Hemodynamic aspects of cerebral arteriovenous malformations

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✓ Local hemodynamics were studied in 16 patients undergoing total extirpation of cerebral arteriovenous malformation (AVM). Directional Doppler technique was used for the registration of blood velocities in vessels feeding and draining the AVM. Calculated flow in single feeding arteries ranged from 3 to 550 ml/min (average, 180 ml/min). An estimation of total AVM flow was possible in nine patients, and ranged from 150 to more than 900 ml/min (average, 490 ml/min). Pressure recordings were made from feeding arteries at their entrance to the AVM. This pressure was well below the systemic arterial blood pressure in all cases, and ranged from 40 to 77 mm Hg (average, 56 mm Hg). On temporary occlusion, this stump pressure instantly rose to from 55 to 95 mm Hg (average, 76 mm Hg). Draining vein pressure before occlusion ranged from 8 to 23 mm Hg (average, 15 mm Hg), and fell to zero in all patients when the AVM was occluded. These data and other clinical observations are discussed with regard to adjacent brain-tissue perfusion, and with special emphasis on the circulatory breakthrough that can follow the occlusion of these high-capacity shunts.

Article Information

Address reprint requests to: Helge Nornes, M.D., Department of Neurosurgery, National Hospital of Norway, Rikshospitalet, Oslo, Norway.

© AANS, except where prohibited by US copyright law.

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Figures

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    Upper: Flow from a reservoir through a tube, with side tubes showing a pressure drop (ΔP) with the faucet open. When the faucet is closed, the pressure in the side tubes equals the reservoir level. The model mimics pressure conditions (ΔPfeeder) from the systemic arterial blood pressure (ABPsystemic) up to the terminal ABP of the feeder. Lower: Pressure recordings proximal and distal to the AVM giving a pressure drop in the feeder (ΔPshunt).

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    Inner diameter of the feeding arteries plotted against time-average blood flow velocity in the 16 patients. Lines connect Figures obtained from different arteries in the same patient.

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    Case 8. Tracings of blood velocities in the main draining vein. Vmax is the maximal flow velocity component within the vessel; Vmean is the average of velocities across the vessel lumen, and must not be confused with the time-average velocity (¯V). This recording was made about 3 to 4 cm distal to the actual arteriovenous malformation. ABPsystemic = systemic arterial blood pressure.

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    Intravascular pressure data from the eight patients summarized in Table 1, showing a pressure drop in the entire shunt system before extirpation of the arteriovenous malformation (AVM). ABP = arterial blood pressure; VBP = venous blood pressure.

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    Upper: Main feeder pressure recording from Case 7 at three consecutive test occlusions showing the marked “stump” pressure. ABP = arterial blood pressure. Lower: Angiograms are shown at the arterial phase (left) and venous phase (right).

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    Recordings from Case 4. A: Electromagnetic flow tracing and intravascular pressure from the main feeder proximal to the arteriovenous malformation (AVM). Test occlusion distal to the recording site shows a drop in flow to zero and marked “stump” pressure. Note the return of variables to previous levels when the clip was released. Absence of postocclusive overshoot in flow demonstrates nonregulation of this system. B: Effect on blood pressure in the main draining vein at main feeder occlusion. Venous pressure fell to zero at full occlusion of all inflow channels (not shown).

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    Case 4. Angiogram, arterial phase. The recording site is about 2 cm proximal to the arteriovenous malformation.

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    Plots showing intravascular pressure data from the eight patients summarized in Table 1. Left: Instant rise in feeder arterial blood pressure at test occlusion (“stump” pressure). Right: Plot showing a calculated rise in local cerebral perfusion pressure at arteriovenous malformation (AVM) exclusion for adjacent areas dependent on these inflow and outflow channels. Arrows point to cases with regional brain swelling (SW) subsequent to AVM extirpation. See also Table 1.

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