IntroductionIntroduction

Cerebral vascular malformations are widely classified as arteriovenous malformations(AVMs),cavernous malformation , venous malformations and telangiectasias based strictly on pathology , mixed or transitional types of malformations

The most common of the vascular malformation is the AVM (about 80%)

AVMsAVMsDEF. Are congenital ,high-flow ,high pressure lesions with primary Risk of devastating intracerebral hemorrhage

PathologyPathologyThe exact pathogenesis is not

knownA genetic factor has been

postulatedAVMs commonly affect distal

arterial branches Often found in the border zone

region shared by the distal anterior , middle and\or posterior cerebral arteries

Primitive circulation begins with a capillary mesh over the entire brain at about fourth week of embryogenesis

An AVM is a cluster of congenital arteriovenous communication without intervening capillaries

The arteries and veins are tortuous and dilated . Nidus is the actual site of the abnormal communication. In most, the AVM is visible in cortex

LocationLocation

They are more commonly supratentorial

particularly in parietal lobeMiddle cerebral Posterior cerebralAnterior cerebral territories are

involved in declining frequencies, nearly 10%.

10-15% of patients with this lesions are found to have aneurysm

LocationLocation

Clinical presentationClinical presentation

Intracranial AVMs are typically , diagnosed before the patient has reached the age of 40 years

Hemorrhage Spont. Hemorrhage most common 41-

79% Intraparenchymal , SDH or SAHIn 5-10% of case IVHSeizures 2nd most common symptoms

20-25%Focal neurological deficit about 10%

of AVMs Headache about 10-15% present with

headache aloneCognitive deficits especially in

children

Grade of AVMs(Grade of AVMs(Spetzler-Martin)

Lesion characteristicPoints Assigned

SIZESmall : diameter <3cm

Medium : diameter 3-6cm

Large : diameter >6cm

1

2

3

Location Noneloquent site

Eloquent0

1Pattern of venous drainageSuperficial only

Any deep 0

1

InvestigationsInvestigations

CT SCANSCT ANGIO MRI (MRA & MRV)DSA (digital subtraction

angiography)

ManagementManagement

Management strategies include MicrosurgeryEndovascular or radiosurgery either

alone or in combination .Surgical excision remains the gold

standard.

Axial magnetic resonance imaging with gadolinium shows an enhancing lesion in the left parietal cortex

Digital subtraction angiography (DSA) of the same patient shows an arteriovenous malformation(AVM) with a middle cerebral arterial feeder and a cortical draining vein to the superior sagittal sinus.

Intraoperative image of the same AVM shows the nidus on the cortical surface. Note the large draining vein with oxygenated blood going superiorly. Here, intraoperative cortical stimulation was attempted because of the eloquent location of the nidus

Post resection imagePost resection image..

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Dr.Abdullah AlsubaieeDr.Abdullah Alsubaiee