ArteriovenousArteriovenousmalformationofmalformationofthebrainthebrainDiagnosisandtreatmentDevelopmentDevelopment•3rdweekofpregnancy•primitivevesselsdonotdevelopintonormalvasculature•formationofanarteriovenousshuntSymptomsSymptomsseizureshemorrhagedeficitHemorrhageHemorrhage•historyofsuddenheadache•ageusually25–35years•hemorrhagelessseverethanSAH•novasospasm•risk2–3%peryearSeizuresSeizures•oftenfocal,butmaygeneralize•oftenbetterafteroperationNeurologicaldeficitNeurologicaldeficit•duetoischaemiaofsurroundingbrain•developswithincreasingage•especiallyinlargeAVM’sDiagnosisDiagnosis•historyandneurologicalexamination•CT-scan•MRIandMRA•angiographyEvaluationEvaluation•size•drainingveins•(deep)arterialfeeders•localizationinbrain•associatedaneurysms•definebleedingsourceTreatmentTreatment•conservative•closingoffeederarteries•excision•endovascular•radiotherapyConservativeConservativetreatmenttreatment•controlofepilepsy•controlofhypertension•life-styleadviceClosingfeederClosingfeederarteriesarteries•reductioninbloodflow•shortlivedeffect•collateralswilldevelop•noriskreduction!ExcisionExcision•size•localisation•numberoffeeders•venousdrainage•±75%canbeexcised•only100%effectivetreatment!dependsonEndovascularEndovascular•balloonocclusion•occlusionofthenidus•identifybleedingsource•onlyindicatedif100%elimination•maybecombinedwithsurgicaltreatmentRadiotherapyRadiotherapy•causeshyperplasiaofintima•secondarythrombosis•fordeep-seatedAVM’s<3cm•occlusionrate80%•effectaftertwoyears•life-longfollow-upnecessary?OperativetechniqueOperativetechnique•BP<100mmHg•moderatecooling•startonthearterialside!•observenaturalshapeofAVM•occlusionofveinsaslaststep•keepBPlowpostop.•keeppatientsedated24–48hoursProblemsProblems•oedema•seizures•perfusionpressurebreakthrough•re-bleed(onlyifexcisionincomplete!)Example#1Example#1Example#2Example#2Whattodo?Whattodo?
