The treatment of large cerebral arteriovenous malformations (AVMs) is still difficult and challenging. Reported here is a case of complete cure of a large right parietal AVM treated by multi-staged embolization and gamma knife surgery (GKS). A 31-year-old woman was referred to our hospital with intraventricular hemorrhage caused by a large AVM in the right parietal lobe. The nidus size was 68×69×37 mm. The main feeders were the right anterior cerebral arteries (ACA), right middle cerebral arteries (MCA) and right posterior cerebral arteries (PCA), and drained by the cortical veins. We embolized feeders of the PCA, ACA and MCA with coils and polyvinyl acetate (PVAc) four times. Thereafter, nidus size was reduced to less than 30 mm and she underwent the first GKS. An angiogram showed the nidus size had been reduced to 6×4×4 mm two years after the first GKS, and a further angiogram one year later showed the nidus size had been reduced to 3×2×2 mm. The patient underwent GKS again four years after the first GKS as the size of the nidus remained unchanged from the last angiogram. An angiogram two years after the second GKS showed the nidus had disappeared. The second GKS was successfully achieved in this patient without neurological deterioration.
Repeated GKS treatment minimizes endovascular complications and maximizes the treatment effect when multimodality therapy is used for large AVMs, illustrating the effectiveness of this approach.