Arteriovenous Malformations and Intracranial Dural Arteriovenous Fistulae in the Intensive Care Unit

Brain arteriovenous malformations (bAVM) and dural arteriovenous fistulae (dAVF) represent two classical causes of intracranial hemorrhage. They may also cause epilepsy, and, especially for dAVF, venous cerebral edema. Neurological symptoms resulting from such complications may require the admission of the patient in an intensive care unit. bAVM and dAVF are usually detected, or at least suspected, with non-invasive imagings and especially with brain MRI. However, conventional digital subtraction angiography should be performed to confirm the diagnosis and to evaluate the therapeutic options. Diagnosis of dAVF may be difficult in some patients with edematous complications, since an inflammatory demyelinating disease of the central nervous system may be suspected. In questionable cases, conventional digital subtraction angiography should be performed prior to lumbar puncture because subtraction of cerebrospinal fluid may worsen neurological symptoms of patients with dAVF. Lumbar puncture may also lead to a bleeding in the perimedullary space through the perforation of a draining vein. A multidisciplinary approach, including interventional neuro-radiologists, neurosurgeons, and neurointensivists, is essential for patients with complications of bAVM and dAVF requiring intensive care. The endovascular approach with embolization is often preferred to neurosurgery; however, embolization must not delay a decompressive surgery in patients with major intracranial hypertension or brain herniation. In these patients, the surgical cure of the bAVM or of the dAVF may be performed in the same surgical time. The cure of a dAVF with hemorrhagic complication should be performed during the first 24 h. Conversely, the treatment of hemorrhagic bAVM is usually delayed.