Surgery cuts down AVM risks

By Maria Endah Hulupi

JAKARTA (JP): Eighteen-year-old Maulana fell and suffered a head injury. The doctors allowed him to go home after he received treatment for it.

Maulana's life returned to normal, but two years later, he suffered severe headaches, seizures, vomiting and became half- paralyzed. He was later diagnosed with multiple Arterio-Venous Malformation (AVM) and was referred to a hospital in Tangerang for endovascular surgery.

AVM, according to Prijo Sidipratomo, a radiologist at the University of Indonesia, is a short circuit which takes place because the artery, which is responsible for transporting red oxygenated blood from the heart, feeds blood directly to the vein carrying deoxygenated blood, without passing through capillary vessels.

This condition will increase pressure in the vein and, over the years, damage vessels, making them prone to ruptures, which in turn, affects connecting veins and arteries. The area of the connection is called the shunt and the location of the AVM is the nidus.

"AVM is asymptomatic and patients know they have it only when it ruptures. However, patients may complain of headaches, seizures, blurred vision, partial paralysis and speech problems," said Prijo, who is also a radiologist with Siloam Gleneagles Hospital, in Tangerang.

A neurosurgeon with the hospital, Eka J. Wahjopramono, warned that failing to detect AVM could lead to ruptures and in turn cause hemorrhaging in the brain.

"This would put pressure on a part of the brain, causing stroke-like symptoms, which could be fatal," he said during a news conference to mark the hospital's fifth anniversary.

AVM, he said, carried a significant risk of disability and death among younger people.

So how can we know if a person has AVM or not?

Prijo said AVM could be confirmed by a computer-assisted tomography (CT) scan, an angiogram to give an image of the brain's major blood vessels and magnetic resonance imaging (MRI) to generate the brain's image using a magnetic field.

AVM treatments include microsurgery, open surgery or a combination of the two, depending on the size of the AVM, its location and the degree of the shunt.

Microsurgery, also called endovascular surgery, is performed by inserting a long, thin, flexible micro catheter through a femoral artery (in the leg) and directing it to the artery that feeds the AVM area. Once the catheter is there, a balloon is released and expanded to separate the veins and arteries and the catheter is then withdrawn. The catheter can also release glue on the nidus to block the vessels that feed the AVM.

"The advantages of the procedures are it doesn't require a craniotomy or opening the skull. It is a low-risk procedure and can reach deep-seated vascular problems in the brain," Prijo said.

Doctors, according to Eka, would reconsider the need to perform surgery to remove the abnormal vessels of AVM once it has been glued.

"If bleeding occurs, open surgery can be performed for hematome evacuation and decompression," Eka said.

Aside from AVM, Prijo said endovascular surgery could be performed to treat various neuro-vascular irregularities that block the flow of blood, which supplies oxygen and nutrients to the brain. It can also be performed on aneurysms (a dilation of the artery in the brain that can lead to stroke caused by hemorrhaging), arterial clogging due to plaque that builds up in the brain's blood vessel or leading to the brain and blood clots that lodge in the brain vessel, which can also lead to stroke.

So far, endovascular surgery can be done at Gleneagles, which is equipped for the procedure. The hospital aims at developing neuroscience in Indonesia to provide proper treatment for neuro- related diseases without having to obtain it abroad.

Performing endovascular surgery in Indonesia would significantly slash costs with the only major expenses being the use of imported disposable tools, such as balloons, catheters and coils.

"But most importantly we would be able to provide immediate treatment, which is important to treat neuro-vascular irregularities. Delayed treatment can be serious and fatal," Eka said.

The hospital has also set up the National Brain Foundation, which is funded by companies grouped under the Lippo Group, to help finance patients with neuro-vascular problems.

"Every year, we plan to support treatment for 100 patients," Eka said.