PROTOCOL BASED MANAGEMENT OF AVM MANAGEMENT: MYTHS AND FACTS

Vipul GuptaNeurointerventional SurgeryArtemis Hospital, Gurgaon

Neurosurgery 2006

Decision algorithm (Neurosurgery 2006)

Step 1 Listing of patient-related factors (such as clinical history, current symptoms, psychological status, familiar and social background) and ranking according to clinical importance (“patient needs”)

Step 2 Analysis of AVM morphology (“classification”) (such as location, size, vascular architecture, flow, etc.) in consideration of surgical, endovascular, and radiosurgical feasibility

Step 3 Choice of treatment modality according to specific capability of each tool to fulfill “patient needs” in given morphological AVM condition with lowest invasiveness and risk ; if necessary, planning of multimodality therapy

Predictors of brain hemorrhage in Brain AVMs, Neurology 2006

Spetzler-Martin scale- for AVMs

Size of nidus3cm- 13-6cm-26cm-3Eloquence of surrounding brainNon-eloquent-0Eloquent-1Venous drainageSuperficial-0Deep-1Grades- I-VIGrades I-III low risk for surgery

Small ruptured AVM

Embolization/surgery first choiceEmbolization- if weak spot, targeted earlySurgery with pre-op embolizationIf residual after embo/surgery- RadiosurgeryIf embo/surgery high risk and no weak spot- radiosurgery

Myth …Embolization is minimally invasive … surgery is

higher risk ..

Emboli

Myth – DSA is gold standard

Fact – DSA and AngioCT is the way to go …

Angiographic CT with intra-arterial injection

Myth

Angiography is best modlity ….tells us everything ….

FISTULAS

Myth - Flow reduction by embolization

Small unruptured AVMs

Radiosurgery If fistula, weak spot- EmbolizationSM Grade I; if patient agrees, Surgery (with

preoperative embolization)

MYTH Both embolization and radiosurgery are minimally invasive …

Patients psychology Immediate versus delayed complicationCan slow occlusion be better for patients ?

Examples: 14 year-old boy with Left Thalamic area AVM

Pre-GK

Post GK 2 years

MYTH We should not treat unruptured AVM …courtesy ARUBA trial

Large AVMs

Much more difficult to treatVery careful consideration regarding treatment aim and

plan, patient counsellingEmbolization- Reduce the size and send for

radiosurgery/surgeryMulti-stage radiosurgeryConservative F/U

Problems in SRS of Pre-embolized AVMs

Presence of ONYXMarking/delineation of AVMPresence of multiple scattered residual AVM

sectorsRecanalization: feeder embolization

Directed treatment, use of cross sectional Directed treatment, use of cross sectional MRA, If possible MRA, If possible inclusion of cast inclusion of cast

marginsmargins

Combined endovascular & gamma therapy

Dural AVFs-

Embolization Onyx/coils -Usually curative If not possible/fails- If bleeding/venous reflux- surgeryIf nothing else possible- radiosurgery

Diffuse AVMs

AVM intermixed with parenchyma- almost impossible to treat

How to decide…Risk of disease- calculationRisk of treatment- availability, expertise

AVM is not a single disease- issues- presentation, morphology (size, angioarchitecture, etc)

Probablity calculationRemoval of bias, egoVery calculated risk….. Issue of perceived invasiveness---- defining non-invasive

Science and art ….

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Dr Vipul Gupta

Thank you ….