Arteriovenous malformations of the brain

The dramatic descriptions by Harvey Cushing regarding his experiences operating on “angiomas” of the brain reflected the initial sense of futility in the treatment of arteriovenous malformations (AVMs). Although Cushing and Bailey (1928) and Dandy (1928) published personal case series, it was the development of cerebral angiography in 1927 (Moniz, 1927) that initiated our modern understanding and treatment of AVMs. AVMs are complex vascular lesions that typically present with hemorrhage or seizures. Classically there is no normal intervening brain within an AVM, and the lack of a capillary bed results in fistulous, rapid shunting of blood from the arterial to the venous system. This creates a sump-like effect that may result in relative ischemia of the surrounding brain, or may cause venous congestion and ischemia through arterialization of the normal venous drainage of the brain. These flow-related effects may be responsible for the focal neurological deficits occasionally observed in patients with an AVM. These congenital lesions occur throughout the brain; however, they most often are located supratentorially (90%), and often project in a funnel-like fashion to a ventricular surface deep within the cerebrum.