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Onyx Embolization Before the Surgical Treatment of Grade III Spetzler-Martin Brain Arteriovenous Malformations: Single-Center Experience and Technical Nuances. World Neurosurg 2018; 116:e340-e353. [DOI: 10.1016/j.wneu.2018.04.203] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 04/26/2018] [Accepted: 04/27/2018] [Indexed: 11/15/2022]
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Delayed hemorrhagic complication after complete embolization of a brain arteriovenous malformation. Neurochirurgie 2018; 64:316-320. [PMID: 29908698 DOI: 10.1016/j.neuchi.2018.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 02/20/2018] [Accepted: 04/13/2018] [Indexed: 11/20/2022]
Abstract
Endovascular embolization is an essential therapeutic approach in the multidisciplinary management of cerebral arteriovenous malformations (AVM). However, it rarely occludes the AVM in its entirety. It is often combined with surgery or stereotactic radiosurgery. The aim of embolization is to reduce the size of the nidus and the intra-nidal flow in order to facilitate the microsurgical or the radiosurgical procedure. We report the case of a 61-year-old patient with a right frontal hemorrhagic AVM treated with complete embolization in a single session. Initially, a surgical procedure for excision of the AVM was scheduled 24hours post-embolization. This surgery was canceled due to a good angiographic result of the embolization. Eight days post-embolization, there was a massive re-bleed of the AVM which justified emergency surgical management. This case illustrates a delayed post-embolization hemorrhagic complication of an occluded AVM and prompts a review of the therapeutic strategy of the cerebral AVM to select the most effective and least morbid procedure or combination of procedures.
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He Y, Bai W, Li T, Hui FK, He Y, Xu B. Curative Transvenous Embolization for Ruptured Brain Arteriovenous Malformations: A Single-Center Experience from China. World Neurosurg 2018; 116:e421-e428. [PMID: 29753079 DOI: 10.1016/j.wneu.2018.04.223] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 04/28/2018] [Accepted: 04/30/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate feasibility and safety of transvenous embolization for brain arteriovenous malformations (AVMs). METHODS Between November 2016 and August 2017, a transvenous endovascular embolization protocol was implemented at the Henan Provincial People's Hospital for consecutive patients with ruptured brain AVMs. Therapeutic decision making was based on Spetzler-Martin grade, brain AVM location, pattern of venous drainage, and angioarchitecture. Transvenous embolization was combined with transarterial support. Complete angiographic obliteration of the nidus was the objective of treatment. RESULTS Among 10 patients with ruptured brain AVMs, 8 were male. Spetzler-Martin grades before transvenous embolization were IV in 3 patients, III in 5 patients, II in 1 patient, and I in 1 patient. Modified Rankin Scale score before the procedure was 0-2 for 6 of 10 patients. Five patients also had deep venous drainage. Arterial blood pressure control and venous pressure cooker technique were used in all 10 patients; 9 patients had immediate angiographic occlusion. Two patients had a ventricular hemorrhage, which did not cause any disability after medical treatment. Seven patients underwent angiography 3-5 months after the procedure, and complete obliteration of the nidus was confirmed. Median clinical follow-up for all 10 patients was 8 months (range, 3-12 months). Epilepsy occurred in 1 patient 3 months after the procedure, and modified Rankin Scale scores for all patients were ≤1. CONCLUSIONS Transvenous embolization of brain AVMs is feasible and may improve cure rates. The safety and long-term effects need further validation.
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Affiliation(s)
- Yingkun He
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, China
| | - Weixing Bai
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, China
| | - Tianxiao Li
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, China.
| | - Ferdinand K Hui
- Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yanyan He
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, China
| | - Bin Xu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, China
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Jin H, Huo X, Jiang Y, Li X, Li Y. Safety and efficacy of endovascular therapy and gamma knife surgery for brain arteriovenous malformations in China: Study protocol for an observational clinical trial. Contemp Clin Trials Commun 2018; 7:103-108. [PMID: 29696173 PMCID: PMC5898568 DOI: 10.1016/j.conctc.2017.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/09/2017] [Accepted: 06/20/2017] [Indexed: 11/08/2022] Open
Abstract
Introduction Brain arteriovenous malformations (BAVMs) are associated with high morbidity and mortality. The treatment of BAVM remains controversial. Microinvasive treatment, including endovascular therapy and gamma knife surgery, has been the first choice in many conditions. However, the overall clinical outcome of microinvasive treatment remains unknown and a prospective trial is needed. Methods This is a prospective, non-randomized, and multicenter observational registry clinical trial to evaluate the safety and efficacy of microinvasive treatment for BAVMs. The study will require up to 400 patients in approximately 12 or more centers in China, followed for 2 years. Main subjects of this study are BAVM patients underwent endovascular therapy and/or gamma knife surgery. The trial will not affect the choice of treatment modality. The primary outcomes are perioperative complications (safety), and postoperative hemorrhage incidence rate and complete occlusion rate (efficacy). Secondary outcomes are elimination of hemorrhage risk factors (coexisting aneurysms and arteriovenous fistula), volume reduction and remission of symptoms. Safety and efficacy of endovascular therapy, gamma knife surgery, and various combination modes of the two modalities will be compared. Operative complications and outcomes at pretreatment, post-treatment, at discharge and at 3 months, 6 months and 2 years follow-up intervals will be analyzed using the modified Rankin Scale (mRS). Discussion The most confusion on BAVM treatment is whether to choose interventional therapy or medical therapy, and the choice of interventional therapy modes. This study will provide evidence for evaluating the safety and efficacy of microinvasive treatment in China, to characterize the microinvasive treatment strategy for BAVMs.
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Key Words
- BAVMs, Brain arteriovenous malformations
- Brain arteriovenous malformation
- CRF, Case report form
- CT, Computed tomography
- ChiCTR, Chinese Clinical Trial Registry
- Clinical trial
- Efficacy
- Endovascular therapy
- FDA, Food and Drug Administration
- Gamma knife
- ICH, Intracerebral hemorrhage
- PRC, People's Republic of China
- REAL-CHINA, Registry of endovascular therapy and Gamma knife surgery for brain Arteriovenous Malformation in China
- SAE, Serious adverse event
- SM, Spetzler Martin grade
- SPIRIT, Recommendations for Interventional Trials
- Safety
- mRS, modified Ranking Scale
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Affiliation(s)
- Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, 100050, Beijing, China.,Beijing Engineering Research Center for Interventional Neuroradiology, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, 100050, Beijing, China
| | - Yuhua Jiang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, 100050, Beijing, China.,Beijing Engineering Research Center for Interventional Neuroradiology, China
| | - Xiaolong Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, 100050, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, 100050, Beijing, China.,Beijing Engineering Research Center for Interventional Neuroradiology, China
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55
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Gorozhanin VA, Pilipenko YV, Belousova OB, Eliava SS. [Microsurgical treatment of non-bleeding cerebral arteriovenous malformations]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2018; 82:119-124. [PMID: 30412165 DOI: 10.17116/neiro201882051119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Treatment of non-bleeding cerebral arteriovenous malformations (AVMs) causes a lot of controversy among neurosurgeons around the world. The most discussed issue is choosing the method and indications for a certain treatment option. Despite the accumulated data, including the results of randomized studies, there is no consensus on this issue among experts. The purpose of this review is to analyze current concepts of the management and reasonability of microsurgical treatment of non-bleeding cerebral AVMs based on the latest published studies.
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Affiliation(s)
| | | | | | - Sh Sh Eliava
- Burdenko Neurosurgical Institute, Moscow, Russia
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56
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Mendes GAC, Kalani MYS, Iosif C, Lucena AF, Carvalho R, Saleme S, Mounayer C. Transvenous Curative Embolization of Cerebral Arteriovenous Malformations: A Prospective Cohort Study. Neurosurgery 2017; 83:957-964. [DOI: 10.1093/neuros/nyx581] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 11/14/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- George A C Mendes
- Department of Interventional Neuro-radiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - M Yashar S Kalani
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Christina Iosif
- Department of Interventional Neuro-radiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - Adson F Lucena
- Department of Interventional Neuro-radiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - Rui Carvalho
- Department of Interventional Neuro-radiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - Suzana Saleme
- Department of Interventional Neuro-radiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - Charbel Mounayer
- Department of Interventional Neuro-radiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
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Fennell VS, Martirosyan NL, Atwal GS, Kalani MYS, Ponce FA, Lemole GM, Dumont TM, Spetzler RF. Hemodynamics Associated With Intracerebral Arteriovenous Malformations: The Effects of Treatment Modalities. Neurosurgery 2017; 83:611-621. [DOI: 10.1093/neuros/nyx560] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 10/13/2017] [Indexed: 12/22/2022] Open
Abstract
Abstract
The understanding of the physiology of cerebral arteriovenous malformations (AVMs) continues to expand. Knowledge of the hemodynamics of blood flow associated with AVMs is also progressing as imaging and treatment modalities advance. The authors present a comprehensive literature review that reveals the physical hemodynamics of AVMs, and the effect that various treatment modalities have on AVM hemodynamics and the surrounding cortex and vasculature. The authors discuss feeding arteries, flow through the nidus, venous outflow, and the relative effects of radiosurgical monotherapy, endovascular embolization alone, and combined microsurgical treatments. The hemodynamics associated with intracranial AVMs is complex and likely changes over time with changes in the physical morphology and angioarchitecture of the lesions. Hemodynamic change may be even more of a factor as it pertains to the vast array of single and multimodal treatment options available. An understanding of AVM hemodynamics associated with differing treatment modalities can affect treatment strategies and should be considered for optimal clinical outcomes.
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Affiliation(s)
- Vernard S Fennell
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nikolay L Martirosyan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
- Division of Neurosurgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Gursant S Atwal
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - M Yashar S Kalani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Francisco A Ponce
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - G Michael Lemole
- Division of Neurosurgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Travis M Dumont
- Division of Neurosurgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Lv X. Letter: Comparison of N-butyl Cyanoacrylate and Onyx for the Embolization of Intracranial Arteriovenous Malformations-Analysis of Fluoroscopy and Procedure Times. Oper Neurosurg (Hagerstown) 2017; 13:E37-E38. [PMID: 29087510 DOI: 10.1093/ons/opx211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Xianli Lv
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital Capital Medical University Beijing, China
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59
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Lin CJ, Yang HC, Chien AC, Guo WY, Wu CC, Hung SC, Chen KK, Wu HM, Luo CB, Chu WF, Hong JS, Wu CSF. In-room assessment of intravascular velocity from time-resolved rotational angiography in patients with arteriovenous malformation: a pilot study. J Neurointerv Surg 2017; 10:580-586. [DOI: 10.1136/neurintsurg-2017-013387] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/07/2017] [Accepted: 09/10/2017] [Indexed: 11/04/2022]
Abstract
BackgroundTime-resolved rotational angiography (t-RA) enables interventionists to better comprehend complex arteriovenous malformations (AVMs), thereby facilitating endovascular treatment. However, its use in evaluating hemodynamic changes has rarely been explored.ObjectiveThis study uses t-RA to estimate intravascular flow in patients with AVM to compare this with flow in the normal population.MethodsPatients with available t-RA scans were prospectively categorized into one of three groups: hemorrhagic AVM, non-hemorrhagic AVM and control. Pulsatile time–density curves (TDCs) for C1, C6 and VOIMCA were used for amplitude and velocity estimation. C1 was at the cervical internal carotid artery (ICA), 2–3 cm below the carotid canal, C6 was at the paraclinoid segment of the ICA, and VOIMCA was at the junction of the first and second segment of the middle cerebral artery (MCA). A waveform amplitude ratio was defined as (peak − trough)/trough contrast intensity. VICA was defined as the distance between C6 and C1 divided by the time required for the wave to pass, and correspondingly, the average velocity of MCA (VMCA) was defined as the distance between C6 and VOIMCA divided by the duration for the same peak to travel from C6 and VOIMCA, AVM volume was estimated by MR angiography.ResultsAmplitude ratios AC1 and AC6, and average flow velocities VICA and VMCA were significantly larger in the non-hemorrhagic group than in the control group, while the hemorrhagic AVM group was not significantly different from the controls. VICA and VMCA showed moderate to good correlations with AVM volume (r=0.51 and 0.73, respectively). VMCA (33.0±9.1) was significantly lower than VICA (41.3±13.2) in the control group, but not in the two AVM groups.ConclusionTDC waveform propagation derived from t-RA can quantify hemodynamic differences between AVM and the control group. t-RA provides both real-time anatomic and hemodynamic evaluation, and can thus potentially improve the interventional workflow.
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60
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Jin H, Liu Z, Chang Q, Chen C, Ge H, Lv X, Li Y. A challenging entity of endovascular embolization with ONYX for brainstem arteriovenous malformation: Experience from 13 cases. Interv Neuroradiol 2017; 23:497-503. [PMID: 28614989 PMCID: PMC5624407 DOI: 10.1177/1591019917711679] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective Brainstem arteriovenous malformations (AVMs) are rare lesions with a high risk of intracranial hemorrhage and are challenging to treat. We present our experience of endovascular embolization with Onyx in these aggressive lesions. Materials and methods Between 2007 and 2016, 13 patients with brainstem AVMs were embolized with Onyx at our center. Twelve patients presented with intracranial hemorrhage and one with headache. Retrospective examinations of patient demographics, clinical presentation, angiographic features, treatment modalities, postoperative complications and outcomes were carried out. Results The AVMs were in the midbrain in 10 patients (one anterior and nine posterior or dorsal), in the posterior pons in two and pontomedullary in one. Complete occlusion was achieved in three patients. Gamma knife radiosurgery was performed in six patients who were near-completely or partially embolized. Postoperative complications, including five cases of ischemia and one case of hemorrhage, resulted in four cases of neurological deterioration and two deaths. Clinical follow-up was obtained in 10 patients at a mean period of 45.2 months (range 3 to 93 months). During the follow-up, good clinical outcomes were observed in seven patients with posterior or dorsal midbrain AVMs, and one patient with a posterior pons AVM that was partially occluded died of intracranial hemorrhage. Conclusion Endovascular embolization for brainstem AVM with Onyx is a technical challenge and the reflux of Onyx may cause severe complications. Individualized treatment is needed based on the specific subtype of brainstem AVM.
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Affiliation(s)
- Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, China
- Beijing Engineering Research Center for Interventional Neuroradiology, China
| | - Zhan Liu
- Department of Neurosurgery, Traditional Chinese Medicine Hospital of Laiwu City, China
| | - Qing Chang
- Department of Neurosurgery, Weifang Yidu Hospital, Qingzhou, China
| | - Chang Chen
- Department of Neurosurgery, Xintai Hospital of Traditional Chinese Medicine, China
| | - Huijian Ge
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, China
- Beijing Engineering Research Center for Interventional Neuroradiology, China
| | - Xianli Lv
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, China
- Beijing Engineering Research Center for Interventional Neuroradiology, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, China
- Beijing Engineering Research Center for Interventional Neuroradiology, China
- Youxiang Li, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, No. 6, Tiantan Xili, Dongcheng, Beijing, 100050, P.R. China.
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Chen QY, Zhu XR, Zhang Y. The Hemodynamic Changes in Patients with Cerebral Arteriovenous Malformations before and after Interventional Embolization Therapy with Glubran 2 Acrylic Glue. Eur Neurol 2017; 78:169-175. [PMID: 28848195 DOI: 10.1159/000478727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 06/14/2017] [Indexed: 11/19/2022]
Abstract
The study explored hemodynamic changes in patients with cerebral arteriovenous malformations (CAVM) before and -after interventional embolization therapy with Glubran 2 acrylic glue and analyzed the related factors. CAVM patients received endovascular embolization therapy with Glubran 2. Patients' systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), blood flow velocity (BFV), and pulsatility index (PI) were measured. The location of malformed vessels, Spetzler-Martin (SM) grade, CAVM size, and type of feeding artery and venous drainage were analyzed. CAVM patients showed increased DBP, SBP, MAP, and PI and decreased average BFV compared to before therapy. CAVM patients with big CAVM size, SM grade IV/V, deep location malformed vessels, deep, and mixed venous drainage, and cortical branch and mixed artery blood-supply exhibited lower DBP, SBP, MAP, and PI but higher average BFV. Hypertensive CAVM patients showed lower DBP, SBP, MAP, average BFV, and PI before or after embolization. Hypertension, SM grade, CAVM size, malformed vessels location, venous drainage, and artery blood-supply were correlated to the hemodynamic changes of CAVM patients. Embolization with Glubran 2 acrylic glue could enhance hemodynamics in CAVM patients, and the hemodynamic changes were in correlation with the SM grade, CAVM size, and malformed vessels location.
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Derdeyn CP, Zipfel GJ, Albuquerque FC, Cooke DL, Feldmann E, Sheehan JP, Torner JC. Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2017. [DOI: 10.1161/str.0000000000000134] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bell DL, Leslie-Mazwi TM, Hirsch JA. Arteriovenous malformation embocure score (AVMES): response. J Neurointerv Surg 2017; 9:e14-e15. [DOI: 10.1136/neurintsurg-2015-012030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 08/17/2015] [Indexed: 11/03/2022]
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Viana DC, de Castro-Afonso LH, Nakiri GS, Monsignore LM, Trivelato FP, Colli BO, Abud DG. Extending the indications for transvenous approach embolization for superficial brain arteriovenous malformations. J Neurointerv Surg 2017; 9:1053-1059. [PMID: 28600483 DOI: 10.1136/neurintsurg-2017-013113] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/13/2017] [Accepted: 05/16/2017] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Transarterial embolization is the standard endovascular treatment strategy for intracranial arteriovenous malformations (AVMs). The transvenous approach has been indicated for the embolization of deep AVMs meeting a set of strict eligibility criteria. The present study aims to assess the safety and efficacy of the transvenous approach for superficial AVMs. METHODS A retrospective series of 12 patients presenting with cortical AVMs were treated by endovascular embolization using a transvenous approach with a curative intent. RESULTS Nine patients (75%) had ruptured AVMs at admission. The mean nidus size was 1.9 cm, six patients (50%) had a nidus in eloquent areas and the median Spetzler-Martin grade was 2. The rate of immediate angiographic occlusion of the AVMs was 91.6% (11/12). One patient in whom immediate angiographic occlusion was not achieved showed spontaneous occlusion at the 6-month follow-up. No procedural or clinical complications were observed. The mean and median modified Rankin scale (mRS) scores at discharge were 1.7 and 2 (range 0-3, SD=0.96), and the mean and median mRS scores at 6 months were 1.6 and 2 (0-3, 1.16). Nine patients (75%) were independent (mRS ≤2) at discharge and 11 patients (91.6%) were independent (mRS ≤2) at the 6-month follow-up. CONCLUSIONS The curative transvenous embolization of superficial intracranial AVMs is feasible and appears safe and effective when strict anatomical selection is respected. This technique extends the current indications for transvenous embolization of intracranial AVMs and may improve cure rates while reducing embolization-related complications.
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Affiliation(s)
- Dinark Conceição Viana
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Luis Henrique de Castro-Afonso
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Guilherme Seizem Nakiri
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Lucas Moretti Monsignore
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Felipe Padovani Trivelato
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Benedicto Oscar Colli
- Division of Neurosurgery, Department of Surgery, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Daniel Giansante Abud
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
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Target Embolization of Associated Aneurysms in Ruptured Arteriovenous Malformations. World Neurosurg 2017; 101:26-32. [PMID: 28153612 DOI: 10.1016/j.wneu.2017.01.081] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/17/2017] [Accepted: 01/19/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The purpose of this study was to examine the safety and efficacy of target embolization of aneurysms associated with ruptured brain arteriovenous malformations (BAVMs). METHODS Ruptured BAVM patients who underwent endovascular treatment at our institution from January 2011 to December 2015 were retrospectively reviewed. Patients were divided into aneurysm (AN) and nonaneurysm (non-AN) groups on the basis of the existence of BAVM-associated aneurysms or not. Demographics, angiographic characteristics, complications, and clinical outcomes were compared between 2 groups. Complication risk factors were analyzed for all objects. Patient outcomes were assessed with modified Rankin Scale (mRS). RESULTS A total of 129 (male = 53) patients were included. In 31 (24.0%) patients, 33 aneurysms were observed, including 16 intranidal and 17 flow-related aneurysms. Of the 166 sessions of embolization performed, there were 13 (10.1% of patients, 7.8% per session) complications in all, including 2 hemorrhagic, 8 transient ischemic, and 3 permanent ischemic types. There was no statistical difference in terms of complication incidence rate between groups. A total of 12 patients (9.3% of patients, 3.3% per person-year) experienced postoperative hemorrhage during follow-up (mean = 3.4 years). The yearly postoperative hemorrhage incidence rate was 3.4% in the non-AN group and 2.0% in AN group. Excellent or good outcomes (mRS ≤ 2) were observed in 103 (91.2%) patients. Unfavorable outcomes (mRS ≥ 3) as a direct result of embolization remained in no patients. CONCLUSIONS Target embolization of aneurysms associated with ruptured BAVMs could significantly decrease postoperative rehemorrhage without increasing complications.
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Ikeda H, Imamura H, Agawa Y, Imai Y, Tani S, Adachi H, Ishikawa T, Mineharu Y, Sakai N. Onyx extravasation during embolization of a brain arteriovenous malformation. Interv Neuroradiol 2016; 23:200-205. [PMID: 27903925 DOI: 10.1177/1591019916680112] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
During Onyx embolization to treat brain arteriovenous malformation (AVM), carefully observing the penetration of Onyx to the nidus is important in order to avoid complications such as hemorrhage, ischemia, and difficulty with microcatheter removal. We encountered a case of Onyx extravasation during embolization of a cerebellar AVM confirmed by surgical resection and pathological analysis. The patient was a 44-year-old man with Spetzler-Martin grade I cerebellar AVM who underwent Onyx embolization prior to resection of the brain AVM. While injecting Onyx into the nidus using the "plug-and-push" technique, Onyx extravasation was observed. Onyx injection was paused and subsequently restarted, thereby allowing continuation of embolization. An oblate Onyx cast that was entirely covered in cerebellar tissue was removed during total resection of the AVM, performed the same day. The surgically removed oblate Onyx cast did not contain brain tissue or vessel wall, and immunohistochemical staining against glial fibrillary acidic protein (GFAP) showed Onyx penetration into GFAP-positive cerebellar tissue. Onyx extravasation was confirmed based on intraoperative findings during resection as well as pathological findings. The patient has been followed for four years postoperatively, and adverse events caused by Onyx extravasation have not been observed. Unexpected cast of Onyx, remote from the vascular architecture of the AVM, may represent an intra-parenchymal extravasation.
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Affiliation(s)
- Hiroyuki Ikeda
- 1 Department of Neurosurgery, Kobe City Medical Center General Hospital, Japan
| | - Hirotoshi Imamura
- 1 Department of Neurosurgery, Kobe City Medical Center General Hospital, Japan
| | - Yuji Agawa
- 1 Department of Neurosurgery, Kobe City Medical Center General Hospital, Japan
| | - Yukihiro Imai
- 2 Department of Pathology, Kobe City Medical Center General Hospital, Japan
| | - Shoichi Tani
- 1 Department of Neurosurgery, Kobe City Medical Center General Hospital, Japan
| | - Hidemitsu Adachi
- 1 Department of Neurosurgery, Kobe City Medical Center General Hospital, Japan
| | - Tatsuya Ishikawa
- 1 Department of Neurosurgery, Kobe City Medical Center General Hospital, Japan
| | - Yohei Mineharu
- 1 Department of Neurosurgery, Kobe City Medical Center General Hospital, Japan
| | - Nobuyuki Sakai
- 1 Department of Neurosurgery, Kobe City Medical Center General Hospital, Japan
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Abstract
OBJECTIVE To determine whether patients with hereditary haemorrhagic telangiectasia were being screened according to international guidelines, and to review recent evidence in order to provide up-to-date guidelines for the initial systemic management of hereditary haemorrhagic telangiectasia. METHODS A retrospective case note analysis was conducted, assessing patients in terms of screening for: genetics, cerebral arteriovenous malformations, pulmonary and hepatic arteriovenous malformations, and gastrointestinal telangiectasia. Databases searched included Medline, the Cumulative Index to Nursing and Allied Health Literature, and Embase. RESULTS Screening investigations were most frequently performed for hepatic arteriovenous malformations and least frequently for genetics. Recent data suggest avoiding routine genetic and cerebral arteriovenous malformation screening because of treatment morbidities; performing high-resolution chest computed tomography for pulmonary arteriovenous malformation screening; using capsule endoscopy (if possible) to reduce complications from upper gastrointestinal endoscopy; and omitting routine liver enzyme testing in favour of Doppler ultrasound. CONCLUSION Opportunities for systemic arteriovenous malformation screening are frequently overlooked. This review highlights the need for screening and considers the form in which it should be undertaken.
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Elkordy A, Endo H, Sato K, Matsumoto Y, Kondo R, Niizuma K, Endo T, Fujimura M, Tominaga T. Embolization of the choroidal artery in the treatment of cerebral arteriovenous malformations. J Neurosurg 2016; 126:1114-1122. [PMID: 27153173 DOI: 10.3171/2016.2.jns152370] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The anterior and posterior choroidal arteries are often recruited to supply arteriovenous malformations (AVMs) involving important paraventricular structures, such as the basal ganglia, internal capsule, optic radiation, lateral geniculate body, and medial temporal lobe. Endovascular embolization through these arteries is theoretically dangerous because they supply eloquent territories, are of small caliber, and lack collaterals. This study aimed to investigate the safety and efficacy of embolization through these arteries. METHODS This study retrospectively reviewed 13 patients with cerebral AVMs who underwent endovascular embolization through the choroidal arteries between 2006 and 2014. Embolization was performed as a palliative procedure before open surgery or Gamma Knife radiosurgery. Computed tomography and MRI were performed the day after embolization to assess any surgical complications. The incidence and type of complications and their association with clinical outcomes were analyzed. RESULTS Decreased blood flow was achieved in all patients after embolization. Postoperative CT detected no hemorrhagic complications. In contrast, postoperative MRI detected that 4 of the 13 patients (30.7%) developed infarctions: 3 patients after embolization through the anterior choroidal artery, and 1 patient after embolization through the lateral posterior choroidal artery. Two of the 4 patients in whom embolization was from the cisternal segment of the anterior choroidal artery (proximal to the plexal point) developed symptomatic infarction of the posterior limb of the internal capsule, 1 of whom developed morbidity (7.7%). The treatment-related mortality rate was 0%. Additional treatment was performed in 12 patients: open surgery in 9 and Gamma Knife radiosurgery in 3 patients. Complete obliteration was confirmed by angiography at the last follow-up in 10 patients. Recurrent bleeding from the AVMs did not occur in any of the cases during the follow-up period. CONCLUSIONS Ischemic complications are possible following the embolization of cerebral AVMs through the choroidal artery, even with modern neurointerventional devices and techniques. Although further study is needed, embolization through the choroidal artery may be an appropriate treatment option when the risk of surgery or radiosurgery is considered to outweigh the risk of embolization.
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Affiliation(s)
- Alaa Elkordy
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai;,Neuroendovascular Section, Department of Neurology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Kenichi Sato
- Neuroendovascular Therapy, Kohnan Hospital, Sendai
| | | | - Ryushi Kondo
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Japan; and
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai
| | | | - Miki Fujimura
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai
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69
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Yang W, Hung AL, Caplan JM, Braileanu M, Wang JY, Colby GP, Coon AL, Tamargo RJ, Huang J. Delayed Hemorrhage After Treatment of Brain Arteriovenous Malformations (AVMs). World Neurosurg 2016; 87:98-109. [DOI: 10.1016/j.wneu.2015.11.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/09/2015] [Accepted: 11/12/2015] [Indexed: 10/22/2022]
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Curative embolization of pediatric intracranial arteriovenous malformations using Onyx: the role of new embolization techniques on patient outcomes. Neuroradiology 2016; 58:585-594. [DOI: 10.1007/s00234-016-1666-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 02/12/2016] [Indexed: 11/26/2022]
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71
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Abstract
In a recent trial limited to arteriovenous malformations discovered not to have bled, medical management was superior to medical management plus intervention. The trial was halted after 226 randomizations and a mean follow-up of 3.3 years owing to a disparity favoring the medical arm. Eligible patients were selected as suitable for lesion eradication. The initial sample size of 800 and follow-up plans for a mean of 7 years were lowered and shortened, respectively, by the outcome data. An application for extended follow-up was given poor priority scores owing to estimations that the disparities in outcomes would not change significantly.
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Affiliation(s)
- J P Mohr
- Department of Neurology, Doris & Stanley Tananbaum Stroke Center, Neurological Institute, Columbia University Medical Center, 710 West 168th Street, New York, NY 10032, USA.
| | - Shadi Yaghi
- Department of Neurology, Doris & Stanley Tananbaum Stroke Center, Neurological Institute, Columbia University Medical Center, 710 West 168th Street, New York, NY 10032, USA
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72
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Abstract
Brain AVMs are complex malformations, usually congenital, that need a deep understanding of anatomy and pathophysiology to be safely treated. Nowadays, embolization and radiosurgery are carried out more frequently due to their reduced invasiveness as compared to conventional neurosurgery. This paper aims to describe different and new endovascular approaches that allow the interventionalist to treat almost all the small AVMs and to reduce the nidus of the bigger ones in order to facilitate the surgical or radiosurgical intervention.
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73
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Ellis JA, Lavine SD. Role of embolization for cerebral arteriovenous malformations. Methodist Debakey Cardiovasc J 2015; 10:234-9. [PMID: 25624978 DOI: 10.14797/mdcj-10-4-234] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Cerebral arteriovenous malformations (AVMs) are complex high-flow lesions that can result in devastating neurological injury when they hemorrhage. Embolization is a critical component in the management of many patients with cerebral AVMs. Embolization may be used as an independent curative therapy or more commonly in an adjuvant fashion prior to either micro- or radiosurgery. Although the treatment-related morbidity and mortality for AVMs--including that due to microsurgery, embolization, and radiosurgery--can be substantial, its natural history offers little solace. Fortunately, care by a multidisciplinary team experienced in the comprehensive management of AVMs can offer excellent results in most cases.
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Affiliation(s)
- Jason A Ellis
- Columbia University Medical Center, New York, New York
| | - Sean D Lavine
- Columbia University Medical Center, New York, New York
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Clarençon F, Maizeroi-Eugène F, Maingreaud F, Bresson D, Ayoub D, Sourour NA, Menjot de Champfleur N, Chiras J, Yardin C, Mounayer C. Interest of convex spherical anamorphosis in better understanding of brain AVMs' angioarchitecture. J Neurointerv Surg 2015; 8:959-64. [PMID: 26362085 DOI: 10.1136/neurintsurg-2015-011888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 08/15/2015] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Convex spherical anamorphosis is a barrel distortion that consists of the application of a plane surface on a convex hemisphere. Applied in vascular imaging of brain arteriovenous malformations (bAVMs), this deformation may help to 'spread' the nidus and surrounding vessels (arteries/veins) and thus to differentiate the different components of bAVMs more accurately. METHODS The imaging data from 15 patients (8 male, 7 female; 14 supratentorial bAVMs, 1 infratentorial) were used to test the algorithm. The algorithm was applied to three-dimensional rotational angiography (3D-RA) volume rendering reconstructions in anteroposterior, lateral and oblique views and compared with regular 3D-RA and DSA. Arterial feeder and draining vein count and quality visualization of the main draining vein and intranidal aneurysms were compared between the three imaging techniques. RESULTS Anamorphosis was able to depict more arterial feeders than 3D-RA alone (p=0.027). There was no statistically significant difference between 6 f/s DSA and anamorphosis for arterial feeder count. No difference was observed in draining vein count between the three imaging modalities. Visualization of the precise origin of the main draining vein was considered to be good in 67% of the cases with anamorphosis versus 47% and 33% for 6 f/s DSA and 3D-RA alone, respectively. Intranidal aneurysms were accurately depicted by anamorphosis (2 cases), whereas 6 f/s DSA and 3D-RA showed doubtful images in one and two additional cases, respectively, which were finally confirmed as focal venous ectasias on supraselective injection. CONCLUSIONS Anamorphosis can help to visualize more precisely the main draining vein origin of the bAVM and depict more accurately intranidal aneurysms.
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Affiliation(s)
- Frédéric Clarençon
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | | | | | - Damien Bresson
- Department of Neurosurgery, Lariboisière University Hospital, Paris, France
| | - David Ayoub
- Department of Neurosurgery, Saint-Joseph University Hospital, Beyrouth, Lebanon Department of Neuroradiology, Limoges University Hospital, Limoges, France
| | - Nader-Antoine Sourour
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | | | - Jacques Chiras
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Catherine Yardin
- Department of Histology, Cytology, Cellular Biology and Cytogenetics, Limoges University Hospital, Limoges, France
| | - Charbel Mounayer
- Department of Neuroradiology, Limoges University Hospital, Limoges, France
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75
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Treatment of unruptured brain AVM in the aftermath of ARUBA and the Scottish Audit of Intracranial Vascular Malformations. Acta Neurochir (Wien) 2015; 157:1291-3. [PMID: 26093622 DOI: 10.1007/s00701-015-2477-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/08/2015] [Indexed: 10/23/2022]
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Bell DL, Leslie-Mazwi TM, Yoo AJ, Rabinov JD, Butler WE, Bell JE, Hirsch JA. Application of a Novel Brain Arteriovenous Malformation Endovascular Grading Scale for Transarterial Embolization. AJNR Am J Neuroradiol 2015; 36:1303-9. [PMID: 25857761 DOI: 10.3174/ajnr.a4286] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 01/02/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The advent of modern neuroendovascular techniques has highlighted the need for a simple, effective, and reliable brain arteriovenous malformation endovascular grading scale. A novel scale of this type has recently been described. It incorporates the number of feeding arteries, eloquence, and the presence of an arteriovenous fistula component. Our aim is to assess the validity of this grading scale. MATERIALS AND METHODS We retrospectively reviewed all suspected brain arteriovenous malformations at Massachusetts General Hospital from 2005 to 2013, identifying 126 patients who met the inclusion criteria. Spearman correlations between endovascular and Spetzler-Martin grading scales and long-term outcomes were performed. Median endovascular grades were compared between treatment modalities and endovascular outcomes. Binary regression analysis was performed with major endovascular complications as a dichotomized dependent variable. Intraclass correlation coefficients were calculated for interobserver reliability of the endovascular grading scale. RESULTS A significant Spearman correlation between the endovascular grade and the Spetzler-Martin grade was demonstrated (ρ = 0.5, P < .01). Differences in the median endovascular grades between the endovascular cure (median = 2) and endovascular complication groups (median = 4) (P < .05) and between the endovascular cure and successful multimodal treatment groups (median = 3) (P < .05) were demonstrated. The endovascular grade was the only independent predictor of complications (OR = 0.5, P < .01). The intraclass correlation coefficient of the endovascular grade was 0.71 (P < .01). CONCLUSIONS Validation of a brain arteriovenous malformation endovascular grading scale demonstrated that endovascular grades of ≤II were associated with endovascular cure, while endovascular grades of ≤III were associated with multimodal cure or significant lesion reduction and favorable outcome. The endovascular grade provides useful information to refine risk stratification for endovascular and multimodal treatment.
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Affiliation(s)
- D L Bell
- From the Department of Radiology, Neuroendovascular Program (D.L.B., A.J.Y., J.D.R., J.A.H.) Harvard Medical School (D.L.B., T.M.L.-M., J.D.R., W.E.B., J.A.H.), Boston, Massachusetts
| | - T M Leslie-Mazwi
- Department of Neurology and Radiology, Neurocritical Care and Neuroendovascular Program (T.M.L.-M.) Harvard Medical School (D.L.B., T.M.L.-M., J.D.R., W.E.B., J.A.H.), Boston, Massachusetts
| | - A J Yoo
- From the Department of Radiology, Neuroendovascular Program (D.L.B., A.J.Y., J.D.R., J.A.H.) Texas Stroke Institute (A.J.Y.), Plano, Texas
| | - J D Rabinov
- From the Department of Radiology, Neuroendovascular Program (D.L.B., A.J.Y., J.D.R., J.A.H.) Harvard Medical School (D.L.B., T.M.L.-M., J.D.R., W.E.B., J.A.H.), Boston, Massachusetts
| | - W E Butler
- Department of Neurosurgery, Vascular Center (W.E.B.), Massachusetts General Hospital, Boston, Massachusetts Harvard Medical School (D.L.B., T.M.L.-M., J.D.R., W.E.B., J.A.H.), Boston, Massachusetts
| | - J E Bell
- From the Department of Radiology, Neuroendovascular Program (D.L.B., A.J.Y., J.D.R., J.A.H.)
| | - J A Hirsch
- From the Department of Radiology, Neuroendovascular Program (D.L.B., A.J.Y., J.D.R., J.A.H.) Harvard Medical School (D.L.B., T.M.L.-M., J.D.R., W.E.B., J.A.H.), Boston, Massachusetts
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Choudhri O, Ivan ME, Lawton MT. Transvenous Approach to Intracranial Arteriovenous Malformations. Neurosurgery 2015; 77:644-51; discussion 652. [DOI: 10.1227/neu.0000000000000869] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
A compartmental conceptualization of intracranial arteriovenous malformations (AVMs) allows recognition of feeding arteries, an intervening plexiform nidus, and draining veins. AVM therapy involves eliminating the nidus, which is the source of hemorrhage, without compromising normal arterial and venous drainage of the brain. Traditional methods of AVM therapy through microsurgery and endovascular embolization involve arterial devascularization, with preservation of AVM venous drainage, until the nidus is excluded. The transvenous approach in treating vascular malformations was popularized by successful treatment models for dural arteriovenous fistulas. More recently, high-flow intracranial AVMs are being managed with transvenous endovascular approaches, although this novel technique has its challenges and perils. We review the current literature on transvenous AVM therapy and highlight its role for AVM therapy in the present day.
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Affiliation(s)
- Omar Choudhri
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michael E. Ivan
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Michael T. Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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79
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Potts MB, Zumofen DW, Raz E, Nelson PK, Riina HA. Curing arteriovenous malformations using embolization. Neurosurg Focus 2014; 37:E19. [DOI: 10.3171/2014.6.focus14228] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endovascular embolization is typically reserved as an adjuvant therapy in the management of cerebral arteriovenous malformations (AVMs), either for preoperative devascularization or preradiosurgical volume reduction. Curative embolization plays a limited role in AVM treatment but several studies have shown that it is possible, especially with later-generation liquid embolic agents. Given the complexity of AVM anatomy and the recent controversies over the role of any intervention in AVM management, it is critical that the cerebrovascular community better define the indications of each treatment modality to provide quality AVM management. In this review, the authors evaluate the role of curative AVM embolization. Important considerations in the feasibility of curative AVM embolization include whether it can be performed reliably and safely, and whether it is a durable cure. Studies over the past 20 years have begun to define the anatomical factors that are amenable to complete endovascular occlusion, including size, feeding artery anatomy, AVM morphology, and endovascular accessibility. More recent studies have shown that highly selected patients with AVMs can be treated with curative intent, leading to occlusion rates as high as 100% of such prospectively identified lesions with minimal morbidity. Advances in endovascular technology and techniques that support the efficacy and safety of curative embolization are discussed, as is the importance of superselective diagnostic angiography. Finally, the durability of curative embolization is analyzed. Overall, while still unproven, endovascular embolization has the potential to be a safe, effective, and durable curative treatment for select AVMs, broadening the armamentarium with which one can treat this disease.
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Affiliation(s)
- Matthew B. Potts
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Daniel W. Zumofen
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Eytan Raz
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Peter K. Nelson
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Howard A. Riina
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
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