Neuropsychological function and brain arteriovenous malformations: redefining eloquence as a risk for treatment

Arteriovenous malformations (AVMs) of the brain, thought to begin during fetal development and undergo an unclear maturation process; most often do not become symptomatic until the patient reaches adulthood. Authors of recent prospective studies have suggested that relatively few patients present with neuropsychological abnormalities in the absence of hemorrhage. In general, neuropsychological evaluations in patients with AVMs have yielded mixed results with respect to localization of function, and the authors of most cognitive studies have not been able to demonstrate the nature and degree of impairment seen in acute ischemic stroke in comparable brain regions. Superselective Wada testing prior to therapeutic embolization, functional imaging studies, and intrasurgical cortical mapping have shown redistribution of language and memory to unpredictable regions. Developmental cognitive history in these patients indicates that most will have at least some background of learning problems during the school-age years with varying degrees of severity, reflecting a time when brain reorganization may be occurring. These data suggest that traditional assumptions about the eloquence of brain regions may not hold for patients with AVMs and that establishing treatment risk in the individual patient needs to be made on an empirical basis.