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Comprehensive Overview of Non-Ruptured AVMs Management Strategies

Explore epidemiology, presentation, and treatment modalities for AVMs with emphasis on decision-making and patient counseling in neurovascular care. Learn about high-flow AVMs, arteriovenous malformation terminology, aneurysms, seizures, and headache presentations. The text covers the management options including medical, surgical excision, embolization, and radiosurgery methods. Discover guidelines from various studies and key factors like the Spetzler-Martin grading system, ARUBA study outcomes, and the efficacy of radiosurgical treatment for AVMs.

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Comprehensive Overview of Non-Ruptured AVMs Management Strategies

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  1. Ross W. Urwin, M.D. South Florida Neurovascular Management of Non-Ruptured AVM’s

  2. Topics • Epidemiology • Presentation • Management Options • Treatment Modalities • Decision making • Counselling patient

  3. Arterio-venous malformation AVM

  4. AVMNormal Circulation

  5. AVMConcept

  6. AVMTerminology • Feeding artery • Nidus • Draining vein

  7. AVM

  8. AVMPathophisiology • High Flow • Pressurized nidus • Pressurized veins • High Flow • Pressurized nidus • Pressurized veins

  9. AVMPathophisiologyAneurysms/Rupture • Nidus • (Intranidal) • Vein • (Varix) Artery

  10. AVMPathophysiologySeizure, deficit • Surrounding tissue • - Steal phenomena • - Compromised venous drainage • ??

  11. AVMPathophysiologyHeadache • Venous Distension • Dural structures • ?

  12. Epidemiology

  13. EpidemiologyIncidence • Rate of detection 1.3 per 100,000 person-years

  14. Presentation

  15. PresentationSymptomatic • Common • Intracranial Hemorrhage • 58% • Seizures • 34% • Less Common • Neurological deficit • 8%

  16. PresentationAsymptomatic • Radiologic study • CT Scan • CTA • MRI • MRA • Cerebral Angiogram

  17. Ruptured & Non-ruptured Management

  18. ManagementOptions • Conservative • Medical management • Treatment • Neurosurgery • Surgical excision • Endovascular • Embolization • Stereotaxtic Radiosurgery • Gamma Knife • Cyber knife

  19. ManagementOptions • Treatment (cont.) • Combined Modalities • Embolization + Surgery • Embolization + Radiation

  20. TreatmentGoal Goal of treatment (Ruptured & non-ruptured) COMPLETE elimination of Nidus A-V shunt

  21. TreatmentGoal • Partial resection/occlusion DOES NOT • reduce risk of ICH • May increase risk of bleed

  22. ManagementofNon-Ruptured AVM

  23. ManagementGuidelines 2001- Recommendations for the Management of Intracranial AVMs • AHA Scientific Statement 2017- Management of brain AVMs • AHA/ASA Scientific statement

  24. ManagementGuidlinesICH • Annual risk of 1st ICH • ~1% • Annual risk of recurrent ICH • ~5%

  25. ManagementSeizures • 5 year risk of 1st seizure • 8% • 5 yr risk of epilepsy after 1st siezure • 58%

  26. ManagementNon-Ruptured AVMARUBA study

  27. ManagementARUBA StudyUnruptured AVM • ARUBA • UnRUptured Brain Avm • Mohr et al. • “International ARUBA investigation,...” • Lancet 2014,383,614-621

  28. ManagementARUBA StudyUnruptured AVM • Randomized to medical management vs TX • Endpoints • Stroke • Death • 39 sites • Worldwide • Adult patients • >18yo

  29. ManagementARUBA StudyUnruptured AVM • Randomized to medical management vs TX • Endpoints • Stroke • Death • 39 sites • Worldwide • Adult patients • >18yo

  30. ManagementARUBA Study • 6 years • 2007-2013 • 226 patients • HALTED

  31. ManagementARUBA Study • HALTED • Stroke, Death • f/u 33 mos • Medical 10% • TX 30% • Follow for 5 more yrs

  32. NeurosurgicalManagement

  33. ManagementSpetzler-Martin •1986- Spetzler, R., Martin, N. “A proposed grading system for arteriovenous malformations” J Neurosurg. 65 (4): 476–83.

  34. ManagementSpetzler-Martin Purpose • Predict risk of mobidity and mortality for surgical excision • Based on a simple grading system

  35. ManagementSpetzler-Martin Grading Scale • Points based on • Size • Venous drainage • Location • Grade • A number I thru V

  36. ManagementSpetzler-Martin Grading Scale • Size • <3cm- 1 • 3-6 cm 2 • >6 cm 3 • Deep Venous drainage • No 0 • Yes 1 • Eloquence • No 0 • Yes 1

  37. ManagementNeurosurgery • Retrospective, single center large studies • Correlate Spetzler-Martin grade with • Rates of cure • Rate of poor outcome

  38. ManagementNeurosurgery • Angiographic documented cure • 95 - 99% (All SM grades)

  39. ManagementNeurosurgerySM grade vs outcome Grade Poor outcome • I 4 % • II 10 % • III 18 % • IV 31 % • V 37 %

  40. ManagementNeurosurgeryConclusions • Suitable for low SM grade • Grade I, II • Not suitable due to poor outcomes • Grade IV, V • ? Grade III ?

  41. ManagementNeurosurgeryGrade III • Prevalence each SM grade not established • However • 3 – 6 cm 55% (2 pt) • Deep veins 55% (1 pt) • Eloquent 71% (1 pt) • Conclusion: Majority Grade III-V

  42. ManagementSpetzler-Martin Update • Supplimented Spetzler-Martin grading system(2010) • Grade is now 1-10 • Usual Spetzler -Martin grade • 1-5 • + Additional factors • Age (1-3) • Ruptured vs unruptured (0-1) • Diffuse (0-1)

  43. ManagementSpetzler-Martin Update • Age • <20 1 • 20-40 2 • >40 3 • Ruptured vs non-ruptured • No 0 • Yes 1 • Diffuse • No 0 • Yes 1

  44. RadiosurgicalManagement

  45. ManagementRadiosurgery • “Stereotactic Radiosurgery” • Gamma knife • Cyber knife

  46. ManagementRadiosurgeryGamma knife

  47. ManagementRadiosurgeryGamma Knife

  48. ManagementRadiosurgeryGamma Knife

  49. ManagementRadiosurgeryGamma Knife

  50. ManagementRadiosurgeyOutcomes • Obliteration rate • ~ 70 – 80 % • ~ 2 - 3 years to occlusion

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