Brain AVM and epilepsy

Q) Does the brain AVM treatment improve the seizure outcomes in patient with brain AVM related epilepsy?

A) Seizure is the most common presentation of AVM. Since 1947, there is no randomized controlled trial (RCT) and only 2 case-controlled studies directly compare interventional treatment and conservative treatment. A meta-analysis of 2 case-controlled studies (N=106) conducted by Josephson et al found that the seizure outcomes were not different between 2 groups (the pooled, weighted relative risk of 0.99, (95% CI 0.69-1.43). 

There is also no RCT evaluating different treatment modality and seizure outcomes. The meta-analysis on this topic (2013) reported that the highest rate of seizure free outcome for surgical resection (78%), followed by stereotactic radiosurgery (SRS) (63%) and embolization (49%). Interestingly SRS-treated patients who had complete AVM eradication had the greatest likelihood of seizure free (85%).  Embolization was associated with a significantly greater risk of new onset seizure (39%), surgery (6%) and SRS (5%). Complete eradication of the AVM was the best associated with seizure control.

Recent systematic review and meta-analysis of seizure outcomes after SRS for AVM demonstrated 73% of patients was achieved seizure control (seizure freedom/seizure improvement). Predictor of seizure freedom were generalized seizure (OR: 2.3), history of seizure </= 5 times (OR: 6.8), AVM obliteration (OR=4.61) and previous AVM hemorrhage (OR: 4.83).

In summary, Josephson mentioned that “There is currently insufficient evidence available to determine if invasive AVM management is superior to antiepileptic treatment only for seizure freedom measured at last follow-up.”

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Reference:

  1. Baranoski JF, Grant RA, Hirsch LJ, et al. Seizure control for intracranial arteriovenous malformations is directly related to treatment modality: a meta-analysis. J Neurointerv Surg. 2014;6(9):684-690.

  2. Ironside N, Chen CJ, Ding D, et al. Seizure Outcomes After Radiosurgery for Cerebral Arteriovenous Malformations: An Updated Systematic Review and Meta-Analysis. World Neurosurg. 2018;120:550-562.

  3. Josephson CB, Sauro K, Wiebe S, Clement F, Jette N. Medical vs. invasive therapy in AVM-related epilepsy: Systematic review and meta-analysis. Neurology. 2016;86(1):64-71.