Elective Treatment Options for Unruptured Brain Aneurysms and AVMs

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• Discovery and Treatment Timing
• Global Access to Elective Care
• Assessing Aneurysm Rupture Risk
• Emergency vs Elective Scenarios
• AVM Rupture Risk Dynamics
• Travel for AVM Treatment
• Conclusion and Next Steps
• Full Transcript

Discovery and Treatment Timing

Dr. Peng Chen, MD, begins by noting a critical reality in cerebrovascular health: many brain aneurysms and arteriovenous malformations (AVMs) are discovered only after they rupture, an event with a tragically high mortality rate. However, advancements in neuroimaging over the past two decades have significantly improved the detection of these conditions while they are still unruptured. This early discovery presents a crucial window of opportunity for patients, who are typically asymptomatic and can therefore pursue treatment on an elective basis rather than in an emergency setting.

Global Access to Elective Care

Dr. Chen confirms that the ability to seek treatment anywhere in the world is a major advantage for patients with an unruptured diagnosis. Because there is no active bleeding or immediate crisis, patients have the time and flexibility to research and travel to a medical center that aligns with their needs. Dr. Anton Titov, MD, and Dr. Peng Chen, MD, discuss how this has led to an increase in international patients seeking highly specialized care, with Dr. Chen’s practice treating individuals from across Asia, Europe, and the Middle East.

Assessing Aneurysm Rupture Risk

The cornerstone of managing an unruptured brain aneurysm is a thorough risk assessment. Dr. Peng Chen, MD, explains that not all aneurysms carry the same risk of rupture. Smaller aneurysms may present a lower immediate threat, while larger ones or those with certain morphological features are considered higher risk. He notes that the methods for objectively assessing this rupture risk remain a topic of some controversy within the field, underscoring the need for evaluation by an experienced cerebrovascular specialist to guide the treatment decision.

Emergency vs Elective Scenarios

The interview with Dr. Anton Titov, MD, highlights the stark contrast between emergency and elective care. A ruptured brain aneurysm creates a dire emergency where patients are too unstable to travel far, necessitating immediate local treatment. This scenario carries the high mortality rate Dr. Chen mentioned initially. In contrast, the unruptured state allows for calm, deliberate planning and travel to a world-class facility, fundamentally changing the patient's potential outcome.

AVM Rupture Risk Dynamics

Dr. Peng Chen, MD, outlines a different risk profile for arteriovenous malformations. While the initial rupture of an AVM is serious, the immediate mortality rate is often not as high as with a ruptured aneurysm. The greater long-term danger is from repeat bleeding. Dr. Peng Chen, MD, states unequivocally that once an AVM has ruptured once, the risk of re-bleeding is significant, and these patients "deserve treatment to prevent re-bleed." This makes intervention a critical step to avoid subsequent, potentially devastating events.

Travel for AVM Treatment

Similar to unruptured aneurysms, AVMs offer a post-rupture travel opportunity. After a patient has recovered from the critical phase following their first bleed, their condition stabilizes. This creates another elective window where they can safely travel to seek specialized care. Dr. Peng Chen, MD, confirms his team frequently treats such patients from across the United States and internationally, leveraging a combination of endovascular and surgical expertise to address the complex lesion.

Conclusion and Next Steps

The conversation between Dr. Anton Titov, MD, and Dr. Peng Chen, MD, concludes by reinforcing the value of expert consultation for unruptured cerebrovascular conditions. The key takeaway is that a diagnosis of an unruptured brain aneurysm or AVM is not an immediate emergency but a signal to begin a careful evaluation process. Patients should seek a comprehensive risk assessment from a specialized neurovascular team to make an informed decision about whether intervention is necessary and, if so, to plan that treatment at a center of excellence.

Full Transcript

Dr. Anton Titov, MD: If somebody has a brain aneurysm or arteriovenous malformation that was discovered before it ruptured, or before it created an emergency situation.

Dr. Peng Chen, MD: That's a very unfortunate fact that a lot of brain aneurysms are discovered when they rupture. And that has a very high mortality; a lot of people die once rupture happens. On the other hand, before the aneurysm ruptures or before there is a problem with arteriovenous malformation, patients can go to treatment anywhere in the world.

Dr. Anton Titov, MD: In which situations would patients particularly benefit from your expertise in endovascular methods and open brain surgery, and therefore they can fly anywhere in the world for treatment before it becomes an emergency?

Dr. Peng Chen, MD: You point very clearly—the world is flat these days. I mean, really, treatment and healthcare change drastically in the entire world, including the US. Obviously, technically, neuroimaging is way more advanced over the past 20 years than before. Therefore, we've seen more and more patients who were found with brain aneurysms or so-called arteriovenous malformations, or anything in the brain that would not be identified previously.

And the good part is that whatever is identified, for example, unruptured brain aneurysms—these patients have no symptoms. So they certainly can get treatment anywhere in the world, just like you said. I think that it's quite true; these patients, certainly, if they do want the treatment, they can be treated anywhere where they feel more comfortable. They can be treated here—we do treat a fair amount of international patients, including from Asia, Europe, and the Middle East.

The key element in the unruptured brain aneurysm, as an example, is that certain aneurysms do carry a higher risk of rupture, and for some aneurysms we know at a very small size they might not carry as high a risk of rupture. First, we need to assess a brain aneurysm—whether it's beneficial or not to treat it. Ideally at this point we want to have a more objective and meaningful idea to assess brain aneurysm rupture risk.

However, I would say that some brain aneurysm rupture risk assessment methods are still very controversial. Unfortunately, if brain aneurysms rupture, then treatment is often done locally, because patients with ruptured brain aneurysms cannot travel that far. But for an AVM, it's a different story.

When AVMs rupture, the key risk factor has been taken care of. Often, mortality is not that high from a single AVM rupture. It is the repeat AVM rupture that presents a problem.

Dr. Anton Titov, MD: Right!

Dr. Peng Chen, MD: So we come down to the question—we know at this point that for unruptured AVM the chances of the first rupture are less known. But for the ruptured AVM, the risk of repeat rupture we know—it's high at this point. I don't think there's any question that these patients deserve treatment to prevent re-bleed, because otherwise they continue to re-bleed. This is one big issue.

At the same time, the risk of AVM bleeding in a short period of time is not that high. These patients certainly can travel once they get over the critical phase of recovery after first AVM bleeding; they can travel anywhere to get treated. We treat a lot of patients like this, from different states, local patients, and from different countries. The same is with carotid disease and similar lesions...