Endovascular Treatment of Cerebral Arteriovenous Malformations

Abstract

Arteriovenous malformations (AVM) are vascular malformations composed of a network of abnormal vessels connecting directly between the artery and vein without an intervening capillary bed. Cerebral arteriovenous malformations have an incidence of 0.8–1.3 per 100.000 person years. Clinical symptoms include intracranial hemorrhage, seizure, headache, and focal neurological deficit. Annual mortality rate associated with hemorrhage is 1–5%, and 10–30% of survivors will have disability. Treatment options for cerebral AVMs include open surgery, embolization, and radiosurgery. Depending on the grade and angioarchitectural characteristics, a combination of these modalities can be used. Endovascular treatment can be performed for size and grade reduction, presurgical devascularization, size reduction before radiosurgery, targeted embolization, and as stand-alone treatment for cure. Targeted embolization can address intranidal or flow-related aneurysms and high flow arteriovenous shunts. Complications of the endovascular treatment include hemorrhage related to vessel perforation or normal pressure breakthrough phenomenon, ischemia, microcatheter retention, and other general complications associated with angiographic procedures. Mortality associated with endovascular treatment is less than 2% and permanent neurological deficit can be seen up to 2–8.9% of cases. New endovascular techniques include balloon-assisted embolization, transvenous embolization, and double microcatheter techniques like pressure cooker technique.