Arteriovenous Malformations

The primary aim in the management of AVMs is to remove the risk of hemorrhage. This risk is 2-4% per annum, with approximately 25-30% mortality rate per bleed. In view of this risk, immediate removal of the lesion is the ideal treatment for those AVMs that can be operated upon with minimal morbidity, and indeed this is the practice in the UK and elsewhere for these lesions. The AVM is characterized by the size, position and venous drainage of the nidus. This allows a classification (Spetzler-Martin grade), which correlates with surgical mortality and morbidity. An AVM in a non-eloquent brain area, less than 3 cm in diameter in size and with superficial venous drainage (Spetzler-Martin grade 1) would be an "operable" lesion.

In emergency situations where a large hematoma requires urgent removal, the AVM is often removed during the same procedure. On the other hand, in these situations it may not be possible to obtain satisfactory angiographic images to plan surgery, and thus many end up with remnants demonstrated on post-operative imaging - requiring further treatment.

In operable, cold cases the risk of neurological complications in the hands of neurosurgeons specializing in this field may be low, and the risks of intracranial surgery (infection, seizures, pneumonia, deep venous thrombosis) and the unavoidable inconvenience (protracted hospital stay, discomfort of a craniotomy, a temporary ban on driving, etc.) may appear worth taking. Thus, surgery is accepted by many patients. However, one has to observe in an increasing proportion of patients the trend to seek less invasive alternatives.

The use of radiosurgery for "operable" AVMs remains controversial; indeed, this group of patients is the only one in which a "surgery vs radiosurgery" debate is still ongoing. Schramm & Schramm [3] performed a meta-analysis of published radiosurgery results for low surgical risk AVMs. His own excellent personal operative results appeared to be better than those for radiosurgery, if the analysis of the latter included the statistical risk of hemorrhage during the latent period, i.e. before radiosurgery would have had its effect. However, the rate of immediate new post-operative neurological

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