Introduction: Management of brain Avms presenting with epileptic seizure remain a controversial issue. Ever since the publications of ARUBA and the Scottish intracranial vascular malformation study which have demonstrated the superiority of medical therapy over interventional therapy in the management of unruptured brain AVM, the role of interventional therapy, even in the management of poorly controlled epilepsy has been largely abandoned. Poorly controlled seizures however', have significant impact on the quality of life of the suffer with associated stigma, particularly in the developing countries like ours. The studies shows that up to 80% of people with epilepsy reside in the poor socio-economic areas where best medical therapy and compliance is elucive target.
Methods: We retrospectively reviewed the clinical notes, radiological imaging and angiographic lmages of patients who were diagnosed with Brain AVM in our center over the period of 10 years, from May 2005 to MAy 2015. Diagnosis of brain AVM were made using CT-scan,MRI, CT angiography and DSA or the combination of these methods. Baseline clinical characteristics were derived from the clinical notes. Radiological features such as the AVM size and location were determined using axial CT scan or MRI. Angioarchitectural features were determined using DSA.
Results: Our search identified 157 patients who met the inclusion criteria. The clinical presentation of seizures occurred in 31.8%. By univariate comparison, Male sex (P=0.037), Increase in AVM size ( P=0.0001), supratentorial lobar location (P=0.001) and superficial venous drainage (P=0.008) were statistically associated with clinical presentation of seizures.
Conclusions: The results in our series are comparable with the results of the previous studies looking at the angioarchitectural features associated with clinical presentation of seizures. Size is the obvious modifiable feature which could be reduced by endovascular embolization in situation where complete eradication could not achieved without significant morbidity.
Patient Care: Treatment gap is the management of epilepsy is higher in the developing countries with less than 50% of patients with epilepsy being on appropriate medical therapy. Even with best medical therapy, only 47% of patients are able to achieve 2 years seizure freedom. This study and the discussions emanating thereof will be able to shape discourse in the best way to manage epilepsy associated with brain AVM in the setting where compliance to medical therapy might be poor.
Learning Objectives: By the conclusion of this session the participants should be able to :
1) appreciate the effect of Brain AVM associated epileptic seizures on the quality of life of the sufferer.
2) To understand that the best medical therapy available in the developed counties as stated in ARUBA is not readily available in the developing countries and compliance is generally poor.
3) discuss in small groups the role of interventional therapy in the management of poorly controlled epilepsy associated with brain AVM amenable to interventional therapy.
References: Al-Shahi R: The outlook for Adults with epileptic seizures associated with cerebral cavernous malformations and arteriovenous malformations; Epilepsia. 53 (supp.4): 34-42, 2012.
2) Ding D, Starke RM, Quigg M, Yen C-P, Przbylowskin CJ, Dodson BK, Sheehan JP; Cerebral arteriovenous malformation and epilepsy, Part 1: Predictors of seizure presentation, World Neurosurgery (2015), doi: 10.1016/j.wneu.2015.02.039.
Galletti F, Costa C, Cupini LM, Eusebi P, Hamam M: Brain Arteriovenous malformation and seizures: an Italian study. J Neurol neurosurg psychiatry. 85:284-288, 2014
4) Garcin B, Houdart E, Porcer R, Manchon E, Sain-Maurice JP, Bresson D, Stapf C: Epileptic seizures at initial presentation in patients with brain arteriovenous malformations.Neurology. 78:626-631,2012.
5) Jennum P, Gyllenborg J, Kjellberg J: The social and economic consequences of epilepsy. A controlled national study. Epilepsia, 52(5):949-956, 2001
6) Hoh BL, Chapman PH, Loeffler JS, Ogilvy C.S: The results of multimodality treatment for 141 patients with brain arteriovenous malformation and seizures: factors associated with seizures incidence and seizures outcome. Neurosurgery. 51;303-311, 2002.