Arterio-Venous Malformations

(AVM) of Brain
Dhaval Shukla
Additional Professor of Neurosurgery
NIMHANS, Bangalore
 Normal Blood Vessels

AVM

Abnormal Connection of Blood Vessels

 Cause of AVM
• Not known
• Usually congenital
• Not hereditary
• Most AVMs do not grow or change in size
– Blood vessels may increase in diameter
– AVMs shrink due to clots in parts of an AVM
– AVMs may enlarge due to redirection of blood flow
 Epidemiology

• Less than one percent of the general

population

• One in 200–500 people may have an AVM

• More common in males than females

Sites
 Symptoms
• Symptoms may vary with location
• More than 50 % present with brain hemorrhage
• 20% - 25% with seizures
• Localized headache
• 15% may have difficulty with movement, speech
and vision
 Brain hemorrhage
• Abnormal and “weakened” blood vessels over
time eventually burst from the high pressure
of blood flow from the arteries

• 1–3 % chance per year of bleeding

• Risk of bleeding = 105 – age (in years)

 Brain hemorrhage
• 10–15% risk of death

• Loss of normal function

– Temporary
– Permanent: 20–30%

• Brain damage depends on

– Amount of blood
– Site of bleed
Symptoms of hemorrhage
 Rebleeding risk

• More during first year after initial bleeding

– 6% to 18%

• Higher in the first year after the second bleed

– 25%

• Higher risk of bleeding in ages 11 – 35 years

 Diagnosis
• Computed tomography (CT)
– Hemorrhage

• Magnetic resonance imaging (MRI)

– Location and size
CT scans showing
hemorrhage due
to AVM
MRI of AVM
 Diagnosis
• Cerebral angiogram (DSA)
– Required for treatment
– Insertion of a catheter (small tube)
through an artery in leg to
each vessels going to brain
– Injection of contrast material (dye)
– Taking pictures of all blood vessels
of brain
 Treatment

• Bleed

• Easily accessible

• Not too large

 Medical Therapy

• Avoid
– Any activities that may excessively elevate blood
pressure
– Blood thinning drugs like warfarin

• Regular checkups with a neurologist

• Antiepileptic drugs
 Surgery

Indications

• Bleeding

• Easily accessible

• Small or medium
 Stereotactic radiosurgery
(Gamma Knife)
Indications
• Small
• Difficult to reach by surgery
Mechanism
• Produce direct damage to the vessels
that will cause a scar and allow the AVM
to “clot off”
• Takes 2 years to cure AVM
 Endovascular treatment
Indications
• Usually for a part of AVM
• Rest of AVM requires treatment either with
surgery or Gamma Knife
• Occasionally for small AVM
Mechanism
• Blocking off abnormal blood vessels to stop blood
flowing to AVM
– Liquid tissue adhesives (glues)
– Coils
– Particles and other materials used
Endovascular treatment
 Outcome – Surgery
• Small AVMs
– Cure: 94 to 100%
– Morbidity and mortality: <10%
– Bleeding
– Infection
– Paralysis or loss of function (temporary or permanent)
– Convulsions (controllable or uncontrollable)
– Coma (reversible or irreversible)
– Death
– Seizure-free: 81%
• Large AVMs
– Morbidity and mortality: 25%
 Outcome – Gamma Knife

• Cure: 61% to 87% (after 2 years)

• Morbidity (during 2years): 1 to 36%

• Mortality (during 2years): 0 to 9%

• Seizure-free: 43%
 Outcome – Endovascular treatment

• Cure: 5 to 40%

• Morbidity rates: 8% -10%

– Same as for surgery

• Mortality rate: 1%

• Seizure-free: 50%
 Conclusion
• AVMs are difficult to treat and treatment decision should be
individualized
• If AVM has not ruptured (never bled) there is no need of specific
treatment.
• Patient requires only symptomatic treatment
• Whenever possible microsurgery is the best option
• Gamma Knife is an optional treatment for inaccessible AVM
• Endovascular treatment is not effective as stand alone for most
cases
• Medium size AVMs require multimodal treatment
• Very large AVMs should not be treated