surgical excision or any combination.

     A retrospective review of demographic data, clinical presentation, AVM and treatment characteristics as well as radiographic and angiographic imaging was used to test for statistical associations between these various risk factors, interventions, and outcomes.

     835 patients (49% initially presenting with symptomatic hemorrhage) were treated with 931 embolization procedures (58% of patients), 503 stereotactic radiation treatments (48%), and 284 surgical resections (33%). 56.2% of patients achieved complete obliteration based on angiography or MR imaging. There were a total of 64 new hemorrhages (7.7%) and 15 mortalities (1.8%). 28 patients (3.4%) acquired new permanent neurologic deficits. Patients undergoing surgical resection were 8.5x more likely to achieve complete obliteration (p <0.005), while patients presenting initially with hemorrhage were 50% less likely to achieve complete obliteration (p=0.004) and 3.9x more likely to suffer a post-treatment hemorrhage (p<0.005). Chances of complete obliteration decrease following the third stage of embolization from 52% to 30%, and the second SRS treatment from 39% to 23%.

     This is a retrospective study.

     Multimodality approach should be utilized for the treatment of AVMs and surgical resection should always be considered.

     This holds true especially in patients with a hemorrhagic presentation.