ANTERIOR VENOUS MALFORMATION (BRAIN) Nurul Fatiehah bt Asmui PZM0044/12

Introduction AVM is vascular abnormalities which consist fistulous connection of arteries and veins Normal condition: artery-capillary-vein AVM: bypass normal brain tissue, and divert blood directly from arteries to the vein Most of AVM do not grow Less than 1 percent having AVM in general population

- brain control the body function Can occur at any site of body, but critical at brain - brain control the body function AVM is develop during embryonic stage but people start showing symptom when they around 20 till 40 years old AVM is not heredity disease

Can be detected using CT-scan, angiography MRI scan There are four types Anterior venous malformation Cavernoma- capillary enlarged Venous malformation- vein enlarged Hemangioma- blood vessel occur at surface of brain Can be detected using CT-scan, angiography MRI scan CT scan can determine the location and the condition of lesion but MRI is better- more detail for soft tissue Angiography is mandatory, provide accurate location of lesion

Symptoms intracerebral hemorrhage ( more than half of patients) Seizure (45-50%) Headache and localized pain Difficulty in speech, motion and vision (little case)

Treatment Spetzler-Martin grading scale - evaluate AVM in order to determine the right treatment can be done Majorly based on -size of lesion -location of the lesion -venous drainage -general condition like age Have 5 grade- grade 1 is small, superficial and non-eloquent cortex, grade 4 is essentially inoperate and grade 5 is really deep and surround by critical organ

-not for cure, just to reduce the symptom Medical therapy-for patient who has no dangerous symptom or inoperate AVM -not for cure, just to reduce the symptom - Anticonvulsant (decrease occurrence of seizure) Surgery- easily operate lesion - usually being followed by other treatment Radiosurgery-used high energy radiation to destroy abnormal vessel -ideal for small AVM and locate at critical area that cannot be operate Embolization-blocking abnormal blood vessel using microcoil for example -used for deeper AVM that cannot be operate -used before surgery to reduce blood flow

Treatment Outcome Follow up procedure being done after treatment -usually used angiography but new technology shows that MRI with contrast enhancement also 86.9% accuracy(Lim and Choi (2012)) after surgery- only 1.1% shows the reoccurrence of AVM (mustafa, 2009) Seizure free- 81% after surgical, radiosurgery(43%) and embolization(50%) (Hoh BL, 2002) After radiosurgery- obliteration rate is 79% for small AVM and 47% for large AVM (Fredman, 1997) - But cured rate for radiosurgery takes time-and show secondary tumor occur due to radiation Past study by Kwon(2000) said embolization shows no significant improvement but recent study by T. Seruga(2009) show by using Onyx (new embolic material) show half successful result.

Complication Before treatment- During treatment -Determine the proper treatment method- -based on Spetzler-Martin grading scale -general health of patient During treatment - tissue damage-wider margin resection of AVM or due to radiation After treatment - Hemorrhage from residual AVM and seizure -auto regulation of blood vessel