• Zaki Ghali George G United States Environmental Protection Agency, Arlington, Virginia, USA; Department of Toxicology, Purdue University, West Lafayette, Indiana, USA., Zaki Ghali Michael George MG Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA; Deptartment of Neurological Surgery, Baylor College of M, and Zaki Ghali Emil E Department of Medicine, Inova Alexandria Hospital, Alexandria, USA; Department of Urological Surgery, El Gomhoureya General Hospital, Alexandria, Egypt..
• United States Environmental Protection Agency, Arlington, Virginia, USA; Department of Toxicology, Purdue University, West Lafayette, Indiana, USA.
• World Neurosurg. 2019 May 1; 125: 481-488.

AbstractBrainstem arteriovenous malformations (AVMs) represent ∼5% of all intracranial AVMs and carry a higher risk of hemorrhage than their supratentorial counterparts. There is a high and near-uniform mortality with initial and recurrent episodes of hemorrhage. Brainstem AVMs may also present symptomatically with focal neurologic deficits or hydrocephalus. Treatment is indicated for ruptured and symptomatic brainstem AVMs, as well as those possessing high-risk angioarchitectural features. Microsurgical resection and stereotactic radiosurgery are ideal therapeutic options when feasible. Embolization is most commonly used as adjunctive treatment before surgery or stereotactic radiosurgical irradiation. Preoperative embolization facilitates microsurgical resection and reduces intraoperative and postoperative hemorrhage rates. Use of embolization preradiosurgically helps to reduce nidal size, transforming a large lesion to a size amenable to radiosurgical intervention, increasing the probability of obliteration, decreasing procedural hemorrhage risk, stabilizing the lesion until radiotherapeutic effect achieves obliteration, and providing interval symptomatic resolution. Embolization may also be used effectively as stand-alone monotherapy for small lesions with 1 or 2 arterial feeders not supplying eloquent parenchyma. Although an extensive evidence base exists for clinical usefulness of stereotactic radiosurgery as monotherapy or in combination with other therapeutic modalities, only a few studies have reported specifically on obliteration and complication rates with monotherapeutic embolization in the treatment of brainstem AVMs. The potential role of embolization as monotherapy for brainstem AVMs is reviewed and discussed.Copyright © 2018. Published by Elsevier Inc.

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