By Matthew E. Fink, MD

Professor and Chairman, Department of Neurology, Weill Cornell Medical College; Neurologist-in-Chief, New York Presbyterian Hospital

Dr. Fink reports he is a consultant for Procter & Gamble and Pfizer.

SOURCE: Josephson CB, et al. Medical vs invasive therapy in AVM-related epilepsy. Neurology 2016;86:64-71.

Treatment of brain arteriovenous malformations (AVMs) is undergoing reevaluation. At the present time, there is evidence to support invasive treatment, i.e., surgery, embolization, or radiation therapy, for brain AVMs after at least one episode of bleeding. However, treatment of unruptured AVMs is uncertain, and whether invasive treatment helps to reduce other symptoms, such as headaches and epilepsy, is unclear at this time. To assess the benefit of AVM treatment for control of associated epilepsy, Josephson et al performed a comprehensive online review of the medical literature to identify controlled observational cohort studies or randomized controlled trials comparing seizure outcomes between invasive AVM treatments vs treatment with anti-epileptic medications. They identified two controlled observational studies and 29 uncontrolled case series. There was only one randomized controlled trial, but this did not report seizure outcomes. By pooling the patient data in all of the studies, they noted that the risk-ratio for freedom-from-seizures in the controlled studies did not indicate superiority to either approach, meaning that invasive therapy and antiepileptic medication treatment were comparable. However, in the various studies, the rate of seizure-freedom varied from 19% to 95%, demonstrating the wide variability in outcomes from various treatment trials, whether they were controlled or not. At the present time, there is insufficient evidence to recommend invasive AVM management to reduce epileptic seizure frequency, and this will have to be evaluated in a long-term randomized, controlled clinical trial.