Skip to main content
  • Flow Dynamics in Previously Treated AVM's

    Final Number:

    Vernard S Fennell MD; Nikolay L. Martirosyan MD; G. Michael Lemole MD; Travis Michael Dumont MD

    Study Design:

    Subject Category:
    Vascular Malformations

    Meeting: AANS/CNS Cerebrovascular Section 2016 Annual Meeting

    Introduction: Intracerebral arteriovenous malformations (AVM’s) are a complex pathology. Of AVM’s that do not present with hemorrhage, treatment strategies are often predicated on reducing risk of hemorrhage and minimizing morbidity. Outcomes are often a result of the efficacy of the selected treatment. Radiosurgical treatment of certain AVM’s can have incomplete rates of obliteration and may also have minimal effect on the presenting, non-hemorrhagic, symptomology. Restriction of venous outflow can be associated with much of the presentation and treatment morbidity associated with intracerebral arteriovenous malformations (AVM’s).

    Methods: We reviewed the surgical treatment of 2 cases of initially radiosurgically treated AVM’s in patients that exhibited primary clinical symptom of headache and persisted after radiosurgical treatment and whose symptoms abated after subsequent microsurgical resection. Intraoperative observations were reviewed and evaluated.

    Results: Intraoperative indocyanine green angiography, represented with what appeared to be competitive outflow between the AVM nidus and the existing venous architecture. Flow was restored to normal once the AVM was micro surgically resected.

    Conclusions: Venous outflow obstruction is likely to be a sizable contributive factor in occipital AVM’s that present with headache and symptoms of intracranial hypertension. These high flow lesions may be sub-optimally responsive to stereotactic radiosurgery. Microsurgical resection, with or without adjunctive endovascular embolization should be considered as an initial and definitive treatment strategy. Optimal outcomes may be achieved in patients with an anatomically correlated visual deficit

    Patient Care: Potentially improve the diagnosis and treatment of occipital avm's

    Learning Objectives: Understand the flow dynamics related to partially treated occipital AVM's

    References: 1. Ahmed RM, Khoury B, Wilkinson M, Parker GD, Halmagyi GM: Venous Hypertension as the Cause of Intracranial Hypertension in Patients With Transverse Sinus Dural Arteriovenous Fistula: J Neuroophthalmol 33:102–105, 2013 2. Ansari SA, Schnell S, Carroll T, Vakil P, Hurley MC, Wu C, et al.: Intracranial 4D Flow MRI: Toward Individualized Assessment of Arteriovenous Malformation Hemodynamics and Treatment-Induced Changes. Am J Neuroradiol 34:1922–1928, 2013 3. Bambakidis NC, Sunshine JL, Faulhaber PF, Tarr RW, Selman WR, Ratcheson RA: Functional evaluation of arteriovenous malformations. Neurosurg Focus 11:1–5, 2001 4. Barrow DL: Unruptured Cerebral Arteriovenous Malformations presenting with Intracranial Hypertension. Neurosurgery 23:484–490, 1988 5. Bradac O, Charvat F, Benes V: Treatment for brain arteriovenous malformation in the 1998–2011 period and review of the literature. Acta Neurochir (Wien) 155:199–209, 2013 6. Brown Jr RD, Wiebers DO, Forbes G, O’Fallon WM, Piepgras DG, Marsh WR, et al.: The natural history of unruptured intracranial arteriovenous malformations. J Neurosurg 68:352–357, 1988 7. Brown Jr RD, Wiebers DO, Forbes GS: Unruptured intracranial aneurysms and arteriovenous malformations: frequency of intracranial hemorrhage and relationship of lesions. J Neurosurg 73:859–863, 1990 8. Chimowitz MI, Little JR, Awad IA, Sila CA, Kosmorsky G, Furlan AJ: Intracranial hypertension associated with unruptured cerebral arteriovenous malformations. Ann Neurol 27:474–479, 1990 9. Colombo F, Pozza F, Chierego G, Casentini L, De Luca G, Francescon P: Linear accelerator radiosurgery of cerebral arteriovenous malformations: an update. Neurosurgery 34:14–21, 1994 10. Da Costa L, Wallace MC, ter Brugge KG, O’Kelly C, Willinsky RA, Tymianski M: The Natural History and Predictive Features of Hemorrhage From Brain Arteriovenous Malformations. Stroke 40:100–105, 2009 11. Ding D, Yen C-P, Starke RM, Xu Z, Sun X, Sheehan JP: Radiosurgery for Spetzler-Martin Grade III arteriovenous malformations: Clinical article. J Neurosurg:1–11, 2014 12. Furlan AJ, Whisnant JP, Elveback LR: The decreasing incidence of primary intracerebral hemorrhage: a population study. Ann Neurol 5:367–373, 1979 13. Gao E, Young WL, Ornstein E, Pile-Spellman J, Ma Q: A Theoretical Model of Cerebral Hemodynamics: Application to the Study of Arteriovenous Malformations. J Cereb Blood Flow Metab 17:905–918, 1997 14. Guo W-Y, Wu Y-T, Wu H-M, Chung W-Y, Kao Y-H, Yeh T-C, et al.: Toward Normal Perfusion after Radiosurgery: Perfusion MR Imaging with Independent Component Analysis of Brain Arteriovenous Malformations. Am J Neuroradiol 25:1636–1644, 2004 15. Kaplan HA, Aronson SM, Browder EJ: Vascular Malformations of the Brain: An Anatomical Study*. J Neurosurg 18:630–635, 1961 16. Karlsson B, Lax I, Söderman M: Factors influencing the risk for complications following Gamma Knife radiosurgery of cerebral arteriovenous malformations. Radiother Oncol 43:275–280, 1997 17. Michelson W: Natural History and pathophysiology of arteriovenous malformations. Clin Neurosurg 26:307–313, 1978 18. Moftakhar P, Hauptman JS, Malkasian D, Martin NA: Cerebral arteriovenous malformations. Part 2: physiology. Neurosurg Focus 26:E11, 2009 19. Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey J, et al.: Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. The Lancet 383:614–621, 2014 20. Nagasawa S, Kawanishi M, Kondoh S, Kajimoto S, Yamaguchi K, Ohta T: Hemodynamic Simulation Study of Cerebral Arteriovenous Malformations. Part 2. Effects of Impaired Autoregulation and Induced Hypotension. J Cereb Blood Flow Metab 16:162–169, 1996 21. Norris JS, Valiante TA, Wallace MC, Willinsky RA, Montanera WJ, TerBrugge KG, et al.: A simple relationship between radiological arteriovenous malformation hemodynamics and clinical presentation: a prospective, blinded analysis of 31 cases. J Neurosurg 90:673–679, 1999 22. Pollock BE, Flickinger JC: A proposed radiosurgery-based grading system for arteriovenous malformations. J Neurosurg 96:79–85, 2002 23. Pollock BE, Gorman D, Schomberg PJ, Kline RW: The Mayo Clinic Gamma Knife Experience: Indications and Initial Results. Mayo Clin Proc 74:5–13, 1999 24. Sasaki T, Kurita H, Saito I, Kawamoto S, Nemoto S, Terahara A, et al.: Arteriovenous malformations in the basal ganglia and thalamus: management and results in 101 cases. J Neurosurg 88:285–292, 1998 25. Sassani SG, Theofani A, Tsangaris S, Sokolis DP: Time-course of venous wall biomechanical adaptation in pressure and flow-overload: Assessment by a microstructure-based material model. J Biomech 46:2451–2462, 2013 26. Spetzler RF, Hargraves RW, McCormick PW, Zabramski JM, Flom RA, Zimmerman RS: Relationship of perfusion pressure and size to risk of hemorrhage from arteriovenous malformations. J Neurosurg:918–923, 1992 27. Spetzler RF, Wilson C, Weinstein P, Mehdorn M, Townshend J, Telles D: Normal Perfusion pressure breaktrough theory. Clin Neurosurg 25:651–672, 1978 28. Toulgoat F, Lasjaunias P: Vascular Malformations of the brain. Handb Clin Neurol 112:1043–1051 29. Vorstman EBA, Niemann DB, Molyneux AJ, Pike MG: Benign intracranial hypertension associated with arteriovenous malformation. Dev Med Child Neurol 44:133–135, 2002

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site. Privacy Policy