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Emergency Management of Ruptured Intracranial AVMs
Pearls
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Acute management of ruptured iAVMs is driven by supportive care required for the intraparenchymal hemorrhage. Medical management focuses on seizure prophylaxis, blood pressure control, and intracranial pressure control.
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Structural imaging (CTA/MRA) and cerebral angiography can identify high-risk features and define the angioarchitecture of the iAVM.
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Delayed treatment with surgery 4–6 weeks after the hemorrhage event may bring technical advantages to surgery. The interval acute rerupture rate for iAVMs is low, in contradistinction to ruptured cerebral aneurysms.
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Treatment decisions among endovascular, surgical, or radiosurgery modalities remain unchanged.
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Personal history of iAVM rupture is the strongest predictor of future iAVM-related events and a strong indication for treatment.
Introduction
Intracranial arteriovenous malformations (iAVMs) are a relatively uncommon source of intraparenchymal hemorrhage (IPH). Identifying an iAVM in a patient with a new IPH is essential to guide treatment and therapy options in the acute period. Newly presenting IPHs are related to iAVMs in about 2% of cases. There are no readily identifiable demographics that might make an iAVM more or less likely as the source of a new hemorrhage. Thus a thorough workup in all cases of new IPH is necessary to prevent misdiagnosis. Workup will most often start with noninvasive vessel imaging, by either CT angiography (CTA) or MR angiography (MRA), before moving to formal angiography. Emergency treatment is focused on preventing morbidity and mortality associated with the acute brain injury. The timing and modality of definitive treatment is still debated, but these decisions depend largely on the clinical condition of the patient at presentation and the location of the iAVM.
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