Endovascular Approach for Curative Embolization of Brain AVMs: Insights from Angio-architectonics and Angio-anatomy

Cerebral arteriovenous malformations (AVMs) are a type of vascular malformation characterized by the presence of arteriovenous shunting between arteries or arterioles and veins or venules, which exhibit mature vessel wall elements known as the nidus (Valavanis et al., Interv Neuroradiol. 11(Suppl 1):37–43, 2005). AVMs may present with intracranial haemorrhage (45–50%), seizure (30%), headache unrelated to haemorrhage (10–15%), and focal neurological deficits or other symptoms like tinnitus (7–10%) (Valavanis et al., Interv Neuroradiol. 11(Suppl 1):37–43, 2005). They may be asymptomatic and detected incidentally on neuroimaging performed for some other reason in 5–7% of cases (Valavanis et al., Interv Neuroradiol. 11(Suppl 1):37–43, 2005). There are various modalities available for the treatment of cerebral AVMs including microsurgical resection, radiosurgical ablation, endovascular embolization, and their combination (Potts et al., Neurosurg Focus. 37(3):E19, 2014). In general, microsurgery is most often used for superficial, non-eloquent, or ruptured AVMs, while radiosurgery is used for deeper, eloquent lesions that have high surgical risk, and endovascular embolization is used as an adjuvant modality to devascularize an AVM before surgical resection or reduce the size of an AVM to facilitate radiosurgery (Potts et al., Neurosurg Focus. 37(3):E19, 2014). The safety of intervention in the case of unruptured AVMs has been questioned in the ARUBA trial (Mohr et al., Lancet Neurol. 19(7):573–81, 2020). However, the curative role of AVM embolization has been emphasized in numerous studies, and in appropriately selected cases, endovascular embolization of cerebral AVM may achieve complete cure without requiring any other treatment modality, when performed by an experienced neurointerventionalist.