BRAIN AVM TREATMENTS
Each AVM treatment option can achieve stand alone cure, however many times using a combined approach works best. The goal of any treatment option is to completely disconnect the connections achieve total cure. Only with a total cure does the risk of bleeding go away.
Open surgical resection of brain arteriovenous malformations has the highest cure rates of all treatments and the risk is particularly associated with the location of the AVM, and its proximity to eloquent brain areas (areas of brain that control important neurologic functions, such as visual perception, language, and movement centers). Other important factors in determining treatment risk are age, the size of the nidus, and if there is a vein that drains into the deep venous system. Surgery involves a skin incision, a craniotomy (removing a window of bone from the skull using a medical drill), and a surgical microscope that will be used to carefully disconnect and remove the AVM nidus.
- Immediate and lasting cure
- Highest cure rates
- Invasive, requiring recovery time
- Risks higher in large and deep locations
Embolization involves using a long plastic tube called a microcatheter to go into either the feeding artery or draining vein and injecting a liquid embolic agent or medical grade "crazy glue" to disconnect the abnormal connections. Embolization has the lowest cure rates, and is not commonly used as a stand alone treatment. It is often used in conjunction with surgery to make surgery easier by taking away some of the blood supply. In certain situations embolization can be curative when there is a singular arterial blood supply and may be optimal for deep small AVMs that have bled. The transvenous approach or going the vein to block the AVM has not been studied well in comparison to other standard treatments. This is a promising new treatment technique with potentially higher cure rates. The risks are still not well known. We are currently enrolling patients in the TATAM trial. Click here for more information.
- Minimally invasive
- Can make surgery easier
- Low cure rates
- Unknown risk for transvenous technique
STEREOTACTIC RADIOSURGERY (SRS)
Steretactic radiation surgery (SRS) involves delivering a focused high intensity amount of radiation to the AVM nidus. The treatment is done in cooperation with a radiation oncologist. The neurosurgeon uses special diagnostic imaging studies to define a target in three dimensional space. The radiation oncologist and radiation physicist then create a radiation plan to deliver the radiation dose to the specified area. This treatment is a highly effective non-invasive treatment specifically for AVMs with a nidus smaller than 3cm. This treatment however can take 3-5 years to achieve cure and over that time there is still a risk for bleeding.
- Totally Non-invasive
- Optimal for smaller deep located AVMs.
- Takes years to achieve cure
- Different side effects with radiation (hair loss, benign tumor growth 20-30 years later, brain inflammatory response)
Sometimes an AVM requires a combination of therapies to offer the best possible chance at cure. The most common is embolization followed by surgery, however there are times where embolization can be combined with SRS or SRS can be combined with surgery. Often these combinations might be necessary for larger size AVMs. The order in which these treatment combinations would be offered requires expert clinical judgement. Embolization and SRS can also be offered in a staged approach meaning multiple treatments. Again this is more commonly required in larger size AVMs.
- May be needed for better chance at cure
- Each treatment comes with additional risk