1. AVM for “Dummies” Cezar Jose Mizrahi MD Neurosurgery Department Hadassah Ein-Kerem 27.05.2014

2. Wikipedia - “Arteriovenous malformation (AVM) is an abnormal connection between arteries and veins, bypassing the capillary system.”arteriesveinscapillary system - “AVMs are usually congenital.”congenital

3. AVM for “Genious” Cezar Jose Mizrahi MD Neurosurgery Department Hadassah Ein-Kerem 27.05.2014

4. Epidemiology The estimated detection rate of AVM in the US general population is 1.4/100,000 per year.* An estimated 300,000 americans have AVMs. 12% symptomatic. *Stapf C, Mast H, Sciacca RR, et al. (May 2003). "The New York Islands AVM Study: design, study progress, and initial results“.Stroke 34 (5): e29–33.

5. Signs and symptoms 88% of people affected with AVM are asymptomatic* *National Institute of Neurological Disorders and Stroke Symptoms of AVM vary according to the location of the malformation and the draining veins. Seizure Headache Progressive neurologic deficit Hemorrhage

6. Pathophysiology Wikipedia Student: “Artery – Capillaries – Vein”. High Pressure → Low Pressure. The resulting tangle of blood vessels: Nidus.

7. Hemorrhage Natural Hystory Overall 2% - 4% annual rate of hemorrhage Type Hemorrhage: - Intraparenchymal; - Intraventricular; - Subdural.

8. Risk Factors - bleeding Hystory of prior bleeding Small AVM Deep Venous Drainage Higher feeding artery pressures Intranidal Aneurysm

9. Diagnosis CT CTA MRI MRA DSA

10. AVM Brain Sleen Lung Kidney Spinal cord Liver Intercostal space Iris Spermatic cord

11. AVM – “to feel smart” → AVMs may occur in isolation or as a part of another disease: - Von Hippel-Lindau disease. - Hereditary hemorrhagic telangiectasia. → Associated with Aortic Stenosis * *Batur, P.; Stewart, WJ; Isaacson, JH (2003). "Increased Prevalence of Aortic Stenosis in Patients with Arteriovenous Malformations of the Gastrointestinal Tract in Heyde Syndrome". Archives of Internal Medicine 163 (15): 1821–4

12. Spetzler-Martin AVM grading system The score correlates with operative outcome. Give a score between 1 and 5. Grade 6 is used to describe inoperable lesions Spetzler RF, Martin NA. (1986) A proposed grading system for arteriovenous malformations. J Neurosurg. Oct;65(4):476-83.

13. Spetzler-Martin AVM grading system Size of nidus small (<3cm) = 1 medium (3 - 6cm) = 2 large (> 6cm) = 3 Eloquence of adjacent brain non-eloquent = 0 eloquent = 1 Venous drainage superficial only = 0 deep = 1

14. Eloquent??? Eloquence brain sensorimotor, language, visual cortex, hypothalamus, thalamus, brain stem, cerebellar nuclei, or regions directly adjacent to these structures. Non-eloquence brain frontal and temporal lobe, cerebellar hemispheres.

15. Diana: Spetzler – Martin?? (A)SM I (B)SM II (C)SM III (D)SM IV (E)SM V (F)SM VI

16. Diana: Spetzler – Martin?? (A)SM I (B)SM II (C)SM III (D)SM IV (E)SM V (F)SM VI

17. Diana: Spetzler – Martin?? (A)SM I (B)SM II (C)SM III (D)SM IV (E)SM V (F)SM VI

18. Ran: Spetzler – Martin?? (A)SM I (B)SM II (C)SM III (D)SM IV (E)SM V (F)SM VI

19. Ran: Spetzler – Martin?? (A)SM I (B)SM II (C)SM III (D)SM IV (E)SM V (F)SM VI

20. Treatment Neurosurgery Endovascular Radiosurgery Symptomatic + F/U

21. Treatment