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Brain AVM Radiosurgery
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Johns Hopkins Brain AVM Radiosurgery
Email Dr. Jeffery Williams. The decisions related to treatment for the brain AVM (arteriovenous malformation) depend upon the complete understanding of the competing risks vs. benefits. The important considerations for treatment of the AVM include the size and location within the brain. Options for treatment include brain AVM surgery, brain AVM embolization and brain AVM radiosurgery.
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Brain AVM TreatmentsBrain AVM (Arteriovenous Malformations) require different treatments depending upon many factors.
Brain AVM HemorrhageThe most neurologically devastating presentation associated with arteriovenous malformations (AVMs) of the brain is intracerebral hemorrhage. Numerous studies have estimated the natural risk of intracerebral hemorrhage associated with AVMs at 3% to 4% per year. When an AVM is identified in a young, otherwise healthy individual, one of several therapies (microsurgery, radiosurgery, or endovascular therapy) is often considered in an attempt to extirpate the lesion before a hemorrhage can occur.
Brain AVM Natural HistoryMany studies have addressed the issue of the natural history of AVMs. Unfortunately, most have selection bias, the use of a variety of therapeutic techniques, relatively short follow-up duration, and the inclusion of only certain subgroups of AVM patients, such as patients presenting with hemorrhage.
Brain AVM BleedingSome have suggested that a history of hemorrhage predisposes a patient to an increased incidence of subsequent hemorrhages. A number of investigators have identified a tendency for smaller AVMs to hemorrhage. Others that this is an artifact due to the fact that smaller lesions are less likely than larger AVMs to present with seizures or vascular steal. Likewise, an increased risk of hemorrhage during pregnancy has been postulated but never proven.
Brain AVM Risk FactorsA variety of angiographic abnormalities have been purported to increase the likelihood of AVM hemorrhage. These include irregularity or stenosis of venous drainage, or absence of the vein of Galen for cases with deep drainage. Arterial aneurysms or venous stenosis are present in many patients presenting with hemorrhage. Periventricular location, intranidal aneurysm, and central venous drainage have been corrleated with the occurrence of AVM hemorrhage.
Brain AVM TreatmentsTreatments include stereotactic radiosurgery, surgery and/or embolization (alone or in combination)
AVM radiosurgery offers non-invasive treatment. The treatment includes placement of the radiosurgery frame via local anesthetic. The radiosurgery frame attaches to the scalp and to the outer table of the skull. The frame is in place during the angiogram. The AVM and the frame are visualized during the angiogrm. The precise location of the AVM in the brain is determined by reference to the visible frame, using a powerful computer.
Selected patients with arteriovenous malformations (AVMs) are candidates for treatment with radiosurgery, and in the majority of cases a cure can be achieved.
Large AVMFor larger AVM the combination of embolization and radiosurgery has proven useful. The embolization can reduce the size of the AVM such that radiosurgery is feasible. The radiosurgery for larger AVM may require 2 to 3 sessions, rather than one, to be successful. This is because the size of the treated AVM is larger and therefore requires a decreased dose to render a safe treatment. The decreased dose implies multiple treatments in order to achieve success. The decision regarding AVM treatments should be made in the context of the risks and benefits of the competing treatments. These vary with the size and location of the AVM within the brain.
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