Management of brain arteriovenous malformations.
OBJECTIVE
This review highlights recent data regarding factors associated with brain arteriovenous malformation hemorrhage and different treatment options.


RESULTS
More risk factors were identified in association with intracranial hemorrhage, including age at initial diagnosis of arteriovenous malformation, co-existing extranidal aneurysms and genetic factors. Patients with unruptured arteriovenous malformations were found to be more susceptible to worsening in neurological function after microsurgery compared with those presenting with hemorrhagic arteriovenous malformation. Radiosurgery has achieved satisfactory obliteration of deep arteriovenous malformations, but with increased actuarial hemorrhage rates from the first to the fifth year. Although the Intraoperative Hypothermia for Aneurysm Surgery Trial failed to show a significant neurological improvement, the superior efficiency of endovascular cooling has offered optimism in cerebral protection during neurovascular surgeries by shortening the time to achieve hypothermia and rewarming. A multi-center trial (ARUBA) has been proposed to test the hypothesis that, for unruptured brain arteriovenous malformations, there is no difference between interventional and conservative management. Recent studies have also shown the promise of using tetracyclines to decrease the rate of spontaneous arteriovenous malformation rupture.


CONCLUSIONS
The recent identification of clinical and genetic factors associated with brain arteriovenous malformation hemorrhage, as well as studies on treatment outcomes, will help risk stratification in management choices. Future studies are needed to identify arteriovenous malformation patients at the greatest risk of spontaneous hemorrhage and to develop specific medical therapies.
Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco General Hospital, California 94110, USA. clee4@anesthesia.ucsf.edu
Chanhung Z
CZ
Lee
William L
WL
Young