A Rational Approach to the Management of Cerebral Arteriovenous Malformations

Abstract

Cerebral arteriovenous malformations (AVMs) typify the delicate balance cerebrovascular specialists face in weighing the treatment risk against the natural history of a pathologic lesion. The goal of our review was to provide an overview of the current evidence for the treatment of cerebral AVMs and describe a contemporary approach to developing a treatment strategy according to individual AVM characteristics. A review of the contemporary literature on the natural history and treatment of cerebral AVMs was completed through the PubMed and Google Scholar databases. The studies were reviewed for original advances in the characterization and treatment of cerebral AVMs. The overall risk of hemorrhage for cerebral AVMs is 2%-4% per year. Individual AVM characteristics, including small size, exclusive deep venous drainage, deep or posterior fossa location, venous ectasia, and the presence of a flow-associated aneurysm, appear to confer a greater risk of presentation with rupture. A diverse array of modalities have been developed to achieve the goal of complete lesion obliteration, including microsurgery, endovascular therapy, and radiosurgery. Advances in treatment strategies and technology have continued to decrease the morbidity associated with lesion obliteration. Microsurgical or multimodal treatment strategies are often required to achieve complete obliteration; however, it remains critical that each treatment approach is individualized by the specific AVM characteristics.