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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