Top Things to Know: Management of Brain Arteriovenous Malformations (bAVMs)
Published: June 22, 2017
- bAVMs have an asymptomatic prevalence on brain magnetic resonance (MR) studies of 0.05% and a prevalence of detected asymptomatic or symptomatic bAVMs in the population of 10-18 per 100,000. New detection rate (incidence) is approximately 1.3 per 100,000 personyears.
- In population-based studies, symptomatic bAVMs manifest with hemorrhagic stroke (58%), epileptic seizure (s) (34%), or other symptoms such as progressive neurological deficit (8%).
- This statement is an update to the 2001 AVM Scientific paper, using the most current data to make suggestions for the diagnosis and management of both ruptured and unruptured brain arteriovenous malformations.
- bAVMs are characterized by direct connections from artery to vein with an intervening tangle of abnormal dilated channels, which are neither arterial nor venous, termed the nidus. Blood is shunted from the artery to the vein through the nidus, resulting in higher than normal flow in both feeding arteries and draining veins, and higher than normal pressure on the venous side.
- Treatment options include conservative management, surgical resection, stereotactic radiosurgery, endovascular embolization, or a combination of these treatments. The main goal of treatment is to prevent hemorrhagic stroke.
- Patients should be informed about risks related to: ICH occurring, development of seizures for people with unruptured bAVM, and a discussion about treatment options considering risks weighed against the relative risk of the different intervention strategies and life expectancy. Natural history of bAVMs should also be discussed.
- The Spetzler-Martin scale is useful for predicting the risk of surgical resection.
- Brain imaging using computed tomographic angiography, magnetic resonance angiography, and digital subtraction angiography can be useful to evaluate for underlying bAVMs in patients presenting with nontraumatic ICH when there is clinical or radiological suspicion of bAVM.
- Uncertainties still exist regarding the best approach to management of bAVMs.
- Medical management of unruptured bAVMs seems to be superior to intervention, but there may be subsets of patients who may do better in terms of reduced risk of rupture and seizures with intervention and complete resection. Other options are available.
Citation
Derdeyn CP, Zipfel GJ, Albuquerque FC, Cooke DL, Feldmann E, Sheehan JP, Torner JC; on behalf of the American Heart Association Stroke Council. Management of brain arteriovenous malformations: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association [published online ahead of print June 22, 2017]. Stroke. doi: 10.1161/STR.0000000000000134.