Chapter 159 - Surgical and Endovascular Management of Acutely Ruptured Arteriovenous Malformations

Abstract

Unruptured arteriovenous malformations (AVMs) have a bleeding rate of about 1–2% per year, but once ruptured, AVMs are far more likely to bleed again. While management of unruptured AVMs remains controversial, ruptured AVMs are treated to prevent death, neurological deficits, and long-term disability that come with hemorrhage. Modern AVM treatment is multimodal and includes microsurgical resection as well as endovascular embolization and radiosurgery, either as adjuncts or as alternatives to surgery. In the acutely ruptured AVMs, surgery for hematoma evacuation, and relief of mass effect and increased intracranial pressure is sometimes required. The Spetzler–Martin and Lawton–Young supplementary grading systems are used to describe AVMs and to predict neurological outcomes after AVM surgery. While microsurgical resection is invasive, it has superior cure rates and is safe in patients with favorable supplemented grades. Endovascular embolization is routinely used preoperatively to eliminate bleeding aneurysms or deep, surgically inaccessible feeding arteries. However, newer embolic agents and delivery systems have improved AVM obliteration rates with fewer complications, making curative embolization a competitive alternative to AVM surgery in highly selected cases. Radiosurgery is utilized for patients with high-grade AVMs with high surgical risk, but is also a competitive alternative for patients with small, low-grade lesions. Complete obliteration depends on the volume of the AVM and the dose of radiation delivered. Patients remain at risk for hemorrhage during the latency period. Regardless of the treatment, only complete angiographic obliteration is considered curative and eliminates the risk of future hemorrhage. The goal of treatment is complete AVM obliteration while preserving neurological function.