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Arteriovenous Malformations Workup

  • Author: Souvik Sen, MD, MPH, MS, FAHA; Chief Editor: Helmi L Lutsep, MD  more...
 
Updated: Mar 27, 2014
 

Imaging Studies

See the list below:

  • High-quality imaging studies are the key to diagnosis of AVMs.
  • CT scan
    • CT scanning easily identifies an intracerebral hemorrhage, raising suspicion of AVM in a younger person or a patient without clear risk factors for hemorrhage.
    • CT scan can identify only large AVMs.
  • MRI
    • MRI is essential for initial diagnosis of AVMs.
    • AVMs appear as irregular or globoid masses anywhere within the hemispheres or brain stem, as shown in the images below.
      Axial T2 MRI showing an arteriovenous malformationAxial T2 MRI showing an arteriovenous malformation with hemorrhage, in the territory of the left posterior cerebral artery.
      T1 axial MRI showing a small subcortical arterioveT1 axial MRI showing a small subcortical arteriovenous malformation in the right frontal lobe.
      T2 coronal MRI showing an arteriovenous malformatiT2 coronal MRI showing an arteriovenous malformation in the left medial temporal lobe.
    • AVMs may be cortical, subcortical, or in deep gray or white matter.
    • Small, round, low-signal spots within or around the mass on T1, T2, or fluid-attenuated inversion recovery (FLAIR) sequences are the "flow voids" of feeding arteries, intranidal aneurysms, or draining veins.
    • If hemorrhage has occurred, the mass of blood may obscure other diagnostic features, requiring angiogram or follow-up MRI.
    • Low signal of extracellular hemosiderin may be seen around or within the AVM mass, indicating prior symptomatic or asymptomatic hemorrhage.
    • Larger aneurysms within the AVM or on feeding arteries may be identified occasionally.
    • Magnetic resonance angiography (MRA) may identify AVMs greater than 1 cm in size, as in the image below, but is inadequate to delineate the morphology of feeding arteries and draining veins; small aneurysms can be missed easily.
      Magnetic resonance angiography showing a left mediMagnetic resonance angiography showing a left medial temporal arteriovenous malformation.
    • A retrospective analysis demonstrated that silent intralesional microhemorrhage on CT/MRI may be a risk factor for intracerbral hemorrhage from a brain AVM rupture.[1]
  • Cerebral angiography
    • Angiogram, shown below, is required for hemodynamic assessment, which is essential for planning treatment.
      Angiogram (anteroposterior view) showing an arteriAngiogram (anteroposterior view) showing an arteriovenous malformation in the deep left middle cerebral artery territory measuring approximately 3 cm in diameter, with a deep draining vein (arrow).
    • The morphology of the AVM determines the treatment algorithm. Important features include feeding arteries, venous drainage pattern, and arterial and venous aneurysms.
    • Ten to fifty-eight percent of patients with AVM have aneurysms located in vessels remote from the AVM, in arteries feeding the AVM, or within the nidus of the AVM itself.
    • Intranidal aneurysms may have a higher risk of rupture than those outside the bounds of the AVM.
    • Other important angiographic features may include kinking or ectasia of draining veins, which can cause venous congestion, thrombosis, or rupture; and stenosis of feeding arteries due to angiopathy caused by high-velocity, turbulent flow into the fistula.
    • Special expertise is required to perform superselective catheterization into AVM feeding arteries, which allows both pressure measurements and superselective anesthetic injections to map neurological function in and around the AVM (see Superselective angiography in Procedures).
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Other Tests

Based on flow-velocity and resistance pattern, transcranial Doppler (TCD) has been demonstrated to be a noninvasive and cost-effective means to detect and follow brain AVMs. Recently, TCD has been found to be a reliable, safe, and noninvasive method to monitor the outcome of gamma knife surgery for brain AVMs.[8]

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Procedures

See the list below:

  • Superselective angiography
    • Superselective angiography is performed with standard cerebral angiography, with access via a femoral artery puncture.
    • A special, flexible, directable catheter is threaded up into one of the main cerebral arteries (carotid or vertebral), then into sequentially smaller branch arteries, until the catheter tip is near or within the AVM nidus.
    • Pressure measurements can be obtained via a coaxial catheter. Higher feeding pressures increase the risk of subsequent hemorrhage.
    • Sodium amytal, an anesthetic agent, can be injected to produce temporary anesthesia of the area perfused by the artery. In this so-called "superselective Wada testing," language, memory, visual-spatial, sensory, and motor function can be tested during 5 minutes of anesthetic effect to determine whether "eloquent" function originates in that region, which would therefore be at risk for neurological deficits should that brain area be injured during embolization or surgery. Arteries directly feeding the AVM or "en passage" vessels that feed the AVM but continue past the AVM to feed normal brain tissue can be studied.
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Contributor Information and Disclosures
Author

Souvik Sen, MD, MPH, MS, FAHA Professor and Chair, Department of Neurology, University of South Carolina School of Medicine

Souvik Sen, MD, MPH, MS, FAHA is a member of the following medical societies: American Academy of Neurology, Association for Patient-Oriented Research, American Heart Association

Disclosure: Nothing to disclose.

Coauthor(s)

James Selph, MD Assistant Professor of Neurology, University of South Carolina School of Medicine; Director of Neurophysiology Lab and Services, Palmetto Richland Hospital

James Selph, MD is a member of the following medical societies: American Association of Neuromuscular and Electrodiagnostic Medicine, American Epilepsy Society

Disclosure: Nothing to disclose.

Sharon W Webb, MD Assistant Professor of Clinical Neurosurgery, University of South Carolina School of Medicine

Sharon W Webb, MD is a member of the following medical societies: American Association of Neurological Surgeons, Congress of Neurological Surgeons, Neurocritical Care Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Neurological Association, American Society of Neurorehabilitation, American Academy of Neurology, American Heart Association, American Medical Association, National Stroke Association, Phi Beta Kappa, Tennessee Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2.

Additional Contributors

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, Society for Neuroscience, American Society for Biochemistry and Molecular Biology, American Academy of Neurology, American Neurological Association, Phi Beta Kappa, Sigma Xi, Southern Clinical Neurological Society

Disclosure: Nothing to disclose.

References
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Axial T2 MRI showing an arteriovenous malformation with hemorrhage, in the territory of the left posterior cerebral artery.
T1 axial MRI showing a small subcortical arteriovenous malformation in the right frontal lobe.
T2 coronal MRI showing an arteriovenous malformation in the left medial temporal lobe.
Magnetic resonance angiography showing a left medial temporal arteriovenous malformation.
Angiogram (anteroposterior view) showing an arteriovenous malformation in the deep left middle cerebral artery territory measuring approximately 3 cm in diameter, with a deep draining vein (arrow).
 
 
 
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