THERAPY FOR CEREBRAL ARTERIOVENOUS-MALFOR MATIONS

The rapid development of modern endovascular,microsurgical,and radiati on therapies has considerably expanded the treatment options for encep halic arteriovenous malformations (AVMs). Surgery has the longest hist ory. Single or staged intravascular procedures (embolizations) using f ast-acting glues, sclerotic agents, and thrombogenic coils serve to re duce the size of AVM to that suitable for extirpation and may reduce t he risk of surgery. Radiation (''gamma-knife'') therapy, most frequent ly used in small, non-operable AVMs, is also viewed by some authors as an alternative or even superior tool in small, operable malformations . Partial embolization to reduce the mass-effect of space-occupying AV Ms,to reverse diaschisis, and to treat AVM-related seizure disorders i s being discussed and practiced. Given the in part competing or even c ontroversial options, the selection of optimal treatment for AVM patie nts is becoming increasingly difficult. Current management is impeded by the paucity of information on the exact risks of invasive therapies and by insufficient criteria for identifying patients at risk of spon taneous bleeding during the natural course, including the seriousness of such hemorrhage.