AVM for “Dummies”Cezar Jose Mizrahi MDNeurosurgery DepartmentHadassah Ein-Kerem

27.05.2014

Wikipedia

- “Arteriovenous malformation (AVM) is an abnormal connection between arteries and veins, bypassing the capillary system.”

- “AVMs are usually congenital.”

AVM for “Genious”Cezar Jose Mizrahi MDNeurosurgery DepartmentHadassah Ein-Kerem

27.05.2014

Epidemiology• The estimated detection rate of AVM in the US general

population is 1.4/100,000 per year.*

• An estimated 300,000 americans have AVMs.

• 12% symptomatic.

*Stapf C, Mast H, Sciacca RR, et al. (May 2003). "The New York Islands AVM Study: design, study progress, and initial results“.Stroke 34 (5): e29–33.

Signs and symptoms

88% of people affected with AVM are asymptomatic**National Institute of Neurological Disorders and Stroke

Symptoms of AVM vary according to the location of the malformation and the draining veins.

• Seizure• Headache • Progressive neurologic deficit• Hemorrhage

Pathophysiology• Wikipedia Student: “Artery – Capillaries – Vein”.

• High Pressure → Low Pressure.

• The resulting tangle of blood vessels: Nidus.

HemorrhageNatural Hystory

• Overall 2% - 4% annual rate of hemorrhage

• Type Hemorrhage:- Intraparenchymal;- Intraventricular;- Subdural.

Risk Factors - bleeding• Hystory of prior bleeding

• Small AVM

• Deep Venous Drainage

• Higher feeding artery pressures

• Intranidal Aneurysm

Diagnosis• CT

• CTA

• MRI

• MRA

• DSA

AVM

•Brain• Sleen• Lung• Kidney• Spinal cord• Liver• Intercostal space• Iris• Spermatic cord

AVM – “to feel smart”

→ AVMs may occur in isolation or as a part of another disease:

- Von Hippel-Lindau disease.- Hereditary hemorrhagic

telangiectasia.

→ Associated with Aortic Stenosis**Batur, P.; Stewart, WJ; Isaacson, JH (2003). "Increased Prevalence of Aortic Stenosis in Patients with Arteriovenous Malformations of the Gastrointestinal Tract in Heyde Syndrome". Archives of Internal Medicine 163 (15): 1821–4

Spetzler-Martin AVM grading system

• The score correlates with operative outcome.

• Give a score between 1 and 5.

• Grade 6 is used to describe inoperable lesions

Spetzler RF, Martin NA. (1986) A proposed grading system for arteriovenous malformations. J Neurosurg. Oct;65(4):476-83.

Spetzler-Martin AVM grading system

• Size of nidus • small (<3cm) = 1• medium (3 - 6cm) = 2• large (> 6cm) = 3

• Eloquence of adjacent brain • non-eloquent = 0• eloquent = 1

• Venous drainage • superficial only = 0• deep = 1

Eloquent???• Eloquence brain • sensorimotor, language, visual cortex, hypothalamus, thalamus,

brain stem, cerebellar nuclei, or regions directly adjacent to these structures.

• Non-eloquence brain • frontal and temporal lobe, cerebellar hemispheres.

Diana: Spetzler – Martin??

(A) SM I(B) SM II(C) SM III(D) SM IV(E) SM V(F) SM VI

Diana: Spetzler – Martin??

(A) SM I

(B)SM II(C) SM III(D) SM IV(E) SM V(F) SM VI

Diana: Spetzler – Martin??

(A)SM I(B) SM II(C) SM III(D) SM IV(E) SM V(F) SM VI

Ran: Spetzler – Martin??

(A) SM I(B) SM II(C) SM III(D) SM IV(E) SM V(F) SM VI

Ran: Spetzler – Martin??

(A) SM I(B) SM II

(C)SM III(D) SM IV(E) SM V(F) SM VI

Treatment• Neurosurgery

• Endovascular

• Radiosurgery

• Symptomatic + F/U

Treatment

Thank you