Therapeutic management of cerebral arteriovenous malformations: a review

Abstract

The therapeutic management of cerebral arteriovenous malformations has undergone significant change over the past 40 years. Embolization, radiosurgery, advanced imaging modalities, neuropsychological testing and advances in surgical technique has both significantly improved our ability to treat patients, as well as confounding the landscape as to what constitutes best medical practice. Variability in natural history provides additional challenges in that it is challenging to determine an accurate estimate of the risk of hemorrhage, morbidity and mortality. It is clear that the complexity of the treatment of these lesions demands a multidisciplinary approach. The need for a team of neurosurgeons, interventional and diagnostic neuroradiologists, neurologists, radiation oncologists and neuropsychologists will improve outcomes and aid in determining best therapy for patients.

Keywords:

• arteriovenous malformation
• arteriovenous malformations treatment
• ARUBA trial
• embolization
• radiosurgery
• Spetzler-Martin grade

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Surgical resection is low risk and leads to 100% cure rate in most patients with Spetzler-Martin grade 1 and 2 arteriovenous malformations (AVMs) and should be considered the preferred modality for these lesions.

• The high risk of therapeutic morbidity for Spetzler-Martin grade 4 and 5 lesions relegates most of these lesions to conversation management.

• Spetzler-Martin grade 3 lesions have significant variability in natural history and treatment-related morbidity and often benefit from a multidisciplinary approach.

• The complexity of the treatment of arteriovenous malformations demands a multidisciplinary approach with physicians who are well trained and experienced in the treatment of arteriovenous malformations.

• There needs to be a push to have tertiary referral centers be the location for treatment of all AVMs due to increased experience and multidisciplinary teams.

• What level of risk is appropriate to undertake with treatment in comparison with the natural history of conservatively managing an arteriovenous malformation.

• The increasing push for AVMs to be managed conservatively by some groups will push the field toward the development of additional randomized controlled treatment trials.

ORCID

Michael Crimmins http://orcid.org/0000-0001-5017-8665