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so an AVM is an abnormal tangle vessels
where arteries connect through a tangle
of weakened vessels to a vein normally
arteries divide into ever smaller
vessels until you get to the capillary
level where the vessels are very tiny
and at that level capillaries can unload
oxygen and nutrients and pick up co2 and
then from there the blood is collected
by small veins that go into ever larger
veins but then go back to the heart with
an AVM however the arteries connect to a
tangle of weakened arteries and that
flow goes right into a vein so as a
result the veins see arterial pressure
normally venous pressure is much lower
than arterial pressure when an AVM the
veins are at under high pressure and
veins don't like high pressure so that
tends to lead to inflammation and
sometimes aneurysms can form and those
aneurysms can lead to rupture and when
an AVM bleeds that can be occasionally
catastrophic or lead to neurological
injury it would be the equivalent of a
column that's designed to hold up a
cardboard roof putting a cement roof on
that on that column will result in the
column collapsing
so one of the challenges with
understanding a vm's and their treatment
options is the fact that they are very
complicated three-dimensional structures
that we often see 2d images and we try
to you look at 2d images to understand a
three-dimensional problem so we've been
using 3d printing and holography to try
to get a better understanding of the m1
for the benefit of the treating team so
that we can better think through what we
may or may not be able to do for the
patient but the second is to also
educate the patient regarding their
problem so this is a 3d print of an AVM
here you can see some normal vessels and
we can see here is what I would call the
bowl of spaghetti these are fragile
vessels that can pop easily they're not
used to or they're not designed to carry
high pressure so they can break and
rupture and that can cause brain
bleeding so as we look at this model we
can start to rotate it and think about
what vessels are coming into it that's
what we call feeding arteries abnormal
vessels that come into this tangle the
spaghetti bowl so to speak and what you
don't see on this model clearly is that
there's usually a vein coming out and
when we go in with surgery we usually
our goal is to separate this mass from
the surrounding brain tissue safely
while preserving the normal arteries and
removing it from the patient that may or
may not be safe depending on the
specific anatomy of that patient
additionally an AVM of this size for
example it may be very beneficial to
inject some glue into the AVM before
surgery to make the surgery safer so
what we would do is under fluoroscopy we
would navigate a very tiny catheter and
let's say this artery and get into an
artery where it would be safe to inject
glue into the AVM we would watch glue
percolate into the AVM plugging up these
no abnormal small arteries and that may
make the surgical plan and execute the
surgical option much much easier to
implement just like snowflakes are no
two AVM that are the same every AVM is
different because it how close you look
and our treatment plans also have to be
unique and uniquely designed to match
the needs of the patient so the
treatment options for AVM include micro
surgery that's where we threw at crania
a cranial opening in using the operating
microscope we can look at the anatomy of
the AVM and disconnect the abnormal
arteries from the surrounding
circulation
remove the AVM the second treatment
option is embolization where a catheter
the size of an angel hair pasta can be
placed into the AVM and glue can be
injected to occlude those abnormal
vessels to make them put to plug them up
that can be done in some cases to
completely cure an AVM typically for
smaller AVM that have one or two feeders
the other treatment option for a TMS is
radiosurgery or we use radiation to
shrink an AVM that treatment has the
advantage of being minimally invasive
essentially and it's an outpatient
procedure but it does take several years
to work so patients can continue to have
risk of bleeding during that period but
for ATMs that cannot be removed
surgically for ATMs that are in
locations that are undesirable from a
surgical standpoint or in patients who
cannot tolerate surgery either due to
age or other comorbidities radiosurgery
may be a good option
another option for larger AVM is to do
is to use staged radiosurgery where we
treat the AVM in different pieces so if
an AVM is too big for a single shot of
radiation we can potentially break it up
into two or three pieces and do it over
the course of three to six months and
finally of course though there is an
innovative option for some AVMs and
that's proton beam therapy and proton
beam therapy has been used successfully
treat certain AVMs
but again the treatment does take time
and not all AVMs can be occluded with
this technique so each of these
techniques has pros and cons it's
important for every patient who would
like to treat their AVM to really
carefully get educated about all those
treatment options and how they can
potentially work together patients with
AVM should have hope and AVMs can be
scary but with modern treatments there
has never been a better time in the
history maybe I'm treatment for patients
with Amiens
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