Endovascular Management of Brain Arteriovenous Malformations

Due to the risk of cerebral hemorrhage, and its related morbidity-mortality, brain arteriovenous malformations (bAVMs) are a rare and potentially life-threatening disease. Despite this, there is only one randomized controlled trial on bAVM management, A Randomized trial of Unruptured Brain Arteriovenous malformations (ARUBA). The results of the ARUBA trial favor a noninterventional approach in the case of an unruptured bAVM; however, implementation of these findings is challenging in daily practice. Instead, management of bAVM relies on multidisciplinary discussions that lead to patient-specific strategies based on patient preferences, local expertise, and experience in referral centers. Considering the diverse patterns of presentation and numerous treatment modalities, implementing standardized guidelines in this context proves challenging, notwithstanding the recommendations or expert opinions offered. Endovascular treatment (EVT) of bAVM can be curative, or can serve as an adjunct treatment prior to surgery or radiosurgery ("pre-EVT"). EVT practice is in constant evolution (i.e., venous approach, combination with surgery during the same anesthesia, etc.). Liquid embolic agents such as ethylene vinyl alcohol (EVOH) copolymer and cyanoacrylates (CYA), and their method of injection to increase bAVM occlusion have also benefited from technical evolutions such as the use of adjunctive flow arrest techniques (mini balloons, pressure cooker technique, and multiple catheters). Further research is necessary to evaluate the advantages and disadvantages of EVT for bAVM.