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Management of Non-Ruptured AVM’s

Ross W. Urwin, M.D. South Florida Neurovascular. Management of Non-Ruptured AVM’s. Topics. Epidemiology Presentation Management Options Treatment Modalities Decision making Counselling patient. Arterio-venous malformation. AVM. AVM Normal Circulation. AVM Concept. AVM Terminology.

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Management of Non-Ruptured AVM’s

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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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