Cerebral arteriovenous malformations

Abstract

To address the problems of surgical risk versus natural risk associated with cerebral arteriovenous malformations (AVM's), and the role of the intravascular operative approach, the authors have assessed a 20-year experience with 450 patients. Results of direct surgery in 90 patients indicate that for the smaller AVM's (Grades I and II), mortality and morbidity rates are lower than a reasonably projected natural risk. Hence, these patients are candidates for surgery in most instances. However, for more extensive AVM's (Grades III and IV), consideration of anticipated future years of exposure to natural risk and the location of the AVM in the brain are necessary for determining operability. In general, neither seizures nor incipient focal neurological dysfunction alone are indications for surgery, and the risks of disability or death from hemorrhage after the fifth decade of life are probably less than the surgical risks by present operative techniques. Considering the usual age of patients at the time of diagnosis, it is estimated that surgical risk is currently less than the natural risk for about 65% to 70% of all AVM patients. The categories of AVM's in which the angiographic effectiveness of the intravascular approach is the greatest correspond to the same categories of AVM's that can be surgically removed with low risk. The intravascular approach is most useful for management of large AVM's causing progressive neurological dysfunction or as a preliminary step to surgery in selected cases in which access to major feeding arteries is difficult. The authors believe that the future of the intravascular approach should be directed toward transforming large inoperable AVM's into operable ones, but that the overall capability for this with acceptable risk is uncertain at present.

Recurrent Cerebral Arteriovenous Malformation in a Child : Case Report and Review of the Literature

“…Recurrence is definitely more common in children than in adults. The early evolution of AVMs is consistent with the diffuse patterns of arteriovenous shunting observed in children as opposed to the more distinct fistulous pattern seen in adults 13) . If more mature AVMs develop along a continuum as the brain develops, children are more likely to have immature vasculature as part of their AVM.…”

Spontaneous Intracranial Hemorrhage in Children

“…Few authors have reported total obliteration of malformation with exclusive embolization [45, 46]. Partial obliteration of AVM could be achieved in 54–90% of cases with improvement in clinical condition related to steal syndrome, although risk of bleeding seems to remains unchanged [41]. Patients with high Spetzler and Martin grades (84% >grade 3) are regarded as unsuitable for surgical excision and were considered for embolization in study by Wikholm et al [43].…”

“…Treatment of AVM in childhood is controversial. Lussenhop and Rosa [41] proposed anatomical grading to compare operative and natural history risk in AVM patients and concluded that in the first 3 decades, risk of surgery is less than the natural course for all patients with grade I and II and for more than half of those in grade III. Surgery is still the treatment of choice in AVM [22, 24, 25, 27].…”

Endovascular Management of Arteriovenous Malformations of the Brain

“…Additionally, occlusion of proximal arterial feeders could prevent entry into the nidus, leaving the nidus unoccluded and active. This often leads to AVM recruitment of deep perforators making surgery ultimately more challenging [35,36]. In 1974, Serbinenko [37] reported on the use of a detachable balloon attached to a flexible flow-directed catheter.…”