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Multiple cerebral arterio-venous malformations: impact of multiplicity and hemodynamics on treatment strategies

Acta Neurochirurgica volume 158, pages 2399–2407 (2016)Cite this article

Abstract

Background

Multiple AVMs are exceptionally rare lesions and only a few larger series have been published, including other vascular pathologies, such as arterio-venous fistulae (AVF) or patients with hereditary syndromes. Our study presents clinical, angiographic, and therapeutic characteristics of patients harboring sporadic multiple AVMs.

Methods

Basic demographic data, vascular architecture, clinical presentation, treatment strategies, and treatment outcome were analyzed retrospectively from patients with cerebral AVMs treated in our department between 1990 and 2015.

Results

Six out of 539 patients (1.1 %) harbored 15 multiple and distinct cerebral lesions. Nidus size was predominantly small, consequently determining a Spetzler–Martin grade °I–°II (three-tier grading system). In three patients, AVMs shared a proximal feeding artery supply, whereas each AVM displayed its own venous drainage. Five of six patients (83 %) presented with hemorrhage. Four patients received therapy of the AVMs with complete elimination in 3/4 patients (75 %) and 8/9 treated AVMs (89 %). All patients with treatment of the AVM showed good-to-excellent recovery (n = 4, mRS ≤ 2).

Conclusions

Multiple cerebral AVMs are complex vascular lesions. The multiplicity of hemodynamic and malformation-related variables influence treatment strategy and sequence. Thus, awareness of these parameters (of various malformations before and during treatment) is important. The high number of hemorrhagic events in the present series might justify a more aggressive treatment of multiple AVMs than previously thought.

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Acknowledgments

The authors thank Mike Sucker and Tobias Schoemberg for assistance in preparing the figures.

Author information

Author notes

  1. Klaus-Peter Stein & I. Erol Sandalcioglu

    Present address: Department of Neurosurgery, KRH Hospital Nordstadt, Haltenhoffstr.41, 30167, Hannover, Germany

Affiliations

  1. Department of Neurosurgery, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany

    Klaus-Peter Stein, Neriman Oezkan, Yuan Zhu, I. Erol Sandalcioglu & Ulrich Sure

  2. Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany

    Isabel Wanke & Michael Forsting

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  1. Klaus-Peter Stein
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Correspondence to Klaus-Peter Stein.

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Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

No IRB approval is needed for retrospective cohorts in academic centers in Germany, so no informed consent was required from any of the patients.

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Comments

The authors present an interesting series of six patients with multiple AVMs who were managed with variety of treatment strategies including conservative management. While two patients had a very poor outcome, four survived with good/reasonable function. The authors encourage the treatment of patients with multiple AVM based on their apparent higher risk of bleed (which is based on small series of multiple AVMs). They also suggest caution in terms of hemodynamic change in multiple AVMs treatment when one is treated and the other is left alone (whether this increases the risk of bleed or decreases is unclear). Theoretically, one could imagine that multiple AVMs in a given patient will put that patient at higher risk of hemorrhagic event than a patient with a single AVM. On the other hand, treatment of all AVMs has undeniably an accumulated risk of complications, especially if multi-modality treatments are undertaken. I personally lean towards the treatment of multiple AVMs (and more so if one has bled) if the neurological morbidity is considered low or acceptable especially in younger patients. Aruba trial is easily criticized for its non-applicability to surgical treatment of AVMs, and certainly cannot be brought as a validation of observation vs. treatment in multiple AVM scenarios.

Amir Dehdashti

NY, USA

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Stein, KP., Wanke, I., Oezkan, N. et al. Multiple cerebral arterio-venous malformations: impact of multiplicity and hemodynamics on treatment strategies. Acta Neurochir 158, 2399–2407 (2016). https://doi.org/10.1007/s00701-016-2989-8

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  • DOI: https://doi.org/10.1007/s00701-016-2989-8

Keywords

  • Cerebral arterio-venous malformation
  • AVM multiplicity
  • Intracranial hemorrhage
  • AVM hemodynamics