Intracranial Arteriovenous Malformation (AVM) Repair
What is intracranial arteriovenous malformation (AVM) repair?
Intracranial arteriovenous malformation (AVM) repair is surgery to fix an abnormal connection between blood vessels in the brain. An AVM causes blood to flow directly from the arteries to the veins without supplying blood to the brain tissue. An AVM can cause serious problems with vision, speech, movement and seizures. AVMs can also rupture and bleed causing stroke and death. Intracranial AVM repair prevents or treats these serious problems.
Intracranial AVM repair has serious risks and potential complications. In rare cases, you may have less invasive treatment options. Consider getting a second opinion about all of your treatment choices before having intracranial AVM repair.
Types of intracranial AVM repair
There are different types of intracranial AVM repair procedures or surgeries. Your doctor will decide which type is best for you based on the size and location of the abnormal blood vessels and other factors.
The types of intracranial AVM repairs include:
Endovascular embolization involves inserting a tube (catheter) into a blood vessel and injecting a sticky substance to stop blood flow through the AVM. Sometimes, it is the only treatment that is necessary. It can also help reduce the size of the AVM or lower the risk of bleeding before other procedures or surgery.
Open surgery (resection) involves removing a piece of the skull to access and remove the AVM.
Stereotactic radiosurgery is a type of radiation therapy. It involves focusing small, highly precise doses of radiation into the AVM. This slowly shrinks and destroys abnormal blood vessels. It can treat small AVMs and those that have not caused a life-threatening hemorrhage.
Why is intracranial arteriovenous malformation (AVM) repair performed?
Your doctor may recommend intracranial arteriovenous malformation (AVM) repair to treat an abnormal connection between blood vessels in the brain. An AVM causes blood to flow directly from the arteries to the veins without supplying blood to the brain tissue.
There are many types of AVMs. Many can seriously affect brain functioning and rupture and bleed into the brain (hemorrhagic stroke). The effects of an AVM vary, depending on the location and the presence of bleeding. Symptoms and problems can be permanent, especially if there is bleeding in the brain.
Symptoms and problems include:
Speech, vision or memory problems
Your doctor will consider many factors when deciding which type of intracranial AVM repair is best for you. These include the type, size and location of your AVM, your symptoms, your age and medical conditions, and the risk of AVM rupture and bleeding. Ask your doctor about all of your repair options and consider getting a second opinion.
Who performs intracranial arteriovenous malformation (AVM) repair?
The following specialists perform intracranial arteriovenous malformation (AVM) repair:
Neuroradiologists specialize in diagnosing and treating diseases of the brain and nervous system using radiation and other imaging technologies. They repair AVMs using endovascular embolization and stereotactic radiosurgery.
Neurosurgeons and pediatric neurosurgeons specialize in the surgical care of diseases and conditions of the brain and nervous system. They repair AVMs using open surgery, endovascular embolization, and stereotactic radiosurgery.
How is intracranial arteriovenous malformation (AVM) repair performed?
Your intracranial arteriovenous malformation (AVM) repair will be performed in a hospital. Your doctor will use one of the following approaches:
Endovascular embolization is a minimally invasive procedure. It involves inserting a catheter into a blood vessel in your groin or arm. Your doctor feeds or guides the catheter wire to the area in the brain where the AVM is located. Your doctor uses X-rays to help guide the catheter to the correct position. Once in position, your doctor injects a sticky substance to stop blood flow through the AVM. This reduces the risk of bleeding. Endovascular embolization generally involves a faster recovery and less pain than open surgery. It may be a good option if you are not a candidate for open surgery. Not all AVMs can be repaired with this procedure.
Open surgery (resection) involves removing a piece of the skull to access the AVM directly. Your surgeon will seal off the AVM with clips so it does not bleed. Your surgeon then removes the AVM and reattaches the piece of skull bone. Open surgery allows your doctor to directly view and access the surgical area. Open surgery generally involves a longer recovery and more pain than minimally invasive surgery. Open surgery involves more cutting and displacement of tissues than minimally invasive surgery. Despite this, open surgery may be a safer or more effective method for certain patients.
Stereotactic radiosurgery is a type of radiation therapy. It that involves focusing small, highly precise doses of radiation into the AVM. This slowly shrinks and destroys abnormal blood vessels. You will be fitted with a special head frame and need to lie very still during the painless treatment.
Your doctor will advise you on which procedure is best for you and how long you need to stay in the hospital based on your diagnosis, age, medical history, general health, and possibly your personal preference. Learn about the different intracranial AVM repair procedures and ask why your doctor will use a certain procedure for you.
Types of anesthesia
Your doctor will perform intracranial AVM repair using either general anesthesia or regional anesthesia.
General anesthesia is a combination of intravenous (IV) medications and gases that put you in a deep sleep. You are unaware of the surgery and do not feel any pain.
Regional anesthesia is also known as a nerve block. It involves injecting an anesthetic around certain nerves to numb a large area of the body. To numb a smaller area, your doctor injects the anesthetic in the skin and tissues around the procedure area (local anesthesia). You will likely have sedation with regional anesthesia to keep you relaxed and comfortable.
What to expect the day of your intracranial AVM repair
The day of your surgery or procedure, you can generally expect to:
Talk with a preoperative nurse. The nurse will perform an exam and ensure that all needed tests are in order. The nurse can also answer questions and will make sure you understand and sign the surgical consent form.
Remove all clothing and jewelry and dress in a hospital gown. It is a good idea to leave all jewelry and valuables at home or with a family member. Your care team will give you blankets for modesty and warmth.
Talk with the anesthesiologist or nurse anesthetist about your medical history and the type of anesthesia you will have.
A surgical team member will start an IV.
The anesthesiologist or nurse anesthetist will start your anesthesia.
A tube may be placed in your windpipe to protect and control breathing during general anesthesia. You will not feel or remember this or the surgery as they happen.
The surgical team will monitor your vital signs and other critical body functions. This occurs throughout the procedure and your recovery until you are alert, breathing effectively, and your vital signs are stable.
What are the risks and potential complications of intracranial arteriovenous malformation (AVM) repair?
As with all surgeries, intracranial arteriovenous malformation (AVM) repair involves risks and potential complications. Complications vary, depending on the procedure, but may become serious and life threatening in some cases. Complications can develop during surgery or recovery.
General risks of surgery
The general risks of surgery include:
Anesthesia reaction, such as an allergic reaction and problems with breathing
Bleeding, which can lead to shock or require blood transfusion
Blood clot, such as a deep vein thrombosis (DVT) in the leg or pelvis
Potential complications of intracranial AVM repair
Complications of intracranial AVM repair include:
Damage to blood vessels
Numbness or weakness in any part of the body
Problems with vision, speech, memory, coordination, balance, and muscle control. These can range from mild to severe and can be temporary or permanent.
Swelling of the brain
Reducing your risk of complications
You can reduce the risk of some complications by following your treatment plan and:
Avoiding pregnancy as directed by your doctor. Notify your doctor immediately if there is any chance of pregnancy.
Following activity, dietary and lifestyle restrictions and recommendations before surgery and during recovery
Notifying your doctor immediately of any concerns, such as bleeding, fever, increase in pain, or wound redness, swelling or drainage
Taking your medications exactly as directed
Telling all members of your care team if you have any allergies
How do I prepare for my intracranial arteriovenous malformation (AVM) repair?
You are an important member of your own healthcare team. The steps you take before surgery can improve your comfort and outcome. You can prepare for intracranial arteriovenous malformation (AVM) repair by:
Answering all questions about your medical history, allergies, and medications. This includes prescriptions, over-the-counter drugs, herbal treatments, and vitamins. It is a good idea to carry a current list of your medical conditions, medications, and allergies at all times.
Getting preoperative testing as directed. Testing varies depending on your age, your health, and specific procedure. Preoperative testing may include imaging tests, blood tests, and other tests as needed.
Losing excess weight before the surgery through a healthy diet and exercise plan.
Not eating or drinking before surgery as directed. Your surgery may be cancelled if you eat or drink too close to the start of surgery because you can choke on stomach contents during anesthesia.
Notifying your doctor and care team if you have any type of implant, such as a stent, artificial heart valve, surgical clip, or pacemaker.
Stopping smoking as soon as possible. Even quitting for just a few days can be beneficial and help the healing process.
Taking or stopping medications exactly as directed. This may include not taking aspirin, ibuprofen (Advil, Motrin), and blood thinners.
Questions to ask your doctor
Facing surgery can be stressful. It is common for patients to forget some of their questions during a doctor’s office visit. You may also think of other questions after your appointment. Contact your doctor with concerns and questions before surgery and between appointments.
It is also a good idea to bring a list of questions and a friend or family member to your appointments. Questions can include:
Why do I need intracranial AVM repair? Are there any other options for treating my condition?
Which type of procedure or surgery do I need? Will I need a combination of procedures and surgery?
How long will my repair take? When can I go home?
What restrictions will I have after the repair? When can I return to work and other activities?
What kind of assistance will I need at home?
What medications will I need before and after the surgery? How do I take my regular medications?
How will you treat my pain?
When should I follow up with you?
How should I contact you? Ask for numbers to call during and after regular hours.
What can I expect after my intracranial arteriovenous malformation (AVM) repair?
Knowing what to expect can help make your road to recovery after intracranial arteriovenous malformation (AVM) repair as smooth as possible.
How long will it take to recover?
Recovery will vary, depending on the type of procedure or surgery you had. You will stay in the recovery room after your repair until you are alert, breathing effectively, and your vital signs are stable.
Some people go directly to a neurological intensive care unit (neuro ICU) after open surgery or endovascular embolization. Neuro ICUs provide 24-hour monitoring and highly specialized critical care for people with brain and nervous system diseases and conditions. Some people go home the same day after stereotactic radiosurgery.
It may take a few hours until the major effects of general anesthesia wear off and you are alert. When you wake up, you may have a breathing tube in your mouth and tubes and wires attached to your body. These allow your team to monitor your vital signs and pressure in your brain, drain bodily fluids, take blood, and give medications and fluids.
You will not be able to talk if you have a breathing tube. Your care team usually removes it within a few days. You may have a sore throat from the tube. This is usually temporary, but tell your care team if you are uncomfortable.
You will move to a hospital room outside the neuro ICU as you recover. The length of a hospital stay after intracranial AVM repair varies. It will depend on the type of repair and anesthesia, and your condition, general health, age, and other factors.
Full recovery is a gradual process. Your doctor may refer you to a rehabilitation program to help you recover and improve functioning. Ask your doctor what to expect after your repair and for your recovery.
Will I feel pain?
Pain control is important for healing and a smooth recovery. There will be discomfort after your intracranial AVM repair. Your doctor will treat your pain so you are comfortable and can get the rest you need. Call your doctor if your pain gets worse or changes because it may be a sign of a complication.
When should I call my doctor?
It is important to keep your follow-up appointments after intracranial AVM repair. Contact your doctor for questions and concerns between appointments. Call your doctor right away or seek immediate medical care if you have:
Fever. A low-grade fever (lower than 101 degrees Fahrenheit) is common for a couple of days after surgery and not necessarily a sign of a surgical infection. However, you should follow your doctor's specific instructions about when to call for a fever.
Inability to urinate or have a bowel movement
Numbness or weakness in any part of the body
Pain that is not controlled by your pain medication
Problems with vision, speech, memory, coordination, balance, and muscle control
Unexpected drainage, pus, redness or swelling of your incision
How might intracranial AVM repair affect my everyday life?
Intracranial AVM repair may cure your condition so you can lead an active, normal life. It also causes significant changes that affect your everyday life such as the need to: