eMedicine Specialties > Neurology > Neuro-vascular Diseases

Arteriovenous Malformations: Follow-up

Author: H Christian Schumacher, MD, Postdoctoral Residency Fellow, Doris and Stanley Tananbaum Stroke Center, Columbia University Presbyterian Medical Center
Coauthor(s): Randolph S Marshall, MD, Co-Director, Levine Cerebral Localization Lab, Associate Professor, Department of Neurology, Division of Cerebrovascular Diseases, Columbia University Presbyterian Medical Center
Contributor Information and Disclosures

Updated: May 31, 2006

Follow-up

Further Inpatient Care

  • The algorithm for surgical treatment is highly individual and is based on the angiographic characteristics of the AVM.
  • The most common treatment scenario is one or more endovascular embolization sessions during separate hospitalizations, followed by surgical resection or radiosurgery.
  • When hemorrhages occur as the presenting event, a longer hospitalization may be required, with supportive care during recovery from the brain hemorrhage.

Further Outpatient Care

  • Seizure and/or headache medications usually are managed by the neurologist or referring physician.
  • Follow-up neuropsychological assessments may be helpful if subtle cognitive impairments are noted.
  • Patients who have suffered hemorrhage may need inpatient or outpatient rehabilitation like other patients with stroke.

Complications

  • The most dreaded complication of the AVMs' natural history is intracerebral hemorrhage (see Prognosis). Treatment decisions are based on the natural history-risk of first or subsequent hemorrhage versus the risk-benefit ratio of treatment.
  • Surgical complications
    • Surgical complications may include persistent neurological deficits associated with hemorrhage and stroke.
    • Surgical outcome risk correlates with score on the Spetzler-Martin scale; higher scores, seen with large-sized AVMs, deep venous drainage, and location of the AVM in eloquent brain regions, increase the surgical risk.
    • A recent meta-analysis reports a morbidity of 8.6% and mortality of 3.3% after mostly surgical treatment in a series of 2452 patients. The surgical risk for morbidity and mortality for Spetzler-Martin grade of less or equal to 3 has been reported to be 2-6.3% and 0-2%, respectively. The surgical risk for morbidity and mortality for Spetzler-Martin grade IV and V has been reported to be 9-39% and 0-9%, respectively.
  • Complications of endovascular embolization
    • Complications of endovascular embolization include persistent neurological deficits related to inadvertent embolization of arteries supplying normal brain tissue or obliteration of the venous outflow leading to intracerebral hemorrhages. The procedure carries an associated risk for morbidity and mortality in the range of 9-22% and 0-9%, respectively.
    • No long-term outcome studies are yet available; however, as endovascular techniques continue to improve, complication rates are likely to diminish.
  • Complications of radiosurgery
    • Complications depend on the size and location of the AVM. AVMs located in eloquent areas and in central locations are more prone to radiation-induced complications.
    • White matter edema and radiation-induced necrosis may occur during the 1- to 3-year treatment period. Persistent neurological deficits after radiation have been reported in 8% of treated patients.Patients with hemorrhagic presentation have a higher mean annual risk for hemorrhage until radiation-induced obliteration of the AVM is achieved compared to patients with a nonhemorrhagic presentation (6.3% vs 3.9%). The risk for hemorrhage seems to be lower after radiation therapy in patients with hemorrhagic presentation compared to the period before gamma knife radiotherapy was initiated.
    • Seizure frequency may increase in the first days to weeks after radiosurgery.
    • The potential for late effects from radiation, such as accelerated atherosclerosis in surrounding blood vessels, does exist.

Prognosis

  • With an overall risk of intracerebral hemorrhage of 2-4% per year, angiographic assessment is recommended to further define prognosis for patients with AVM.
  • Those with superficial, moderate-sized AVMs have a good long-term prognosis and may not have any additional benefit with interventional treatment.
  • Lifetime risk of hemorrhage may be substantial for young patients with AVM.
  • Prognosis after AVM hemorrhage is generally better than that after intracerebral hemorrhage from other causes. Better prognosis may be due to the relatively younger age of patients and a greater potential for reorganization of brain function. More accurate prognosis awaits the results of currently active, long-term, population-based outcome studies.

Patient Education

For excellent patient education resources, visit eMedicine's Stroke Center. Also, see eMedicine's patient education article Stroke.

 


More on Arteriovenous Malformations

Overview: Arteriovenous Malformations
Differential Diagnoses & Workup: Arteriovenous Malformations
Treatment & Medication: Arteriovenous Malformations
Follow-up: Arteriovenous Malformations
Multimedia: Arteriovenous Malformations
References
[ CLOSE WINDOW ]

References

  1. ARUBA Investigators. Unruptured brain arteriovenous malformation trial. [The Internet Stroke Center]. Feb 2006;[Full Text].

  2. ARUBA Study. Unruptured brain arteriovenous malformation trial. [ARUBA Study Site]. Feb 2006;[Full Text].

  3. Al-Shahi R, Bhattacharya JJ, Currie DG. Prospective, population-based detection of intracranial vascular malformations in adults: the Scottish Intracranial Vascular Malformation Study (SIVMS). Stroke. May 2003;34(5):1163-9. [Medline].

  4. ApSimon HT, Reef H, Phadke RV. A population-based study of brain arteriovenous malformation: long-term treatment outcomes. Stroke. Dec 2002;33(12):2794-800. [Medline].

  5. Castel JP, Kantor G. [Postoperative morbidity and mortality after microsurgical exclusion of cerebral arteriovenous malformations. Current data and analysis of recent literature]. Neurochirurgie. May 2001;47(2-3 Pt 2):369-83. [Medline].

  6. Flickinger JC, Kondziolka D, Lunsford LD. A multi-institutional analysis of complication outcomes after arteriovenous malformation radiosurgery. Int J Radiat Oncol Biol Phys. Apr 1 1999;44(1):67-74. [Medline].

  7. Halim AX, Johnston SC, Singh V. Longitudinal risk of intracranial hemorrhage in patients with arteriovenous malformation of the brain within a defined population. Stroke. Jul 2004;35(7):1697-702. [Medline].

  8. Hartmann A, Mast H, Mohr JP, et al. Determinants of staged endovascular and surgical treatment outcome of brain arteriovenous malformations. Stroke. Nov 2005;36(11):2431-5. [Medline]. [Full Text].

  9. Hillman J. Population-based analysis of arteriovenous malformation treatment. J Neurosurg. Oct 2001;95(4):633-7. [Medline].

  10. Hofmeister C, Stapf C, Hartmann A, et al. Demographic, morphological, and clinical characteristics of 1289 patients with brain arteriovenous malformation. Stroke. Jun 2000;31(6):1307-10. [Medline]. [Full Text].

  11. Maruyama K, Kawahara N, Shin M. The risk of hemorrhage after radiosurgery for cerebral arteriovenous malformations. N Engl J Med. Jan 13 2005;352(2):146-53. [Medline].

  12. Mast H, Young WL, Koennecke HC. Risk of spontaneous haemorrhage after diagnosis of cerebral arteriovenous malformation. Lancet. Oct 11 1997;350(9084):1065-8. [Medline].

  13. Nataf F, Ghossoub M, Schlienger M. Bleeding after radiosurgery for cerebral arteriovenous malformations. Neurosurgery. Aug 2004;55(2):298-305; discussion 305-6. [Medline].

  14. Ogilvy CS, Stieg PE, Awad I. AHA Scientific Statement: Recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Stroke. Jun 2001;32(6):1458-71. [Medline].

  15. Stapf C, Mast H, Sciacca RR. The New York Islands AVM Study: design, study progress, and initial results. Stroke. May 2003;34(5):e29-33. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

cerebrovascular malformation, vascular malformation, AVM, cerebral AVM, stroke, cerebral hemorrhage, intracranial hemorrhage, arteriovenous malformations, cerebral arteriovenous malformations, AVMs, hemorrhagic stroke

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

H Christian Schumacher, MD, Postdoctoral Residency Fellow, Doris and Stanley Tananbaum Stroke Center, Columbia University Presbyterian Medical Center
H Christian Schumacher, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Randolph S Marshall, MD, Co-Director, Levine Cerebral Localization Lab, Associate Professor, Department of Neurology, Division of Cerebrovascular Diseases, Columbia University Presbyterian Medical Center
Randolph S Marshall, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Edward L Hogan, MD, Professor, Department of Neurology, Medical College of Georgia; Emeritus Professor and Chair, Department of Neurology, Medical University of South Carolina
Edward L Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Neurological Association, American Society for Biochemistry and Molecular Biology, Phi Beta Kappa, Sigma Xi, Society for Neuroscience, and Southern Clinical Neurological Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center
Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Novartis Consulting fee Review panel membership

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health and Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Boston Scientific Honoraria Speaking and teaching; Concentric Medical None Review panel membership; Northstar Neuroscience  Review panel membership; ev3 Consulting fee Review panel membership

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.