Brain arteriovenous malformations: A review of natural history, pathobiology, and interventions

Ching-Jen Chen, From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ.
Dale Ding, From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ.
Colin P. Derdeyn, From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ.
Giuseppe Lanzino, From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ.
Robert M. Friedlander, From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ.Follow
Andrew M. Southerland, From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ.
Michael T. Lawton, From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ.Follow
Jason P. Sheehan, From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ. jsheehan@virginia.edu.

Document Type

Article

Abstract

Brain arteriovenous malformations (AVMs) are anomalous direct shunts between cerebral arteries and veins that convalesce into a vascular nidus. The treatment strategies for AVMs are challenging and variable. Intracranial hemorrhage and seizures comprise the most common presentations of AVMs. However, incidental AVMs are being diagnosed with increasing frequency due to widespread use of noninvasive neuroimaging. The balance between the estimated cumulative lifetime hemorrhage risk vs the risk of intervention is often the major determinant for treatment. Current management options include surgical resection, embolization, stereotactic radiosurgery (SRS), and observation. Complete nidal obliteration is the goal of AVM intervention. The risks and benefits of interventions vary and can be used in a combinatorial fashion. Resection of the AVM nidus affords high rates of immediate obliteration, but it is invasive and carries a moderate risk of neurologic morbidity. AVM embolization is minimally invasive, but cure can only be achieved in a minority of lesions. SRS is also minimally invasive and has little immediate morbidity, but AVM obliteration occurs in a delayed fashion, so the patient remains at risk of hemorrhage during the latency period. Whether obliteration can be achieved in unruptured AVMs with a lower risk of stroke or death compared with the natural history of AVMs remains controversial. Over the past 5 years, multicenter prospective and retrospective studies describing AVM natural history and treatment outcomes have been published. This review provides a contemporary and comprehensive discussion of the natural history, pathobiology, and interventions for brain AVMs.

Medical Subject Headings

Arteriovenous Fistula (complications, etiology, pathology, therapy); Humans; Intracranial Arteriovenous Malformations (complications, etiology, pathology, therapy); Outcome Assessment, Health Care

Publication Date

10-3-2020

Publication Title

Neurology

E-ISSN

1526-632X

Volume

95

Issue

20

First Page

917

Last Page

927

PubMed ID

33004601

Digital Object Identifier (DOI)

10.1212/WNL.0000000000010968

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