Arteriovenous Malformation (AVM)

Arteriovenous are malformation of the cerebrovascular system in which

tortuous, tangled, and malformed arterial channels drain directly into the
venous system without an intervening capillary bed. The arteries supplying the
AVM tend to dilate with time as a result of increased flow through the lesion.
The veinsenlarge as the flow increases; creating a vicious cycle that can
make this lesion increase in size. This large flow or shunting of the blood
through the AVM can render adjacent areas (and sometimes distal areas) of
the brain ischemic. The high flow state can lead to increased pressure and
eventually hemorrhage, typically into the subarachnoid space and
parenchymal tissue.
Signs and Symptoms
Headache
Seizures
Syncope
Progressive neurologic deficits
Hemorrhage
Physical Examination
Vital signs:

BP: Normotensive or hypertensive

HR: Mild tachycardia may be present
RR: Eupnea
Neurologic: depending on the area of the brain in which the AVM is located,
there may be speech, motor, or sensory deficits. There also may be problems
with vision, memory, and coordination.

Acute Care Patient Management

Nursing Diagnosis: Ineffective tissue perfusion: Cerebral related to
shunting of blood from cerebral tissue and/ or intracerebral hemorrhage (ICH).
Outcome Criteria
Alert and oriented
Pupils equal and normoreactive
BP 90 to 140 mmHg
HR 60 to 100 beats/minute
RR 12 to 20 breaths/minute, eupnea
 Motor function equal bilaterally
Absence of headache, nystagmus, and nausea
Intracranial pressure (ICP) <20 mm Hg
Cerebral perfusion pressure (CPP) 60 to 100 mm Hg
Nursing Interventions
Patient Monitoring
1. Monitor ECG continuously because hypoxemia and cerebral
bleeding are risk factors for pronounced ST segment and T-wave
changes and life-threatening dysrhythmias.
2. Monitor ICP, analyze the ICP waveform, and calculate CPP
every hour.
3. Monitor BP and pulse every 15 to 30 minutes initially, then
hourly.
4. Obtain CVP and/ or PA pressures if available, every hour or
more frequently if indicated.
Patient Assessment
1. Assess pain using the patients self-repot whenever possible.
2. Note headache onset and severity; presence of stiff neck; and
insidious onset of confusion, disoreintatio, decline in
consciousness, and/or focal deficits (weakness of extremity).
3. Assess neurologic status using Glascow Coma scale and assess
for changes suggesting increased ICP and herniation.
4. Be alert for subtle changes and new focal deficits.
5. Assess for factors that can cause increased ICP, evaluate the
patient for restlessness, distended bladder, constipation,
hypovolemia, headache, fear, or anxiety.
Diagnostic Assessment
Review serial ABGs for decreasing Pao2 (<60 mm Hg) or
increasing Paco2 (.40 mm Hg) to identify causes for increased
ICP.
Nursing Interventions
1. Maintain patent airway and administer oxygen as ordered to
prevent hypoxemia.
2. Institute measures to minimize external stimuli and maintain
BP level.
3. Administer antihypertensive drugs as ordered. To control blood
pressure.
4. Sedatives and stool softeners may be prescribed to reduce
agitation and straining.
5. Anticipate interventions such as embolization, resection,
clipping, ligation of feeding vessels, proton-beam therapy, or
gamma radiation.

Cerebrovascular accident, also known as stroke, cerebral infarction, brain attack, is any
functional or structural abnormality of the brain caused by pathological condition of the
cerebral vessels of the entire cerebrovascular system. It is the sudden impairment of
cerebral circulation in one or more of the blood vessels supplying the brain. This pathology
either causes hemorrhage from a tear in the vessel wall or impairs the cerebral circulation
by a partial or complete occlusion of the vessel lumen with transient or permanent effects.
The sooner the circulation returns to normal after a stroke, the better the chances are for
complete recovery. However, about half of those who survived a stroke remain disabled
permanently and experience the recurrence within weeks, months, or years.

Thrombosis, embolism, and hemorrhage are the primary causes for CVA, with thrombosis
being the main cause of both CVAs and transient ischemic attacks (TIAs). The most
common vessels involved are the carotid arteries and those of the vertebrobasilar system at
the base of the brain.

A thrombotic CVA causes a slow evolution of symptoms, usually over several hours, and is
completed when the condition stabilizes. An embolic CVA occurs when a clot is carried
into cerebral circulation and causes a localized cerebral infarct. Hemorrhagic CVA is
caused by other conditions such as a ruptured aneurysm, hypertension, arteriovenous (AV)
malformations, or other bleeding disorders
Cerebral arteriovenous malformation

A cerebral arteriovenous malformation is an abnormal connection between the arteries

and veins in the brain that usually forms before birth.

Causes
The cause of cerebral arteriovenous malformation (AVM) is unknown. The
condition occurs when arteries in the brain connect directly to nearby veins
without having the normal vessels (capillaries) between them.

AVMs vary in size and location in the brain.

An AVM rupture occurs because of pressure and damage to blood vessel

tissue. This allows blood to leak (hemorrhage) into the brain or surrounding
tissues, and reduces blood flow to the brain.

Cerebral AVMs are rare. Although the condition is present at birth, symptoms
may occur at any age. Hemorrhages occur most often in people ages 15 to
20. It can also occur later in life. Some people with an AVM also have brain
aneurysms.

Symptoms
In about half of people with AVMs, the first symptoms are those of
a stroke caused by bleeding in the brain.
 Symptoms of an AVM that is bleeding are:

Confusion

Ear noise/buzzing (also called pulsatile tinnitus)

Headache in one or more parts of the head, may seem like a migraine
Problems walking

Seizures

Symptoms due to pressure on one area of the brain include:

Vision problems
Dizziness

Muscle weakness in an area of the body or face

Numbness in an area of the body

Exams and Tests

A complete physical examination and neurologic examination are needed.

Tests that may be used to diagnose an AVM include:

Brain angiogram
Computed tomography (CT) angiogram

Head MRI
Electroencephalogram (EEG)
Head CT scan
Magnetic resonance angiography (MRA)
Magnetic resonance veinogram

Treatment
Finding the best treatment for an AVM that is found on an imaging test but is
not causing any symptoms can be difficult. Your doctor will discuss with you:

The risk that your AVM will break open (rupture). If this happens, there may
be permanent brain damage.

The risk of any brain damage if you have one of the surgical treatments listed
below.
 Your doctor may discuss different factors that may increase your risk of
bleeding, including:

Current or planned pregnancies

What the AVM looks like on imaging tests

Size of the AVM

Your age

Your symptoms

A bleeding AVM is a medical emergency. The goal of treatment is to prevent

further complications by controlling the bleeding and seizures and, if
possible, removing the AVM.

Three surgical treatments are available. Some treatments are used together.

Open brain surgery removes the abnormal connection through an opening

made in the skull.

Embolization (endovascular treatment):

A catheter is guided through a small cut in your groin to an artery and then to
the small blood vessels in your brain where the aneurysm is located.

A glue-like substance is injected into the abnormal vessels to stop blood flow
in the AVM and reduce the risk of bleeding. This may be the first choice for some
kinds of AVMs, or if surgery cannot be done.

Stereotactic radiosurgery:

Radiation is aimed directly on the area of the AVM. This causes scarring and
shrinkage of the AVM and reduces the risk of bleeding.

It is particularly useful for small AVMs deep in the brain that are difficult to
remove by surgery.

Anticonvulsant medicines are usually prescribed if seizures occur.

 Outlook (Prognosis)
1 in 10 people whose first symptom is excessive brain bleeding will die.
Some people may have permanent seizures and brain and nervous system
problems.

AVMs that do not cause symptoms by the time people reach their late 40s or
early 50s are more likely to remain stable and rarely cause symptoms.

Possible Complications
Complications may include:

Brain damage

Intracerebral hemorrhage

Language difficulties

Numbness of any part of the face or body

Persistent headache

Seizures

Subarachnoid hemorrhage
Vision changes

Water on the brain (hydrocephalus)

Weakness in part of the body

Possible complications of open brain surgery include:

Brain swelling

Hemorrhage

Seizure

Stroke