Arteriovenous Malformations in the Brain or Spine (AVMs)

An arteriovenous malformation (AVM) is an abnormal tangle of blood vessels located on, in, or near the spinal cord or brain. In individuals who have AVM, blood passes directly from the arteries to the veins, bypassing capillaries and depriving the spinal cord or brain of oxygen-rich blood. This disruption causes cells in the spinal tissues or brain tissues to deteriorate and die. The arteries in an AVM are also at risk of rupturing, causing hemorrhaging in the spinal cord or brain, or an AVM that enlarges over time as blood flow increases can compress the spinal cord or brain, leading to disability or other issues.

AVMs can range from having no symptoms and little to no risk to one’s health, to being severe and devastating. Accordingly, treatment options can range from merely keeping an eye on the condition to performing surgery, depending on the type, symptoms, and location of the AVM. Common symptoms of a spinal AVM include sudden and severe back pain, weakness in the legs or arms, and paralysis, and common symptoms of a brain AVM include sudden onset of a very severe headache, vomiting, stiff neck, seizures, migraine-like headaches, and an abnormal swishing or ringing sound in the ear.


Subclavian Steal Syndrome

Subclavian steal syndrome refers to a condition where blood flow is reversed in the vertebral artery or the internal thoracic artery as a result of a narrowing or occlusion of the subclavian artery. This causes a decreased blood flow to the posterior brain and upper arm on the affected side, which can result in a variety of symptoms including the sensation of almost fainting, actual fainting, neurologic deficits, differing blood pressure between the individual’s two arms, severe memory problems, weakness, coldness, or paresthesis in the arm, and the hands showing signs of circulation problems.

Subclavian steal syndrome is frequently asymptomatic and often found incidentally, sometimes being detected when a discrepancy is found between the blood pressures of the two arms. Asymptomatic patients do not usually require treatment aside from lifestyle changes to prevent the progression of atherosclerosis – the formation of plaque within the arterial wall that can cause blockages – and symptomatic patients may be treated with angioplasty and stenting or surgical revascularization.


Vertebrobasilar Dolichoectasia (VBD)

Vertebrobasilar dolichoectasia (VBD) is a condition that is characterized by the elongation and tortuosity of the basilar artery, which is part of the blood supply system for the brain and the central nervous system. While most cases are asymptomatic, some individuals may experience ischemic stroke, brain stem or cranial nerve compression, hydrocephalus (the buildup of fluid deep within the brain), or cerebral hemorrhage. Effective treatment for this condition can be difficult because VBD predominantly occurs in deep parts of the brain, so many treatments mainly target certain symptoms or complications resulting from VBD.

The most common symptom of VBD is ischemic stroke, and it is also the most common cause of death from this condition. If you or someone else is experiencing symptoms of a stroke, such as sudden numbness or weakness of the face, arm, or leg, especially in one side of the body, sudden confusion or trouble understanding, loss of vision in one or both eyes, trouble walking, dizziness, loss of balance or coordination, or a sudden severe headache with no known cause, call 911 immediately.


Dural Arteriovenous Fistulas

Dural arteriovenous fistulas (dAVFs) are abnormal connections between an artery and a vein in the tough covering over the brain or spinal cord. Dural AVFs can occur in the brain, spinal cord, or other areas of the body, and typically occur later in life and are not passed on genetically. Some individuals with dAVF may not experience any symptoms, but for those that do, symptoms are characterized as aggressive or benign.

Aggressive dAVF symptoms can be the result of bleeding in the brain, or from neurological effects of non-hemorrhaging neurological deficits. Bleeding in the brain often causes the sudden onset of a headache with varying degrees of neurological disability based on the location and size of the bleed. Non-hemorrhaging neurological deficits usually develop more gradually over the course of days to weeks, and produce symptoms related to their location. These can include seizures, speech or language issues, face pain, dementia, Parkinsonism, coordination issues, burning or prickling sensations, weakness, apathy, failure to thrive, headaches, nausea, or vomiting.

Benign dAVF symptoms can include hearing issues including pulsatile tinnitus, and vision problems including visual deterioration, eye bulge, swelling in the eye lining, eye-related palsies, and cavernous sinus syndrome.

It is important to seek medical care if you develop any symptoms that seem unusual or worrisome, and if you or someone else is experiencing any symptoms of seizure or symptoms that suggest a brain hemorrhage, call 911 immediately. These symptoms can include a sudden severe headache, nausea, vomiting, weakness or numbness on one side of the body, difficulties speaking or understanding speech, loss of vision, double vision, or difficulties with balance.


Management And Treatment Of Dissection Of Neck Or Cerebral Blood Vessels

Dissection of the neck or cerebral blood vessels, or a cerebral arterial dissection, can lead to severe complications including stroke or even death. When an individual presents with a cerebral arterial dissection and has not yet had a stroke, preventing a stroke is the primary goal. If the patient has already experienced a stroke, then treating it to prevent lasting complications is the goal.

The first treatment that is typically given is anti-platelet agents or anti-coagulation medication to prevent the formation of blood clots and help protect against stroke. In some cases, endovascular treatments or surgical repair may be utilized to treat the dissection. These are normally minimally invasive treatments such as angioplasty to repair the dissected section of the artery with the inflation of a special balloon, or placement of a stent, a mesh-like device that holds the artery open. These two procedures are often used together to provide the longest-lasting treatment.


Subclavian Steal Syndrome: Angioplasty and Stenting Treatment

Subclavian steal syndrome refers to a condition where blood flow is reversed in the vertebral artery or the internal thoracic artery as a result of a narrowing or occlusion of the subclavian artery. This causes a decreased blood flow to the posterior brain and upper arm on the affected side. While subclavian steal syndrome is often asymptomatic and does not require treatment, it can cause symptoms and will then require treatment. One option for treatment is angioplasty and stenting.

Angioplasty and stenting is a minimally invasive method of treating subclavian steal syndrome. During this procedure, a surgeon inserts a catheter with a deflated balloon at its tip into an artery at the groin, and then threads it through until it reaches the affected area. The narrowed artery is then expanded by inflating the balloon, and a stent is inserted to keep the artery propped open.

While this procedure is generally safe, there are some risks which the doctor will discuss with the patient. Recovery is usually fairly fast with some patients able to move about within hours, and complete recovery is typically within a week or less.


Arteriovenous Malformations (AVMs): Diagnosis, Minimally Invasive Treatment And Surveillance

An Arteriovenous Malformation, or AVM, occurs when a group of blood vessels forms incorrectly. The result is a disruption of normal blood flow and healthy oxygen circulation.

An AVM can transpire anywhere, causing the affected arteries and veins to rupture, but is most common in the brain or spine. When an AVM occurs in the brain, a rupture can result in brain bleeding, stroke, or permanent brain damage.

It is generally unclear what causes an AVM, but it is not a hereditary condition. Signs of AVMs include headache or seizures, although it is most common for an AVM to be detected during a brain scan for an unrelated health issue or as a result of a blood vessel rupture. When diagnosed, an AVM can be successfully treated to prevent or reduce additional complications.

Treatment varies depending on the location and size of the AVM as well as the symptoms. If an AVM is not causing pain or loss of function, then treatment might include simply monitoring and follow up visits. In the event that bleeding has occurred or if the AVM is in an area that can be easily accessed, surgery might be recommended.


Arteriovenous Fistulas (AVFs)

Arteriovenous fistula, or AVF, presents itself due to an abnormal connection between an artery and a vein. An individual can be born with an AVF, but more commonly it occurs as the result of an accident or trauma. It is not considered hereditary. The two major types of AVFS are Dural AVFs and carotid-cavernous fistulas. While an AVF can occur anywhere, it is most commonly found in the head, neck, spine, and liver.

Tinnitus is the most common symptom of an AVF, causing an unusual sound in one or both ears. Eye symptoms include pain behind the eye, bulging, double vision, and eye swelling. Brain hemorrhage can also occur, resulting in a stroke, with symptoms that include sudden headache, nausea, vomiting, numbness or weakness in one side of the body, struggles with balance and difficulties communicating.

Treatment options for an AVF include:

  • Endovascular embolization
  • Microsurgery
  • Stereotactic Radiosurgery

The goal is to close the AVF to avoid an increase of pressure in the venous system. Observation is an option when there is no cortical venous drainage or if treatment carries a higher risk than monitoring the issue.


Head & Neck Vascular Malformations: Minimally Invasive Embolization Procedures

Vascular malformations of the head and neck consist of a group of lesions resulting from an abnormal development of blood vessels. The lesions present themselves cosmetically and can cause pain, limits to function, and bleeding. The most common are congenital venous malformations that grow with the child over time.

Potential locations for a vascular malformation include:

  • Large Arteries & Veins
  • Arterioles & Venules
  • Microscopic Capillaries
  • Lymphatic Channels

While this can be observed via physical examination, it is often necessary to take imaging to ensure accurate diagnosis, as well as to assess viable treatment options. A minimally invasive method of treatment involves embolization. A catheter is placed into the vein and an embolic agent is released to block blood flow to that area. Materials used include:

  • Ethanol
  • Cyanoacrylate
  • Coils
  • Polyvinyl Alcohol
  • Sodium Tetradecyl Sulfate
  • Gelatin Sponge and Microspheres

Treatment occurs over the course of several weeks to eradicate the presence of the malformation.


Epistaxis or Nosebleeds (uncontrolled): PVA particulate embolization treatment

The Greek word for nosebleed is epistaxis and it is a highly common malady that usually resolves on its own. The application of pressure or nasal packing generally suffices as effective treatment options when the nosebleed is not serious.

In the event of a severe nosebleed, duration, frequency, and loss of blood should be considered when assessing the appropriate treatment. Call your doctor or go to the emergency room if:

  • Bleeding persists for more than 15 to 20 minutes after the application of pressure
  • Bleeding is fast and leads to more than a cup of blood loss
  • You are having difficulty breathing
  • Experience vomiting
  • Nosebleed results from a serious head injury

When nosebleeds are unable to be controlled, occur at a high frequency, and/or a prolonged length of time, embolization is recommended to stop the flow of blood to that site. This is a minimally invasive technique in which a small catheter is placed inside the blood vessel that connects to the area that is bleeding. PVA, or polyvinyl alcohol, particles are introduced and used to safely and effectively block the supply of blood that flows to this area.