Brain Arteriovenous Malformation Treatment

The Department of Neurosurgery at Rutgers Health and RWJBarnabas Health treats the full gamut of neurological conditions, including brain arteriovenous malformations (AVM). If you have been incidentally diagnosed with a brain AVM, it’s important to seek treatment as soon as possible to avoid the potentially deadly consequences of a brain bleed, which is the primary danger of having an AVM.

What Is Arteriovenous Malformation?

An arteriovenous malformation (AVM) in the brain or spine is a rare condition involving an abnormal tangle of blood vessels in the brain or spine. An AVM can form anywhere in the body where there are arteries and veins, and an AVM in the brain can occur on the surface, deep inside, or within the dura (the outer protective covering of the brain). A brain AVM can cause severe problems if it bleeds (called a hemorrhagic stroke, or brain bleed), however, most people with an AVM are unaware because they experience no symptoms.

To better understand AVM, it helps to understand how blood normally flows from the heart to the brain. In a healthy person, the veins take blood into the heart for re-oxygenation, and blood goes back to the heart through the arteries. The arteries are responsible for delivering oxygenated and nutrient-rich blood to the brain from the heart. These arteries branch into smaller blood vessels called capillaries, which are only a single cell thick. Capillaries are the hub where blood exchanges oxygen and nutrients with body tissues.

In AVM patients, the arteries connect directly to veins without a capillary between them, which disrupts the process of oxygen flow to the brain. Also, the veins are unable to handle the extra pressure of blood coming directly from the arteries, and begin to stretch to try to accept more blood. This weakens the blood vessels, which can cause them to rupture and bleed, causing a stroke or an aneurysm. A brain bleed, also called a hemorrhagic stroke, has devastating neurological consequences. The lack of oxygen delivered to the brain causes brain damage within minutes as the cells die due to lack of oxygen. Brain damage is permanent.

An AVM damages the brain and/or spinal cord in these ways:

  1. If it ruptures/bleeds in the brain, it is called a hemorrhagic stroke.

  2. A large AVM can create pressure against the surrounding brain tissue, which can lead to a seizure or hydrocephalus.

  3. An AVM can reduce the amount of oxygen delivered by blood to nearby tissues.

The risk of an AVM bleeding is very slight, at about 2 to 3% per year. However, once it has occurred, it is 9 times as likely to bleed again within one year. An AVM should be taken seriously, because brain bleeds carry a serious risk of death, with about 10 to 30% of patients dying from a hemorrhagic stroke or aneurysm.

AVM Symptoms

Depending on the location of the AVM, symptoms vary. Most AVM patients have no symptoms, and these people are unaware they have an AVM and then only receive the diagnosis incidentally, when they have a magnetic resonance imaging scan (MRI) for another condition. However, when an AVM bleeds, it causes a medical emergency.

What Happens When an AVM Bleeds?

Sometimes an AVM will bleed, causing severe complications. This brain bleed is also called a cerebral hemorrhage, or a hemorrhagic stroke. The result can be devastating.

Symptoms of a bleeding AVM include:

  • Rapid loss of neurological function

  • Severe headache

  • Nausea and vomiting

  • Seizures

  • Weakness

  • Back pain

  • Coordination problems

  • Dizziness

  • Vision problems

  • Trouble speaking or understanding speech

  • Permanent brain damage

Causes of AVM

The cause of AVMs is not well understood, and they’re not considered hereditary. Most people who have an AVM were born with it, although it can sometimes develop after head or spine trauma. Most researchers believe an AVM occurs during fetal development. One known risk factor is the patient’s sex, as males are more likely to have an AVM compared to females.

AVM Diagnosis

Your doctor will learn as much as possible about your medical history, the symptoms you’re experiencing, and perform a physical and neurological exam to diagnose an AVM. The diagnostic process is different for patients brought to the emergency room for what will later be diagnosed as a brain bleed vs. those patients whose AVM is diagnosed incidentally. Many patients are unaware they have an AVM unless it is discovered when performing an MRI for another reason.

Diagnostic tests for AVM include:

  • Imaging scans: Computed tomography (CT) scans and magnetic resonance imaging (MRI) scans are noninvasive ways to view the anatomical structures within the brain. This can determine the size and location of the AVM, and whether or not it has ruptured.

  • Angiogram: This procedure involves inserting a catheter into an artery in the brain, and using a contrast dye injection to take X-ray images of the brain.

AVM Treatment

Whether you were brought by ambulance to the emergency room for a brain bleed or you have been incidentally diagnosed with an unruptured AVM will factor into your treatment options. Fortunately, AVM treatment has improved leaps and bounds in the past decade. The goal is to cure the patient by closely closing off the abnormal blood vessels, which can be achieved in a variety of ways. A customized treatment plan for AVM depends on the goals of the treatment team and the patient. Your multi-disciplinary team of physicians will take into account your age and overall health, as well as weigh the potential risks versus benefits of proceeding with surgery.

  • Stereotactic computer-assisted microsurgical resection: During craniotomy surgery, a surgical opening is made through the skull to access a portion of the brain. The AVM is shrunken and dissected from normal brain tissue using a variety of techniques, including laser and electrocautery. The advantage of this procedure is that the AVM can be cured if all of the AVM is removed. The disadvantage of this procedure is the risk of bleeding, damage to surrounding brain tissue, and stroke in other areas of the brain once the AVM is taken out.

  • Stereotactic radiotherapy with Gamma Knife or CyberKnife®: This procedure involves the treatment of tumors of the brain or spine which targets the abnormal blood vessels with unprecedented precision by using highly-focused radiation. The procedure is non-invasive, painless, and the patient goes home the same day. It works best on smaller AVMs.

  • Endovascular embolization: This minimally-invasive procedure uses a small catheter to deliver glue into the AVM so blood no longer flows through it. It is performed by passing a catheter through an artery in the thigh and threading it through the blood vessels to the feeding arteries of the AVM in the brain. While this is a less invasive procedure than craniotomy surgery, the disadvantage is the risk of embolic stroke from the catheter, or rebleeding if the AVM is not completely obliterated. Multiple treatments are sometimes needed to cure the patient. An advantage of endovascular embolization is the fact that it can treat inoperable, deeper AVMs.

  • Clinical trials: These research studies are designed to improve the standard of medical care offered to patients by investigating new treatments, such as drugs, procedures, and other therapies, to see if they are safe and effective. Studies may be funded either by pharmaceutical companies or the National Institutes of Health.

Request an appointment online now or call 833-656-3876.