Endovascular Management of Brain Arteriovenous Malformations

Abstract

Due to the risk of cerebral hemorrhage, and its related morbidity-mortality, brain arteriovenous malformations (bAVM) are a rare and threatening disease. Concerning bAVM management, only one randomized control trial -the ARUBA trial -has been published so far. The results of the ARUBA trial favor a non-interventional approach in the case of an unruptured bAVM, however implementation of these findings is challenging in daily practice.Instead, management relies on multidisciplinary discussions that lead to patient-specific strategies based on local expertise and experience in reference centers. Given the wide patterns of presentation and multiple treatment modalities recommendations are also difficult to follow. Endovascular treatment (EVT) is a widely used modality which can be used for curative treatment, or prior to surgery or radiosurgery ("pre-EVT"). EVT practice is in constant evolution (i.e. venous approach, combination with surgery during the same anesthesia, etc.). Liquid embolic agents (LEA) such as ethylene vinyl alcohol (EVOH) copolymer and cyanoacrylates (CYA), and their method of injection to increase bAVM occlusion, have also benefited from technical evolutions such as the use of adjunctive flow arrest techniques (mini balloons, pressure cooker technique and multiple catheters). Further research is necessary to evaluate the advantages and disadvantages of EVT.