Masterclass #2: A deep AVM is not a cortical AVM deeply located. Its impact on endovascular management

Adam S. ARTHUR, Uday LIMAYE, Jacques MORET, Laurent SPELLE

What’s really at stake when dealing with a deep intracranial arteriovenous malformation (AVM) – Is it the deep location, the complexity of the venous drainage…or both? Why do certain AVMs rupture?

Join Professors Jacques Moret, Laurent Spelle and their expert international panel as they explore the challenge of treating AVMs in two specially chosen cases:

• What do we know about venous drainage – the vast territory that must be understood for AVM management? How do we control the complex connections involved with an AVM, where any change can be deleterious – the veins of the surface of the ventricle, the veins of the white matter, the reflux through the veins of the white matter, all hyper-pressurized?
• What do we know about the variability and functionality of the deep venous system? Venous drainage can be variable too – the strategy that works in one patient might not work in another.

• What are our non-endovascular options: Can heparin be used? Surgery?

The two cases that follow are very different. Both are in locations where the deep venous anatomy is central to understanding how to treat the disease.

• But are they both true AVMs? What features set them apart?
• Could the second be a cortical AVM in a deep location independent of the deep venous drainage?
• How bad is a partial cure?

As the cases proceed, from the initial punctures to the embolization procedures themselves, follow each step:

• Tips and tricks such as the technique of curving the wire to help it advance through the thalamic perforators, or the chemical and mechanical effect that takes place when you pull on the microcatheter.
• As the nidus is approached, and the injection of the embolic agent begins, see how the reflux – the cork effect – is employed.
• What do you do as the “door opens” and the embolic agent enters the nidus of the malformation – keep pushing?
• As you approach the venous system, how do you check for stagnation or an occluded vein?

How do you know when to stop filling and decide the intervention is over?