From the Guidelines
Seizures due to arteriovenous (AV) malformations should be managed with antiepileptic drugs (AEDs) until definitive surgical treatment can be performed, with the goal of reducing seizure activity and improving quality of life. The management of seizures prior to surgical intervention is crucial to prevent further brain damage and improve patient outcomes. According to the American Heart Association scientific statement 1, obliteration of AVMs may reduce the incidence of seizures, and several reports have documented the efficacy of surgical resection of AVMs in decreasing the seizure rate.
Medication Selection
First-line medications for seizure management include:
- Levetiracetam (Keppra) at 500-1500 mg twice daily, which is often preferred due to its favorable side effect profile and minimal drug interactions
- Lamotrigine (starting at 25 mg daily and gradually increasing to 100-200 mg twice daily)
- Carbamazepine (200-400 mg twice daily)
- Valproic acid (500-1000 mg twice daily) Medication selection should be individualized based on seizure type, patient characteristics, and potential side effects 1.
Seizure Precautions
Beyond medication, patients should:
- Avoid seizure triggers such as alcohol, sleep deprivation, and excessive stress
- Follow seizure precautions including avoiding swimming alone, not driving until cleared by a physician, and educating family members about seizure first aid Regular monitoring of drug levels and liver function may be necessary for certain AEDs.
Goal of Treatment
The goal of treatment is to achieve seizure control while minimizing side effects until the underlying AV malformation can be surgically addressed, with the ultimate goal of improving patient outcomes and reducing morbidity and mortality 1.
From the Research
Management of Seizures due to Arteriovenous (AV) Malformation
- The management of seizures due to AV malformation prior to surgical intervention involves medical treatment, with the goal of controlling seizures and preventing further complications 2, 3.
- Antiepileptic treatment strategy plays an important role in the management of intracranial vascular malformations, including AV malformations 3.
- The decision to use antiepileptic drugs is based on various factors, including the type and severity of seizures, the presence of other symptoms, and the patient's overall health status 3.
- Levetiracetam is a commonly used antiepileptic drug for seizure prophylaxis in patients with intracerebral hemorrhage, traumatic brain injury, supratentorial neurosurgery, and spontaneous subarachnoid hemorrhage, but its efficacy and optimal dosing for AV malformation-related seizures are unclear 4.
Factors Influencing Seizure Risk
- The risk of seizures in patients with AV malformations is influenced by various factors, including the size and location of the malformation, as well as the presence of other symptoms such as hemorrhage 5.
- AVMs larger than 4 cm and those fed by dilated arterial feeders are associated with an increased risk of seizures 5.
- Cortical AVMs and those fed by middle and posterior cerebral arteries branches are also more likely to be associated with seizures 5.
Treatment Outcomes
- Surgical resection of AV malformations can be effective in controlling seizures, with some studies reporting seizure freedom rates of up to 61.54% 6.
- The use of embolization and other treatment modalities may also be effective in controlling seizures, although the outcomes may vary depending on the individual patient and the specific treatment used 6.
- Long-term outcomes of AV malformation-related epilepsy are poorly characterized, but studies suggest that treatment of the underlying malformation can improve seizure outcomes 6.