Brain arteriovenous malformations treatment can be very complex. Observation, open brain surgery or endovascular embolization. These are three treatment methods for cerebral AVMs. They can be used together or sequentially.
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Brain arteriovenous malformations treatment strategy depends on location and type of AVM. Probability of cerebral arteriovenous malformation hemorrhage is higher with AVMs that contain a brain aneurysm. Dr. Peng Roc Chen, MD. Top cerebrovascular neurosurgeon shares his experience in brain arteriovenous malformations treatment. Video interview with top expert in endovascular neurosurgery. Medical second opinion confirms that brain or spine arteriovenous malformation diagnosis is correct and complete. Medical second opinion helps to choose the best treatment for brain or spine arteriovenous malformation. Get Medical second opinion on arteriovenous malformation and be confident that your treatment is the best. Dr. Peng Roc Chen, MD. Arteriovenous malformation is an indication for open brain surgery and for endovascular treatment. AVM bleeding risk depends on previous history of hemorrhage and AVM size and shape. Intracranial arteriovenous malformations of Spetzler Martin AVM grade 4 is lower than usually reported. Eloquent brain areas locations of AVM have to be assessed for watchful waiting observation. Brain arteriovenous malformations. 1234 What are the nuances of treatment of Brain arteriovenous malformation? What are modern methods to treat cerebral arteriovenous malformations? 1234 (Skull Base Neurosurgeon and Endovascular neurosurgeon, University of Texas). Dr. Peng Roc Chen, MD. Brain arteriovenous malformations (brain AVM) are a big category of cerebrovascular lesions. Broad definition of arteriovenous malformations is this. The brain includes high-flow arteriovenous malformations and dural arteriovenous fistulas. Cerebral arteriovenous malformations are usually congenital. They form during 4 to 8 weeks of fetal development, when vascular structures develop in the fetus. Wrong development of cerebral blood vessels results in plexiform web of incorrectly formed connections between arteries and veins. Second type of vascular malformation in the brain is called brain dural arteriovenous fistula (BDAVF). This malformation often forms during patient’s lifetime. We do not know the reasons why brain dural arteriovenous fistulas develop. They could be a result of venous thrombosis in the brain. But we do not really know. Third type of brain arteriovenous malformation is cavernous malformation (cavernous angioma). They are not visible on vascular imaging. But brain MRI and CT scans can show cavernous malformations well. Brain cavernous malformations can cause brain hemorrhage (bleeding) on a small scale. So these are three types of brain arteriovenous malformations. High-flow brain arteriovenous malformations have a risk of bleeding into the brain. The risk of brain hemorrhage from unruptured cerebral arteriovenous malformations is a controversial issue. 1234 Probability of rupture of brain arteriovenous malformation has been studied. However, we do not know with certainty how big is the risk of bleeding. Dr. Peng Roc Chen, MD. I think that the risk of rupture of any unruptured brain arteriovenous malformation is 1% to 4% per each year. This risk of bleeding depends on the size of arteriovenous malformation. The risk of Brain arteriovenous malformation rupture also depends on geometry of vascular channels inside the arteriovenous malformation. Very large brain arteriovenous malformations are called “Spetzler Martin AVM grade 4” or “Spetzler Martin AVM grade 5”. Risk of rupture of large brain AVMs decreases if we deduct the risk of rupture of brain aneurysms. Brain aneurysms can sometimes co-exist with brain arteriovenous malformations. The risk of rupture and bleeding of these large brain arteriovenous malformations (Spetzler Martin grade 4 and 5) is much lower than we previously thought. Risk of rupture of Brain arteriovenous malformation is about 1% one percent per each year. Or it is less than 1% one percent per each year. We previously treated large brain arteriovenous malformations very aggressively. But risks from surgical and endovascular treatment of large brain AVMs are also very high. Dr. Peng Roc Chen, MD. Risks of treatment could be higher than risks of spontaneous aneurysm rupture. Therefore, we currently do not aggressively treat very large brain arteriovenous malformations. Sometimes patients with brain AVMs also have brain aneurysms. Aneurysms form in such patients because of many years of high pressure blood flow through brain vessels. Brain aneurysms in patients with cerebral arteriovenous malformations carry increased risk of bleeding from the aneurysm. We can often treat brain aneurysms in such patients by endovascular methods. Approximately two thirds of patients with large cerebral arteriovenous malformations may have seizures. We can successfully treat seizures in these patients too. The risk of bleeding from rupture of cerebral arteriovenous malformation is higher in those patients. They have brain arteriovenous malformations of SMALLER size. Sometimes brain arteriovenous malformation is located in the area of brain that does not contain very important functional area around AVM. Then we can treat Brain arteriovenous malformation very safely. It is better to treat such cerebral arteriovenous malformations. Because the risk of their rupture is higher than the risk of surgical or endovascular treatment. Risk of brain AVM rupture is higher in younger patients. Dr. Peng Roc Chen, MD. Particularly younger patients can benefit from open brain surgery or endovascular embolization procedure. Combination of both treatments methods can often remove cerebral arteriovenous malformation completely. Stereotactic radiosurgery (“gamma knife”) can be used to treat brain arteriovenous malformation in areas of the brain. This is very difficult to reach or where surgery can damage brain function. But it is most important to carefully and fully assess the situation of the patient with brain arteriovenous malformation. Do it before deciding about any method of treatment or observation of Brain arteriovenous malformation. Incomplete, half-way treatment of patients with unruptured brain AVM is not good. It is best to use combination of endovascular embolization and open brain operation. Do not use only one method of treatment. Doctors should use multidisciplinary team approach. Surgeons must carefully prepare a detailed plan of treatment of brain arteriovenous malformation. It is done before any method of treatment is initiated. For ruptured brain arteriovenous malformations the risk of repeat rupture is much higher. Risk of repeat brain bleeding is 4% per year to 7% per year. So we know that patients with ruptured brain AVMs in general require treatment. Dr. Peng Roc Chen, MD. The principle of treatment of ruptured brain arteriovenous malformations is the same as in treatment of unruptured brain AVMs. Sometimes cerebral AVM is located in less important area of their brain. Open brain surgical operation can be used. Sometimes cerebral arteriovenous malformation is located in area of the brain that has functionally important cortex. Then the decision about treatment is complex and difficult. Neurosurgeons, endovascular neurosurgery specialists and radiosurgery specialists have to decide how to obliterate brain arteriovenous malformations. How to treat a patient without damaging functionally important areas of the brain. Dr. Peng Roc Chen, MD. This is the current level of our approach to treatment of cerebral arteriovenous malformations. Brain arteriovenous malformations treatment. Observation or intervention? Endovascular embolization or open brain surgery? Advances in treatment of AVMs.