Skip to main content
SpringerLink
Log in

Intracranial Arteriovenous Malformations

  • Chapter
  • First Online:
Evidence-Based Management of Head and Neck Vascular Anomalies

Abstract

Intracranial AVMs are complex lesions requiring multidisciplinary expertise for optimal patient outcomes. While the optimal treatment depends on AVM-specific factors such as rupture status, size, location within the brain, and the presence of deep venous drainage, the treating neurosurgeon must be able to synthesize the risks and benefits of multiple treatment options to best determine the safest treatment modality for each patient. In this chapter we present current review on best practices for the treatment of intracranial AVMs.

Would be helpful to have a table showing the different classification methods. There is too much text in this chapter dedicated to this.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 139.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Al-Shahi R, Fang JSY, Lewis SC, Warlow CP. Prevalence of adults with brain arteriovenous malformations: a community based study in Scotland using capture-recapture analysis. J Neurol Neurosurg Psychiatry. 2002;73:547–51. https://doi.org/10.1136/jnnp.73.5.547.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Hartmann A, Mast H, Mohr JP, et al. Morbidity of intracranial hemorrhage in patients with cerebral arteriovenous malformation. Stroke. 1998;29:931–4.

    Article  CAS  Google Scholar 

  3. Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. J Neurosurg. 1986;65:476–83. https://doi.org/10.3171/jns.1986.65.4.0476.

    Article  CAS  PubMed  Google Scholar 

  4. **Spetzler RF, Ponce FA. A 3-tier classification of cerebral arteriovenous malformations. Clinical article. J Neurosurg. 2011;114:842–9. https://doi.org/10.3171/2010.8.JNS10663.

    Article  PubMed  Google Scholar 

  5. *Lawton MT, Kim H, McCulloch CE, et al. A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery. Neurosurgery. 2010;66:702–13 discussion 713. https://doi.org/10.1227/01.NEU.0000367555.16733.E1.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Höllerhage HG. Cerebral arteriovenous malformations: factors influencing surgical difficulty and outcome. Neurosurgery. 1992;31:604–5.

    Article  Google Scholar 

  7. Spears J, Terbrugge KG, Moosavian M, et al. A discriminative prediction model of neurological outcome for patients undergoing surgery of brain arteriovenous malformations. Stroke. 2006;37:1457–64. https://doi.org/10.1161/01.STR.0000222937.30216.13.

    Article  PubMed  Google Scholar 

  8. Hashimoto T, Lawton MT, Wen G, et al. Gene microarray analysis of human brain arteriovenous malformations. Neurosurgery. 2004;54:410–25. https://doi.org/10.1227/01.NEU.0000103421.35266.71.

    Article  PubMed  Google Scholar 

  9. Satomi J, Mount RJ, Toporsian M, et al. Cerebral vascular abnormalities in a murine model of hereditary hemorrhagic telangiectasia. Stroke. 2003;34:783–9. https://doi.org/10.1161/01.STR.0000056170.47815.37.

    Article  PubMed  Google Scholar 

  10. Girerd X, London G, Boutouyrie P, et al. Remodeling of the radial artery in response to a chronic increase in shear stress. Hypertension. 1996;27:799–803. https://doi.org/10.1161/01.HYP.27.3.799.

    Article  CAS  PubMed  Google Scholar 

  11. Hashimoto T, Emala CW, Joshi S, et al. Abnormal pattern of Tie-2 and vascular endothelial growth factor receptor expression in human cerebral arteriovenous malformations. Neurosurgery. 2000;47:910–9. https://doi.org/10.1097/00006123-200010000-00022.

    Article  CAS  PubMed  Google Scholar 

  12. Thorpe ML, Cordato DJ, Morgan MK, Herkes GK. Postoperative seizure outcome in a series of 114 patients with supratentorial arteriovenous malformations. J Clin Neurosci. 2000;7:107–11. https://doi.org/10.1054/jocn.1999.0159.

    Article  CAS  PubMed  Google Scholar 

  13. Englot DJ, Young WL, Han SJ, et al. Seizure predictors and control after microsurgical resection of supratentorial arteriovenous malformations in 440 patients. Neurosurgery. 2012;71:572–80. https://doi.org/10.1227/NEU.0b013e31825ea3ba.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Higuchi M, Bitoh S, Hasegawa H, et al. Marked growth of arteriovenous malformation 19 years after resection: a case report. No Shinkei Geka. 1991;19:75–8.

    CAS  PubMed  Google Scholar 

  15. Fuwa I, Wada H, Matsumoto T. Recurrence of AVM after disappearing on postoperative angiography – report of two cases. No Shinkei Geka. 1988;16:887–91.

    CAS  PubMed  Google Scholar 

  16. Gabriel EM, Sampson JH, Wilkins RH. Recurrence of a cerebral arteriovenous malformation after surgical excision. Case Rep J Neurosurg. 1996;84:879–82. https://doi.org/10.3171/jns.1996.84.5.0879.

    Article  CAS  Google Scholar 

  17. Freudenstein D, Duffner F, Ernemann U, et al. Recurrence of a cerebral arteriovenous malformation after surgical excision. Cerebrovasc Dis. 2001;11:59–64.

    Article  CAS  Google Scholar 

  18. *Ondra SL, Troupp H, George ED, Schwab K. The natural history of symptomatic arteriovenous malformations of the brain: a 24-year follow-up assessment. J Neurosurg. 1990;73:387–91. https://doi.org/10.3171/jns.1990.73.3.0387.

    Article  CAS  PubMed  Google Scholar 

  19. ***Mohr JP, Parides MK, Stapf C, et al. Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet. 2014;383:614–21. https://doi.org/10.1016/S0140-6736(13)62302-8.

    Article  CAS  PubMed  Google Scholar 

  20. Magro E, Gentric J-C, Darsaut TE, et al. Responses to ARUBA: a systematic review and critical analysis for the design of future arteriovenous malformation trials. J Neurosurg. 2016:1–9. https://doi.org/10.3171/2015.6.JNS15619.

    Article  Google Scholar 

  21. Russin J, Spetzler R. Commentary: the ARUBA trial. Neurosurgery. 2014;75:E96–7. https://doi.org/10.1227/NEU.0000000000000357.

    Article  PubMed  Google Scholar 

  22. Bervini D, Morgan MK, Ritson EA, Heller G. Surgery for unruptured arteriovenous malformations of the brain is better than conservative management for selected cases: a prospective cohort study. J Neurosurg. 2014;121:878–90. https://doi.org/10.3171/2014.7.JNS132691.

    Article  PubMed  Google Scholar 

  23. Nerva JD, Mantovani A, Barber J, et al. Treatment outcomes of unruptured arteriovenous malformations with a subgroup analysis of ARUBA (a randomized trial of unruptured brain arteriovenous malformations)-eligible patients. Neurosurgery. 2015;76:563–70. https://doi.org/10.1227/NEU.0000000000000663.

    Article  PubMed  Google Scholar 

  24. Rutledge WC, Abla AA, Nelson J, et al. Treatment and outcomes of ARUBA-eligible patients with unruptured brain arteriovenous malformations at a single institution. Neurosurg Focus. 2014;37:E8. https://doi.org/10.3171/2014.7.FOCUS14242.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Javadpour M, Al-Mahfoudh R, Mitchell PS, Kirollos R. Outcome of microsurgical excision of unruptured brain arteriovenous malformations in ARUBA-eligible patients. Br J Neurosurg. 2016;30:619–22. https://doi.org/10.1080/02688697.2016.1181153.

    Article  PubMed  Google Scholar 

  26. Schramm J, Schaller K, Esche J, Boström A. Microsurgery for cerebral arteriovenous malformations: subgroup outcomes in a consecutive series of 288 cases. J Neurosurg. 2011:1–8. https://doi.org/10.3171/2016.4.JNS153017.

    Article  Google Scholar 

  27. Wong J, Slomovic A, Ibrahim G, et al. Microsurgery for ARUBA trial (a randomized trial of unruptured brain arteriovenous malformation)-eligible unruptured brain arteriovenous malformations. Stroke. 2017;48:136–44. https://doi.org/10.1161/STROKEAHA.116.014660.

    Article  PubMed  Google Scholar 

  28. Lawton MT, UCSF Brain Arteriovenous Malformation Study Project. Spetzler-Martin grade III arteriovenous malformations: surgical results and a modification of the grading scale. Neurosurgery. 2003;52:740–8. discussion 748–9.

    Article  Google Scholar 

  29. Frizzel RT, Fisher WS III. Cure, morbidity, and mortality associated with embolization of brain arteriovenous malformations. Neurosurgery. 1995;37:1031–40. https://doi.org/10.1227/00006123-199512000-00001.

    Article  CAS  PubMed  Google Scholar 

  30. Saatci I, Geyik S, Yavuz K, Cekirge HS. Endovascular treatment of brain arteriovenous malformations with prolonged intranidal Onyx injection technique: long-term results in 350 consecutive patients with completed endovascular treatment course. J Neurosurg. 2011;115:78–88. https://doi.org/10.3171/2011.2.JNS09830.

    Article  PubMed  Google Scholar 

  31. Katsaridis V, Papagiannaki C, Aimar E. Curative embolization of cerebral arteriovenous malformations (AVMs) with Onyx in 101 patients. Neuroradiology. 2008;50:589–97. https://doi.org/10.1007/s00234-008-0382-x.

    Article  PubMed  Google Scholar 

  32. Alexander MD, Cooke DL, Hallam DK, et al. Less can be more: targeted embolization of aneurysms associated with arteriovenous malformations unsuitable for surgical resection. Interv Neuroradiol. 2016;22:445–51. https://doi.org/10.1177/1591019916641316.

    Article  PubMed  PubMed Central  Google Scholar 

  33. ***Xu F, Zhong J, Ray A, et al. Stereotactic radiosurgery with and without embolization for intracranial arteriovenous malformations: a systematic review and meta-analysis. Neurosurg Focus. 2014;37:E16. https://doi.org/10.3171/2014.6.FOCUS14178.

    Article  PubMed  Google Scholar 

  34. Xhumari A, Rroji A, Enesi E, et al. Glioblastoma after AVM radiosurgery. Case report and review of the literature. Acta Neurochir. 2015;157:889–95. https://doi.org/10.1007/s00701-015-2377-9.

    Article  PubMed  Google Scholar 

  35. Chang SD, Shuster DL, Steinberg GK, et al. Stereotactic radiosurgery of arteriovenous malformations: pathologic changes in resected tissue. Clin Neuropathol. 1997;16:111–6.

    CAS  PubMed  Google Scholar 

  36. Flickinger JC, Kondziolka D, Maitz AH, Lunsford LD. An analysis of the dose-response for arteriovenous malformation radiosurgery and other factors affecting obliteration. Radiother Oncol. 2002;63:347–54.

    Article  Google Scholar 

  37. Schlienger M, Lefkopoulos D, Mérienne L, et al. Linac radiosurgery for cerebral arteriovenous malformations (AVM): results in 173 patients. Int J Radiat Oncol Biol Phys. 1998;42:212. https://doi.org/10.1016/S0360-3016(98)80277-0.

    Article  Google Scholar 

  38. Flickinger JC, Pollock BE, Kondziolka D, Lunsford LD. A dose-response analysis of arteriovenous malformation obliteration after radiosurgery. Int J Radiat Oncol Biol Phys. 1996;36:873–9.

    Article  CAS  Google Scholar 

  39. Friedman WA, Bova FJ, Mendenhall WM. Linear accelerator radiosurgery for arteriovenous malformations: the relationship of size to outcome. J Neurosurg. 1995;82:180–9. https://doi.org/10.3171/jns.1995.82.2.0180.

    Article  CAS  PubMed  Google Scholar 

  40. Pollock BE, Flickinger JC, Lunsford LD, et al. Factors associated with successful arteriovenous malformation radiosurgery. Neurosurgery. 1998;42:1239–44. discussion 1244–7.

    Article  CAS  Google Scholar 

  41. Pollock BE, Link MJ, Brown RD. The risk of stroke or clinical impairment after stereotactic radiosurgery for ARUBA-eligible patients. Stroke. 2013;44:437–41. https://doi.org/10.1161/STROKEAHA.112.670232.

    Article  PubMed  Google Scholar 

  42. **Ding D, Starke RM, Kano H, et al. Radiosurgery for cerebral arteriovenous malformations in a randomized trial of unruptured brain arteriovenous malformations (ARUBA)-eligible patients. Stroke. 2016;47:342–9. https://doi.org/10.1161/STROKEAHA.115.011400.

    Article  PubMed  Google Scholar 

  43. Graf CJ, Perret GE, Torner JC. Bleeding from cerebral arteriovenous malformations as part of their natural history. J Neurosurg. 1983;58:331–7. https://doi.org/10.3171/jns.1983.58.3.0331.

    Article  CAS  PubMed  Google Scholar 

  44. Halim AX, Johnston SC, Singh V, et al. Longitudinal risk of intracranial hemorrhage in patients with arteriovenous malformation of the brain within a defined population. Stroke. 2004;35:1697–702. https://doi.org/10.1161/01.STR.0000130988.44824.29.

    Article  PubMed  Google Scholar 

  45. da Costa L, Wallace MC, Brugge Ter KG, et al. The natural history and predictive features of hemorrhage from brain arteriovenous malformations. Stroke. 2009;40:100–5. https://doi.org/10.1161/STROKEAHA.108.524678.

    Article  PubMed  Google Scholar 

  46. Chen C-J, Chivukula S, Ding D, et al. Seizure outcomes following radiosurgery for cerebral arteriovenous malformations. Neurosurg Focus. 2014;37:E17. https://doi.org/10.3171/2014.6.FOCUS1454.

    Article  PubMed  Google Scholar 

  47. Hoh BL, Chapman PH, Loeffler JS, et al. Results of multimodality treatment for 141 patients with brain arteriovenous malformations and seizures: factors associated with seizure incidence and seizure outcomes. Neurosurgery. 2002;51:303–9. discussion 309–11.

    Article  Google Scholar 

  48. de Los Reyes K, Patel A, Doshi A, et al. Seizures after Onyx embolization for the treatment of cerebral arteriovenous malformation. Interv Neuroradiol. 2011;17:331–8.

    Article  Google Scholar 

  49. Young WL, Kader A, Ornstein E, et al. Cerebral hyperemia after arteriovenous malformation resection is related to “breakthrough” complications but not to feeding artery pressure. The Columbia University arteriovenous malformation study project. Neurosurgery. 1996;38:1085–93. discussion 1093–5.

    Article  CAS  Google Scholar 

  50. Spetzler RF, Wilson CB, Weinstein P, et al. Normal perfusion pressure breakthrough theory. Clin Neurosurg. 1978;25:651–72.

    Article  CAS  Google Scholar 

  51. Batjer HH, Devous MD. The use of acetazolamide-enhanced regional cerebral blood flow measurement to predict risk to arteriovenous malformation patients. Neurosurgery. 1992;31:213–7. discussion 217–8.

    Article  CAS  Google Scholar 

  52. Irikura K, Morii S, Miyasaka Y, et al. Impaired autoregulation in an experimental model of chronic cerebral hypoperfusion in rats. Stroke. 1996;27:1399–404.

    Article  CAS  Google Scholar 

  53. Young WL, Prohovnik I, Ornstein E, et al. The effect of arteriovenous malformation resection on cerebrovascular reactivity to carbon dioxide. Neurosurgery. 1990;27:257–66. discussion 266–7.

    Article  CAS  Google Scholar 

  54. Young WL, Solomon RA, Prohovnik I, et al. 133Xe blood flow monitoring during arteriovenous malformation resection: a case of intraoperative hyperperfusion with subsequent brain swelling. Neurosurgery. 1988;22:765–9.

    Article  CAS  Google Scholar 

  55. Ogasawara K, Yoshida K, Otawara Y, et al. Cerebral blood flow imaging in arteriovenous malformation complicated by normal perfusion pressure breakthrough. Surg Neurol. 2001;56:380–4.

    Article  CAS  Google Scholar 

  56. Barnett GH, Little JR, Ebrahim ZY, et al. Cerebral circulation during arteriovenous malformation operation. Neurosurgery. 1987;20:836–42.

    Article  CAS  Google Scholar 

  57. Sorimachi T, Takeuchi S, Koike T, et al. Blood pressure monitoring in feeding arteries of cerebral arteriovenous malformations during embolization: a preventive role in hemodynamic complications. Neurosurgery. 1995;37:1041–7. discussion 1047–8.

    Article  CAS  Google Scholar 

  58. Viñuela F, Nombela L, Roach MR, et al. Stenotic and occlusive disease of the venous drainage system of deep brain AVM’s. J Neurosurg. 1985;63:180–4. https://doi.org/10.3171/jns.1985.63.2.0180.

    Article  PubMed  Google Scholar 

  59. al-Rodhan NR, Sundt TM, Piepgras DG, et al. Occlusive hyperemia: a theory for the hemodynamic complications following resection of intracerebral arteriovenous malformations. J Neurosurg. 1993;78:167–75. https://doi.org/10.3171/jns.1993.78.2.0167.

    Article  CAS  PubMed  Google Scholar 

  60. Tseng W-L, Tsai Y-H. Vasospasm after intraventricular hemorrhage caused by arteriovenous malformation. Asian J Neurosurg. 2015;10:114–6. https://doi.org/10.4103/1793-5482.154984.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Dull C, Torbey MT. Cerebral vasospasm associated with intraventricular hemorrhage. Neurocrit Care. 2005;3:150–2. https://doi.org/10.1385/NCC:3:2:150.

    Article  PubMed  Google Scholar 

Download references

To assist the reader in gaining familiarity with available evidence, the following rating system has been used to indicate key references for each chapter’s content:

***: Critical material. Anyone dealing with this condition should be familiar with this reference.

**: Useful material. Important information that is valuable in in clinical or scientific practice related to this condition.

*: Optional material. For readers with a strong interest in the chapter content or a desire to study it in greater depth.

Author information

Authors and Affiliations

  1. Department of Neurological Surgery, University of Washington, Seattle, WA, USA

    Jacob Ruzevick MD, Gabrielle White-Dzuro MD & Manuel Ferreira Jr. MD, PhD

  2. Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA

    Michael Levitt MD & Louis Kim MD

Authors
  1. Jacob Ruzevick MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gabrielle White-Dzuro MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Michael Levitt MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Louis Kim MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Manuel Ferreira Jr. MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Manuel Ferreira Jr. MD, PhD .

Editor information

Editors and Affiliations

  1. Otolaryngology-Head and Neck Surgery, University of Washington, Seattle Children’s Hospital, Seattle, WA, USA

    Jonathan A. Perkins

  2. Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA

    Karthik Balakrishnan

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG, part of Springer Nature

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Ruzevick, J., White-Dzuro, G., Levitt, M., Kim, L., Ferreira, M. (2018). Intracranial Arteriovenous Malformations. In: Perkins, J., Balakrishnan, K. (eds) Evidence-Based Management of Head and Neck Vascular Anomalies. Springer, Cham. https://doi.org/10.1007/978-3-319-92306-2_22

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-92306-2_22

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-92305-5

  • Online ISBN: 978-3-319-92306-2

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation