About the treatment

The aim of the treatment is to completely eliminate the AVM to prevent a hemorrhage or to reduce/stop symptoms. There are various treatment techniques to achieve this goal.

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About the treatment

The aim of the treatment is to completely eliminate the AVM to prevent a hemorrhage or to reduce/stop symptoms. Please note that in some cases a treatment cannot be completed in one go.
There are various treatment techniques to achieve this goal. The correct treatment is tailored to the individual patient, as decided by the treatment team of neurosurgeons, neurologists, neuroradiologists and radiotherapists. It is impossible to predict whether a treatment will be successful.

When to treat?

An AVM that has not started hemorrhaging does not always require treatment. In certain cases, treatment is not even the best option. Your general health, age, the position, size and shape of the AVM and the risks of the treatment determine whether the AVM needs to be treated and what the best treatment is. Your desire for treatment plays an important role in this decision. Your treating neurosurgeon or neurologist will discuss this with you at the outpatient clinic.

There may be reasons to treat a non-hemorrhaged AVM, for example to stop or reduce worsening symptoms of the AVM or to prevent them worsening. We will weigh the risks of the treatment against the risk of hemorrhaging.

Complications

Each treatment carries a risk of complications. For example, surgery carries a risk of damage to the brain tissue surrounding the AVM and embolization carries a small risk of blood clots detaching and causing a bleed or lack of oxygen in a part of the brain. The risk of bleeding remains during the first years after Gamma Knife treatment. It is important that the benefits and disadvantages of each form of treatment are weighed and compared to the risk of suffering a hemorrhage if you do not receive treatment. 

Risks 

The risk of a hemorrhage in an AVM that has not started hemorrhaging is 2-3% per year. The risk of a new hemorrhage after a hemorrhage from an AVM is 6-8% per year in the first year after the hemorrhage. This risk decreases to 2-3% per year in subsequent years.

Therefore, having an AVM at a young age and the accumulated risk of the patient’s life expectancy should be taken into consideration when deciding whether to treat the AVM or not.

Surgery

The aim of surgery is to remove all the abnormal blood vessels. The surgeon performs the surgery via a bone flap in the skull using a surgical microscope.

Embolization

A tube is inserted in the femoral artery (in the groin) and moved up to the abnormal blood vessels. The AVM is glued shut with surgical glue and/or filled with platinum coils.

Stereotactic radiation (LINEAC, Gamma Knife)

During radiation treatment, thin beams of radiation are targeted at the AVM from the outside of the skull. The AVM is located exactly in the position where all the beams intersect. The radiation causes the blood vessels to seal off. The result of the radiation treatment can be measured after two to four years.

Combination treatment

It is possible, for example, to treat parts of the AVM via embolization first and then remove the entire remaining AVM by means of surgery at a later stage. By combining the various options, it is sometimes possible to eliminate complicated AVMs.

Treatment via the femoral artery


Preparations

If you decide together with your treating specialist to opt for treatment via the femoral artery, then you will need to undergo certain preparations.

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Preparations

If you decide together with your treating specialist to opt for treatment via the femoral artery, then you will need to undergo certain preparations.
You will be called up to attend the anesthetist’s outpatient clinic (the doctor who administers anesthetic). He or she will assess the risks of administering anesthetic in relation to your general health. Sometimes consultations with other specialists are required. The anesthetist will also give you instructions about the medication that you can or cannot continue using up to the treatment.
The appointment with the anesthetist is usually followed by an appointment with a doctor or nurse practitioner in the Neurosurgery department. The admission consultation and neurological exam will be performed here. You will also receive an explanation about the procedure, any instructions and you can ask questions. You may need to have some blood work done.

Usually you will be admitted in fasting state (nil by mouth) on the morning of the treatment. The nurse will welcome you, prepare you and take you to the treatment room at the correct time.
 

After the treatment

You will remain in the recovery room for several hours after the treatment. If your situation is stable, you will return to your room on the nursing ward.

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After the treatment

You will remain in the recovery room for several hours after the treatment. If your situation is stable, you will return to your room on the nursing ward. The nurse will check you very regularly to monitor your level of consciousness, blood pressure, pupil reflexes and your wound (or the puncture site in the groin). You will be connected to monitoring equipment and IV lines and you will have a urinary catheter. A plaster will cover the wound or puncture site.

Flat bed rest

You will have to lie flat in bed for the first hours after the treatment. You must not bend the leg on the side of the groin that was used for the treatment. If you are taking anticoagulants, then you will usually receive an extra pressure dressing. This dressing will remain in place for several hours and will prevent you from developing a large bruise. The nurse will tell you when you can get out of bed.
Usually the puncture site in the artery will be sealed with an Angio-SealTM. This is a type of plug. In some cases, this is not possible. If this is not possible, pressure will be applied to your groin for 15 to 20 minutes after the catheter is removed. You will then receive a pressure dressing on your groin. The Angio-SealTM dissolves over the course of three months.

What do you need to bring for your admission?

In addition to your daily toiletries, it is best to bring comfortable clothing and underwear, as your groin may feel tender after the treatment. 
The hospital will supply your medication. It is best to bring along your own medication in boxes in case there are any problems with the supply.
Any valuable items can be stored at your own risk in your bedside cabinet with code lock. 

Going home

If you have recovered from the anesthetic and the treatment, then you will be allowed to go home the day after the treatment. You will be given a follow-up appointment with your treating physician for six weeks after the treatment. The ward doctor will discuss the follow-up appointments with you before you are discharged.
Following a treatment via the groin, you are not allowed to do anything that places pressure on the groin for five days after the surgery. For example, you may not lift heavy objects, strain, drive a vehicle or ride a bicycle.
You may shower from 24 hours after the surgery.
If you need to start taking new medication after being discharged, you will be given a prescription. You can take this prescription to any pharmacy.

Problems after discharge

If you experience any of the following symptoms in the week after the treatment, please contact your family physician or the relevant department in your treatment center.

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Problems after discharge

If you experience any of the following symptoms in the week after the treatment, please contact your family physician or the relevant department in your treatment center.
  • you feel more drowsy than usual
  • you feel nauseous or start vomiting
  • you experience loss of function, such as difficulty speaking or reduced strength
  • the wound in the groin starts swelling
  • the wound in the groin becomes red and the pain increases
  • you notice blood, fluid or puss leaving the wound
  • you have no sensation in your leg and/or your leg hurts
  • you have a fever
  • your headache becomes worse

Surgical treatment


Preparations

If you decide together with your treating specialist to opt for surgical removal of the AVM, then you will need to undergo certain preparations.

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Preparations

If you decide together with your treating specialist to opt for surgical removal of the AVM, then you will need to undergo certain preparations.
You will be called up to attend the anesthetist’s outpatient clinic (the doctor who administers anesthetic). He or she will assess the risks of administering anesthetic in relation to your general health. Sometimes consultations with other specialists are required. The anesthetist will also give you instructions about the medication that you can or cannot continue using up to the treatment.
The appointment with the anesthetist is usually followed by an appointment with a doctor or nurse practitioner in the Neurosurgery department. The admission consultation and neurological exam will be performed here. You will also receive an explanation about the procedure, any instructions and you can ask questions. You may need to have some blood work done.

Usually an MRI scan of your brain will be performed the day before the surgery, to determine the exact location of the AVM as navigation for the surgeon. If this MRI takes place before the weekend, then you can stay at home on the weekend. Blood samples will also be collected on the day before surgery.
Usually you will be admitted in fasting state (nil by mouth) on the morning of the surgery. The nurse will welcome you, prepare you and take you to the operating room at the correct time.

After the treatment

After the treatment you may spend a night in Intensive Care or Medium Care, so that your vital signs can be monitored closely.

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After the treatment

After the treatment you may spend a night in Intensive Care or Medium Care, so that your vital signs can be monitored closely. Your treating physician and anesthetist (doctor who administers the anesthetic) will determine if this is necessary.
The nurse will check you very regularly to monitor your level of consciousness, blood pressure, pupil reflexes and your wound (or the puncture site in the groin). You will be connected to monitoring equipment and IV lines and you will have a urinary catheter. A plaster will cover the wound or puncture site.

What do you need to bring for your admission?

In addition to your daily toiletries, it is usually best to bring comfortable clothing. 
The hospital will supply your medication. It is best to bring along your own medication in boxes in case there are any problems with the supply.
Any valuable items can be stored at your own risk in your bedside cabinet with code lock. 

Going home

You will be allowed to go home once you have recovered from the surgery without any problems. This is usually two to three days after the surgery, depending on how you are feeling. You will be given a follow-up appointment with your treating physician for six weeks after the treatment. The ward doctor will discuss the follow-up appointments with you before you are discharged.
You may shower from 24 hours after the surgery.
If you need to start taking new medication after being discharged, you will be given a prescription. You can take this prescription to any pharmacy.
If you have sutures that do not dissolve on their own, your family physician can remove these after eight days. You will receive information about this at discharge.
 

Problems after discharge

If you experience any of the following symptoms in the week after the treatment, please contact your family physician or the relevant department in your treatment center.

read more

Problems after discharge

If you experience any of the following symptoms in the week after the treatment, please contact your family physician or the relevant department in your treatment center.
  • you feel more drowsy than usual
  • you feel nauseous or start vomiting
  • you experience loss of function, such as difficulty speaking or reduced strength
  • the wound in the groin starts swelling
  • the wound in the groin becomes red and the pain increases
  • you notice blood, fluid or puss leaving the wound
  • you have no sensation in your leg and/or your leg hurts
  • you have a fever
  • your headache becomes worse

Stereotactic radiation


Preparations

If you decide together with your treating specialist to opt for treatment using the Gamma Knife, then you will need to undergo certain preparations.

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Preparations

If Gamma Knife treatment is one of the treatment options, then your treating doctor will discuss your details with the Gamma Knife specialist. You will be invited for a meeting in the Gamma Knife Center. If you decide - together with the Gamma Knife specialist - to have this treatment, then a number of preparations will need to take place.

On the day of the treatment, you will be expected in the Gamma Knife Center at the agreed time. You must fast prior to the treatment. A nurse and radiotherapy technician will welcome you and guide you throughout the day.
The treatment starts with the placement of a lightweight metal frame — under local anesthetic — using screws to secure the frame to your head. This frame is necessary in order to draw up and perform an accurate treatment plan. You will receive pain medication via an injection in your thigh and a tablet before the frame is positioned. You will feel pressure in and on the head whilst the frame is being positioned. This pressure eases on its own after a few minutes. During the course of the morning, a plastic helmet will be placed on the frame to determine the dimensions of your head.

Once the frame has been positioned on your head, an MRI scan and angiogram (X-ray of the blood vessels) will be performed. These are necessary to determine the location of the AVM accurately. During the MRI scan, the frame on your head will be attached to the table of the MRI scanner. Please read the leaflet “MRI examination” for more information. A contrast agent will be administered during the angiogram. This contrast agent ensures that the AVM is clearly visible on an X-ray. The contrast agent causes mild side effects, such as a warm sensation moving through the body, a strange taste in the mouth and the urge to urinate. Sometimes you may experience nausea. These symptoms usually disappear after a few minutes. The contrast agent is administered via a thin catheter (tube) in the femoral artery. This catheter is passed through the blood vessels into the region where the contrast agent is required. Once the X-rays have been taken, the catheter will be removed from the artery in the groin and firm pressure will be applied for approximately ten minutes. Following the angiogram, you will go back to your room and will have to lie flat in bed for four hours. The MRI scan and angiogram will take about 1½ hours to complete.

The radiotherapist-oncologist, neurosurgeon and clinical physicist will draw up a treatment plan together. They will calculate how and how often you will need to be moved in the machine, the so-called shots. The amount of time it takes to draw up the plan depends on the malformation. You can remain in your room during this time. Once the plan has been drawn up, it will be sent in digital form to the radiation machine.

You will be secured to the treatment table using the frame. The radiotherapy technician will perform the final checks and will then leave the treatment room and the treatment will start. During the treatment, the abnormality that requires treatment will be placed in the center of the Gamma Knife in a step-by-step manner. This is achieved by moving the table in small increments. You will be positioned in the machine up to your waist to receive the radiation treatment. You will not feel, smell or see any of the radiation used during the treatment. You can talk to the technician via an intercom system during the treatment. The technician can also see you via a camera system. You can also listen to the radio or your own music on CD during the treatment. The duration of the treatment will only be known once the treatment plan has been drafted and the treatment can take several hours.
 

After the treatment

The frame will be removed after the treatment. You may feel pressure in and on the head whilst the frame is being removed, which can cause a headache. You will be able to go home that same day. Bring someone with you as you are not allowed to drive a vehicle yourself.

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After the treatment

The frame will be removed after the treatment. You may feel pressure in and on the head whilst the frame is being removed, which can cause a headache. You can request pain medication if this headache occurs. Once the frame has been removed, you will remain in the room for a short while to rest if necessary.
You will be able to go home that same day. Bring someone with you as you are not allowed to drive a vehicle yourself. You will meet with the radiotherapist-oncologist before going home to discuss the treatment, follow-up and possible side effects once more.

 

Problems after discharge

The screws that were used can cause swelling of the eyelids and/or a numb sensation on the head in the first week after the treatment. There is a risk of damage caused by the treatment itself. Severe, debilitating damage is very rare.

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Problems after discharge

The screws that were used can cause swelling of the eyelids and/or a numb sensation on the head in the first week after the treatment. The swelling will disappear after a few days, the numbness can last a while longer.

Depending on the position of the AVM, hair loss can occur in this area. Usually there are no other symptoms after the treatment. If you do develop acute symptoms, then you can contact the department where you underwent treatment.

There is a risk of damage caused by the treatment itself. Severe, debilitating damage is very rare. The treating physician will discuss the type of damage and the risk of this damage with you. If the risk is too great, then the treatment will not be performed.