Arteriovenous Malformation
Arteriovenous Malformation
Arteriovenous Malformation
MALFORMATION
AVM-Introduction
Vascular malformation:
► AVM
► Venous malformation
► Cavernous
malformation
► Capillary telangiectasia
► AVF
AVM-introduction
► Most dangerous vascular malformation
► Congenital lesion
► Abnormal collection of vessels
wherein arterial blood flows directly
into draining veins without the
normal capillary beds
► Feeding arteries/ Nidus/ Draining veins
► Static/ Grow/ Regress
AVM-Presentation
► Hemorrhage(50%)
► Seizure
► Mass effect
► Ischemia; steal phenomenon
► Headache
► Bruit
► HCP
► Peds: hydrocephalus, heart failure
AVM-Hemorrhage
► Peak age: 15-20 y/o
► 10 % mortality; 30-50% morbidity
► ICH(80%)/IVH/SAH
► Risk of hemorrhage: www.brain-surgery.com
3. Ondra SL, Troupp H, et al: The natural history of symptomatic cerebral arteriovenous
malformation: A 24-year follow-up assessment. J Neurosurg 25:387-91, 1990
AVMs & Associated Aneurysms
► 7% of pts with AVMs have aneurysms
► 75% are located on major feeding artery;
probably from increased flow 1
► The symptomatic one is treated first
► Although 66% of related aneurysms will
regress following AVM removal, this does
not always occur 4
1) Surgery: mainstay
2) Stereotactic Radiosurgery (SRS):
high-risk for surgery
3) TAE: adjunct to 1) & 2)
Surgery
American Stroke Association recommends:
► Low grade ( I & II )- surgery alone
► Higher grade(>III)-TAE before surgery
► Facilitates
OP (less bleeding) & possibly SRS
► Can’t be used alone, acute hemodynamic
change, multiple procedures
Endovascular Approach (TAE)
► Glue: N-butyl cyanoacrylate (nBCA), Lipiodol,
tantalum powder, D5W
► Embolization of the nidus through the
feeders without any significant glue entering
the draining veins
► In general, only 2-3 vessels are embolized
per session.
Endovascular Approach (TAE)
► Anesthesia: MAC/ GA
► Induced hypotension with vasoactive agents,
general anesthesia, or even brief adenosine-
induced cardiac pause at the time of
embolization to allows the glue to set
► Provocation test:
Sodium amytal & cardiac lidocaine injection
to determine that embolization will not
result in neurologic deficit
Anesthesia-related Considerations
for Cerebral AVMs
► Extensiveblood loss
► Pharmacological brain protection
► Non-pharmacological brain protection
► Euvolemia
► Optimal cerebral perfusion pressure
Induced Hypotension
► Aneurysm/ AVM
► Large AVMs with deep a. supply
► Barbiturate therapy
Fluid and Electrolyte Management
► Isotonicity
Stable cardiovascular status
Prevention of cerebral edema
Aggressive isotonic crystalloids may worsen brain
edema by decreasing colloid oncotic pressure. 6
► Euglycemia
less than 200mg/dl
6. Drummond JC, Patel PM, et al: The effect of the reduction of colloid
oncotic pressure, with and without reduction of osmolarity, on
post-traumatic cerebral edema. Anesthesiology 88:993-1002,1998
Toleration of Modest Hypothermia
► Post-resection BP challenge;
Hemostasis/ Residual nidus/ Areas prone to NPPB
► BP control: most important
► NE
Postoperative Management
► BP control
SBP< 120mmHg x 2d
► BT control
Any Comment or Question?
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Attention
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Have a Good Day!!!