Arteriovenous Malformations: Management Today and Tomorrow (Podcast)

Blood flow typically goes through a large vessel into smaller vessels and capillaries that feed back into small venous collection areas and then larger veins. Arteriovenous malformations (AVMs) disrupt normal blood flow and oxygen circulation.

“An arteriovenous malformation is an abnormal high-flow connection between the artery to the vein, bypassing some of those smaller pathways,” notes Nina Moore, MD, a neurosurgeon in Cleveland Clinic’s Cerebrovascular Center. “In the brain, this can be particularly dangerous, carrying about a 3% rupture risk per year — sometimes up to 9% to 10% if some high-risk features are involved.”

In the latest episode of Cleveland Clinic’s Neuro Pathways podcast, Dr. Moore shares insight on current methods for managing AVMs and looks to what’s on the horizon in AVM care. The discussion covers:

• Clinical presentation and diagnosis of AVMs
• Medical management and surgical treatments for AVMs in the brain
• Advances in surgery, including the use of fluorescence imaging techniques
• Management of facial and body AVMs
• Research on the role of genetics, mechanical properties of vessels, and cell-level changes in AVMs

Click the podcast player above to listen to the 20-minute episode now, or read on for a short edited excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

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Excerpt from the episode

Podcast host Glen Stevens, DO, PhD: I’m sure it’s difficult to make treatment decisions. I imagine you use some of these grading systems that tell you where the risk is, along with patient preferences as well. How are you deciding?

Dr. Moore: There are certain locations in the brain that make AVMs very amenable to surgery. If an AVM is located deep within a vital structure, like the brain stem, surgical resection can be very damaging to the surrounding area. And so something like radiosurgery — here we use Gamma Knife® — can be a very eloquent way of taking care of the AVM. It doesn’t give you a definitive cure right away, but over the course of three years it has a decently high success rate in curing the AVM.

Sometimes, for large AVMs that are not resectable, we can do staged Gamma Knife therapy. We can do staged embolization to try to take down some of the more dangerous feeders. Obviously, if it’s a very large AVM, sometimes we unfortunately can’t do a whole lot. And so we hope that some of these new medications coming down the line will give us some more options.

From a planning standpoint, we are trying to determine ways of more accurately predicting who will need an AVM resection or treatment. My lab is working on doing fluid structure modeling, where we look at AVM mechanics — both fluid flow and the actual mechanical properties of these vessels — to see if we can take a patient’s specific anatomy and do a mechanical model of it, where we import based on their own characteristics what the mechanical properties of those vessels are. We also look at the fluid flow, based on preoperative imaging, to see if we can predict whether the AVM is going to rupture, and over what time frame.