Right Parietal AVM

Contributor:

Dr. Chris Ekong

Consultants:

Dr. Krishna Kumar
Dr. Christopher Wallace
Dr. R Willinsky
Dr. J Max Findlay
Dr. John Wong
Dr. Mike Tymianski
Dr. Fred Gentili
Dr. Renn Holness

Case 27

Age: 57

Sex: Male

History: August 7, 2004 - One grand mal seizure. Controlled with dilantin. Examination - normal.

Diagnosis

Right Partial AVM

Would you?

- Leave it alone?

- Embolize it

- Treat with radiosurgery

- Combination?

October 17, 2004 - Dr. Chris Ekong, Neurosurgeon, Regina

To: Neurovascular Internet Rounds Group

What would you do for this man with an unruptured AVM, who presents with seizures? He is in excellent health.

Regards,

Chris E

October 18, 2004 - Dr. Mike Tymianski, Neurosurgeon, Toronto

Hi All...

Compact Rt Parietal AVM <3cm, Eloquent, Supeficial drainage (though can't be sure of a whisp of deep with these pics) = Grade II in otherwise young and healthy man.

His risk of hemorrage is ~4% per year.

I Recommend treatment.

Treatment options:

1. Embo for cure - not likely in this AVM. Risk of embo with nidal penetration ~4-5% M&M.

2. Radiosurgery - about 60-79% obliteration rate at 3 years. Risk of radiosurgical complications ~3-5%, Risk of bleed during 3 years ~12%, with 50% having M&M from bleed so total risk of treatment ~10% M&M

3. Surgery - about 100% cure rate, immediate during same admission. Would quote surgical M&M of 5% permanent, 20% transient (days - weeks) weakness contralateral side. If contemplating surgery, woul contemplate pre-op embo for prenidal arterial ligations (risk <1% of additional M&M).

Would offer the patient treatment. Would give the options of Radiosurgery and Surgery. Would rank Surgery higher. Would do what patient wants.

Best

Mike Tymianski

October 18, 2004 - Dr. Christopher Wallace, Neurosurgeon, Toronto

I favour treatment. The risk is 3-4% per year with 17% mortality and 30% morbidity associated with a bleed....so given good general health, I would favor treatment to obliterate his risk of hemorrhage. We'd probably all fix an asymptomatic 8mm MCA aneurysm which has a lower annual risk of bleeding.

I agree with Michael T's approach and would offer surgery or rads as definitive treatment. For this lesion, I would probably not add pre-op embo as flow is average and vessels of supply easily accessible. I cannot see any aneurysms or arterial ectasias and so would not add pre-rads embo.

Chris

October 18, 2004 - Dr. Max Findlay, Neurosurgeon, Edmonton

Chris,

I would recommend treatment. To decide between radiosurgery vs. embolization/microsurgery we would need to get an accurate measurement & consult radiosurgeons, and look at a catheter angio.. I would be leaning towards radiosurgery personally.

Yours,

Max

October 18, 2004 - Dr. Renn Holness, Neurosurgeon, Halifax

There is no right answer here; depends on the patient & his understanding of Mike T's stats & whether he is a betting man!

Clearly surgery is the most predictable and Mike make a good case for it.(I would like to see a detailed psychometric & quality of life evaluation of patients who had lesions like this excised from in their R.Parietal lobe--is there such a series?)

Our current stats favour treatment.I am not persuaded that the outcome stats of radiosurgery are all that clear cut from series to series. Nevertheless the "non-invasiveness" of the method is attractive and the patient would have to understand that the risks of a bleed is the same as "no RX" till obliteration occurs.

For me (in the same half decade age group) I 'd take the chance that I'd be in the 70% cured by radiosurgery along with the ~20% risk of a bleed while waiting which has a reasonable chance (~80%?) of not killing me and at he worst a 50% chance of maiming me (non dominant hemisphere).

Renn

October 21, 2004 - Progress

Had a meeting with patient. He is not certain what he wants done. He wants to think about all the options carefully.

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