Centers of Excellence in Interventional Cardiology and Radiology

INTERVENTIONAL NEURORADIOLOGY

Cerebral arteriovenous malformation

The procedure performed by team of specialists from abroad!

Our center has saved the lives of over 4,500 patients in the last 4 years

The most modern equipped angiography room , an exceptional medical team

We have the most famous abroad specialists! Team from Romania, Israel, Greece and Germany!

Only 24 hours hospitalization

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Generalities

What are arteriovenous malformations (AVM)?

Arteriovenous malformation (AVM) is an abnormal, fragile connection between arteries and veins, bypassing the capillary system. They have a higher rate of bleeding than normal vessels. AVMs can occur anywhere in the body. Brain AVMs are of special concern because of the damage they cause when they bleed. AVMs that occur in the coverings of the brain are called dural AVMs.

Wath is the cause of AVM ?

The cause is not known. AVMs are thought to be due to abnormal development of blood vessels in utero and may be present since birth. Most AVMs are not inherited. Dural AVMs, in adults are an acquired disorder that can occur following an injury.

They can occur in people of all races and sexes in almost equal proportions. The typical time of discovery is between the ages of 20 and 40 years, and the diagnosis is due to complications like bleeding (the risk of bleeding is 4% per year, which means that 4 out of every 100 people with an AVM will have a bleed (hemorrhage) during any one year) or seizures.

Symptoms

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A variety of symptoms may be produced which will depend on the location and size of the AVM. Common problems including:

Seizures – an AVM in the brain may act as an irritant resulting in abnormal electrical activity.

Headache – headaches may be caused by the high blood flow through the AVM . These headaches may be similar to a migraine or be actual migraines.

Stroke-like symptoms – brain AVMs may cause stroke-like symptoms by depriving the nearby brain tissue of oxygen and nutrients. The symptoms vary with the location of the AVM and include: weakness or paralysis on one side of the body, numbness and tingling, problems with vision, hearing, balance, memory and personality changes

Sudden, severe headaches can be caused by bleeding. These headaches are often followed by nausea , vomiting , neurological problems or a decreasing level of consciousness.

Bleeding – this is the most serious complication of an AVM. Sometimes, a bleed may be small and produce no noticeable symptoms.

It is important to know that an AVM can be present and not produce any symptoms.

There is an increased risk of hemorrhage from an AVM during pregnancy, usually after the first three months of pregnancy. Although not all AVMs bleed during pregnancy, we recommend delaying pregnancy until after the AVM has been completely treated.

Diagnosis

Diagnosis is settled using imaging studies: angio-computer tomography, angio-magnetic resonance imagistic, cerebral angiogram.

Indications

As we pointed above, AVMs associate a risk of bleeding of 4% per year. Bleeding may injure the surrounding brain resulting in a stroke , with possible permanent disability or even death

Treatment is offered is to try to prevent bleeding from the AVM.

Treatment consists of: surgery ( microneurochirurgical techniques), interventional treatment (mnimally invasive procedure which enables the injection of medical grade “glue”, directly into the abnormal connection or ‘site’ to block off the abnormal blood vessel connection) or radiation treatment (also know as radiosurgery or stereotactic radiotherapy; a narrow x-ray beam is focused on the AVM such that a high dose is concentrated on the AVM with a much lower dose delivered to the rest of the brai )

Your doctor will recommend the best treatment for you and this will be determined by the size of your AVM and also the location. It is not uncommon to recommend a combination of treatments.

Treatment planning for cerebral arteriovenous malformation is based on the hemodynamics of the lesion, location, but also on the possible consequences (the risk if AVM remain untreated vs the risk associated with the procedure).

Interventional treatment:

the chances of completely curing an AVM using only embolization treatment is about 20%

may reduced the AVM’s size so that the AVM can be suitable for other forms of therapy such as radiation and surgery

no open surgical procedure.

short hospital stay

multiple sessions may be required; can be early repeated and staged

the chance of bleeding every year in a partially treated AVMs is likely reduced by embolization, but not eliminated

can be palliative and should be targeted to relieving symptoms

not all AVMs can be treated with embolization. AVMs are carefully studied at the time of a preliminary angiogram to determine if catheters can be passed up into the AVM without any complications before they are considered for embolization.

Procedure

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The interventional treatment – know as “embolization” – is a minimally invasive technique wich involves the injection of glue or other non-reactive liquid adhesive material into the AVM in order to block it off. The glue rapidly hardens as it is injected into the AVM.

This procedure is performed using a technique similar with angiography. Embolization is done under local or general anaesthesia and sometimes under light sedation and heparin.

A small cut (less than 1 centimetre) is made in the skin of your groin. Through this cut, the femural artery is punctured with a small needle and a catheter (long thin hollow plastic tube) is inserted into the artery.

Very tiny catheters are used. This is a similar procedure to a cerebral angiography except that in addition to dye being injected to show the AVM, these tiny catheters are positioned near the AVM and glue or particles are injected into the AVM to block it off. Through the catheter, serial angiograms are performed, checking the position of the catheter, but also the indication for interventional treatment (the initial planning of the procedure takes place before you are admitted to hospital, but the final steps in the planning process are done after seeing the images from the angiogram). After the embolisation, a new angiogram is performed.

If the doctors do not think that they can safely embolize the AVM, then the embolization procedure will be discontinued. A single AVM may need to be embolized several times before satisfactory results are obtained or until no further embolization is possible. If more than one embolization is necessary, the procedures are usually done in stages spread over weeks or months.

When the procedure is done (either the total obstruction was achived, either there is nothing to do in this session) the catheters are removed.

Is it painful?

The doctor may use general anesthesia, so the patient will not feel any pain, and after the procedure it will received pain drugs.

How long does it take?

Typically it takes 2 to 3 hours and is performed in the cath lab.

Risks

Complications are rare and the risk is decreased because the proper preparation and the permanent surveillance.

• damage to surrounding blood vessels, organs, or other structures by instruments

• puncture site infection or bleeding or arteriovenous fistula

• pain

• gaseous embolia

• allergic reaction from the general anaesthesia

• fever

• headaches are not infrequently reported. They will usually subside, but if they are persistent, the doctor will prescribe a short course of medication and this will usually take away the headache.

• puncture site haematoma

• other possible complications include stroke like symptoms such as weakness in one arm or leg, numbness, tingling, speech disturbances and visual problems

• very low risk of stroke and death

Before procedure

The preop consult establishes if AVM can be treat using either the embolisation technique, either surgery. For this main, angiogram is very useful.

Preadmission will be done one day prior to the embolization.

If you are on medication, your will discuss with you whether to continue with your medication and give you full instructions. In particular, if you have diabetes, kidney or thyroid diseases, or if you are on blood thinning (anticoagulant) medication, special instructions will be provided to you.

You will have a medical check up to ensure that you are fit for the operation and for the anaesthetic, to have any necessary blood tests performed, and to give you any information or any special medication that you may need to take before the embolisation procedure. You will also need to sign a consent form to give permission to treat you. You will be asked to fast for eight hours before the procedure, generally after midnight. If you are pregnant or suspect that you are pregnant, you should notify your health care provider.

Notify your doctor if you are sensitive to or are allergic to any medications, latex, iodine, tape, contrast dyes, and anesthetic agents (local or general).

After procedure

This is a minimally invasive procedure so the recovery is quick.

You may be taken to the intensive care unit and you will be connected to monitors that will constantly display your electrocardiogram (ECG or EKG) tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level. You will be given pain medication for incisional pain. Your doctor will instruct you to remain still, lying flat in bed for up to eight hours. This rest period allows the groin artery to heal.

You can leave the hospital after 1-2 days.

The surgical incision may be tender or sore for several days.Take a pain reliever for soreness as recommended by your doctor. You should not drive until your doctor tells you to. Other activity restrictions may apply, if needed. Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation. Check out for fever, pain or alteration at the incision plance, but also for neurologic events.

After the procedure, you will need to have follow up radiology tests such as magnetic resonance imaging (MRI) scans or angiograms to see how effective the procedure has been – usually, first time after few months (your doctor will tell you).

It is important for you to know that embolization will not usually completely close off an AVM. A person may still bleed from an AVM in such a case. It is not known whether or not partial embolization treatment reduces the risk of future bleeding.

Important!

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Do not forget that AVMs involves a high risk of bleeding and untreated, these can lead to severe consueqences(including death). Treatment is offered is to try to prevent bleeding from the AVM

Embolisation is a minimally invasive procedure, efficient, with a quick recovery and short hospitalison.

Multiple sessions may be required – your doctor will discuss this with you.

DOCTORS
that perform the procedure

X

Sună Mesaj