Endovascular management of arteriovenous malformations of the brain

Abstract

Arteriovenous malformations (AVMs) of the brain are rare, complex, vascular lesions that can result in significant morbidity and mortality. Modern treatment of brain AVMs is a multimodality endeavor, requiring a multidisciplinary team with expertise in cerebrovascular neurosurgery, endovascular intervention, and radiation therapy in order to provide all therapeutic options and determine the most appropriate treatment regimen depending on patient characteristics and AVM morphology. Current therapeutic options include microsurgical resection, radiosurgery (focused radiation), and endovascular embolization. Endovascular embolization is primarily used as a preoperative adjuvant before microsurgery or radiosurgery. Palliative embolization has been used successfully to reduce the risk of hemorrhage, alleviate clinical symptoms, and preserve or improve neurological function in inoperable or nonradiosurgical AVMs. Less frequently, embolization is used as 'primary therapy' particularly for smaller, surgically difficult lesions. Current embolic agents used to treat brain AVMs include both solid and liquid agents. Liquid agents including N-butyl cyanoacrylate and Onyx are the most commonly used agents. As newer embolic agents become available and as microcatheter technology improves, the role of endovascular treatment for brain AVMs will likely expand.

Keywords: Arteriovenous malformations; Embolization; Endovascular treatment; Microcatheters; Multimodality treatment.

Fig. 1

Lateral (a) and anteroposterior view (b) of a 56-year-old male with left eye pain, erythema, and signs of venous congestion secondary to a left ophthalmic artery AVM.

Fig. 2

A 28-year-old female with diffuse intraventricular hemorrhage and hydrocephalus secondary to rupture of a posterior right temporal lobe AVM. Intranidal anterior choroidal artery aneurysm (arrows) was identified and felt to be the source of bleeding. a Anteroposterior view, arterial phase. b Anteroposterior view, late arterial phase. c Lateral view. d Superselective angiogram of the anterior choroidal artery.

Fig. 3

A 65-year-old male presented with intraventricular hemorrhage secondary to right pericallosal splenial region parasagittal AVM. a Anteroposterior view, left internal carotid artery injection. b Lateral view, left internal carotid artery injection. The patient went on to have radiosurgery with complete AVM resolution (images not shown).

Fig. 4

A 39-year-old male presented with SAH related to a large AVM involving the left frontal lobe, left basal ganglia and left temporal lobe. a Lateral view, left ICA injection – arterial phase. b Left ICA injection – venous phase. c Subtracted microcatheter injection of feeding pedicle. d NBCA in nidus (arrow) on unenhanced CT image.

Fig. 5

A 40-year-old male with a left occipital AVM. a AP view, left vertebral artery injection – arterial phase. b Lateral view, left vertebral artery injection – venous phase. c NBCA in nidus on unsubtracted lateral image. d Final digital subtraction angiography after embolization. The AVM was embolized using NBCA with satisfactory reduction in size and flow. The patient went on to have complete surgical resection.