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Mamaril-Davis JC, Aguilar-Salinas P, Avila MJ, Nakaji P, Bina RW. Complete seizure-free rates following interventional treatment of intracranial arteriovenous malformations: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:1313-1326. [PMID: 34988732 DOI: 10.1007/s10143-021-01724-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/09/2021] [Accepted: 12/20/2021] [Indexed: 11/27/2022]
Abstract
Seizures are common presenting symptoms of intracranial arteriovenous malformations (AVMs). This systematic review and meta-analysis aims to assess the current evidence regarding complete seizure freedom rates following surgical resection, stereotactic radiosurgery (SRS), and/or endovascular embolization of intracranial AVMs. A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included manuscripts were methodically scrutinized for quality, spontaneous AVM-associated or hemorrhage-associated seizures, complete seizure-free rates following each interventional treatment, follow-up duration; determination methods of seizure outcomes, and average time-to-onset of recurrent seizures after each treatment. Manuscripts that described patients with nondisabling seizures or reduced seizure frequency in their seizure-free calculations were excluded. Seizure freedom rates following surgical resection, SRS, and endovascular embolization were compared via random-effect analysis. Thirty-four studies with a total of 1765 intracranial AVM patients presenting with spontaneous AVM-associated seizures and 408 patients presenting with hemorrhage-associated seizures were qualitatively analyzed. For patients presenting with AVM-associated seizures, the complete seizure-free rates were 73.0% (321/440 patients; 95% CI 68.8-77.1%) following surgical resection, 60.5% (376/622 patients; 95% CI 56.6-64.3%) following SRS, and 44.6% (29/65 patients; 95% CI 32.5-56.7%) following endovascular embolization alone. For patients presenting with either AVM-associated or hemorrhage-associated seizures, the complete seizure-free rates were 73.0% (584/800 patients; 95% CI 69.9-76.1%) following surgical resection, 46.4% (572/1233 patients; 95% CI 43.6-49.2%) following SRS, and 44.6% (29/65 patients; 95% CI 32.5-56.7%) following embolization. For patients presenting with either AVM-associated or hemorrhage-associated seizures, the overall improvements in seizure outcomes regardless of complete seizure freedom were 82.6% (661/800 patients; 95% CI 80.0-85.3%), 70.6% (870/1233 patients; 95% CI 68.0-73.1%), and 70.8% (46/65 patients; 95% CI 59.7-81.1%) following surgical resection, SRS, and embolization, respectively. No study reported information about the time-to-onset for recurrent seizures in any patient following treatment, as seizure outcomes were only described at the last follow-up visit. The available data suggests that surgical resection results in the highest rate of complete seizure freedom. The rate of seizure improvement following surgery increased further to 82.3% when including patients who had improved seizure frequency without achieving true seizure freedom. Complete seizure-free rates following SRS or embolization were more ambiguous and lower when compared to surgical resection. There is a need for high quality studies evaluating AVM treatment modalities and clearly defined seizure outcomes, as the current literature consists mostly of heterogenous patient populations.
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Affiliation(s)
- James C Mamaril-Davis
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, Tucson, AZ, USA
| | - Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, Tucson, AZ, USA
| | - Mauricio J Avila
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, Tucson, AZ, USA
| | - Peter Nakaji
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, 755 E. McDowell Rd., Phoenix, AZ, 85006, USA
| | - Robert W Bina
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, 755 E. McDowell Rd., Phoenix, AZ, 85006, USA.
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Mamonov NA, Samochernykh KA. [Relationship between the features of venous drainage of supratentorial arteriovenous malformations and the risk of intracranial hemorrhage]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:104-108. [PMID: 35942844 DOI: 10.17116/neiro202286041104] [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: 06/15/2023]
Abstract
BACKGROUND Intracranial hemorrhage is the most common complication of cerebral arteriovenous malformations (AVM). In recent years, most studies devoted to the features of AVM functioning consider venous drainage as important factor influencing the rupture of malformation. OBJECTIVE To review the literature data on the relationship between the features of venous drainage of cerebral arteriovenous malformations and intracranial hemorrhage. MATERIAL AND METHODS We found 43 studies discussing the features of AVM venous drainage for the period from 1982 to 2020. Most of reports were published between 2005 and 2020. RESULTS Deep venous drainage and a single drainage vein were the most significant factors influencing the risk of hemorrhage. Venous ectasia, reflux, stenosis, number, length and tortuosity of drainage veins were less important for the risk of AVM rupture. CONCLUSION Analysis of the features of AVM venous drainage can make it possible to predict the natural course of disease and risk of intracranial hemorrhage. These aspects are essential for neurosurgical treatment.
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Affiliation(s)
- N A Mamonov
- Polenov Research Neurosurgical Institute, St. Petersburg, Russia
| | - K A Samochernykh
- Polenov Research Neurosurgical Institute, St. Petersburg, Russia
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103
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Genetics and Vascular Biology of Brain Vascular Malformations. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00012-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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104
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Colombo E, Fick T, Esposito G, Germans M, Regli L, van Doormaal T. Segmentation techniques of brain arteriovenous malformations for 3D visualization: a systematic review. LA RADIOLOGIA MEDICA 2022; 127:1333-1341. [PMID: 36255659 PMCID: PMC9747834 DOI: 10.1007/s11547-022-01567-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/30/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Visualization, analysis and characterization of the angioarchitecture of a brain arteriovenous malformation (bAVM) present crucial steps for understanding and management of these complex lesions. Three-dimensional (3D) segmentation and 3D visualization of bAVMs play hereby a significant role. We performed a systematic review regarding currently available 3D segmentation and visualization techniques for bAVMs. METHODS PubMed, Embase and Google Scholar were searched to identify studies reporting 3D segmentation techniques applied to bAVM characterization. Category of input scan, segmentation (automatic, semiautomatic, manual), time needed for segmentation and 3D visualization techniques were noted. RESULTS Thirty-three studies were included. Thirteen (39%) used MRI as baseline imaging modality, 9 used DSA (27%), and 7 used CT (21%). Segmentation through automatic algorithms was used in 20 (61%), semiautomatic segmentation in 6 (18%), and manual segmentation in 7 (21%) studies. Median automatic segmentation time was 10 min (IQR 33), semiautomatic 25 min (IQR 73). Manual segmentation time was reported in only one study, with the mean of 5-10 min. Thirty-two (97%) studies used screens to visualize the 3D segmentations outcomes and 1 (3%) study utilized a heads-up display (HUD). Integration with mixed reality was used in 4 studies (12%). CONCLUSIONS A golden standard for 3D visualization of bAVMs does not exist. This review describes a tendency over time to base segmentation on algorithms trained with machine learning. Unsupervised fuzzy-based algorithms thereby stand out as potential preferred strategy. Continued efforts will be necessary to improve algorithms, integrate complete hemodynamic assessment and find innovative tools for tridimensional visualization.
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Affiliation(s)
- Elisa Colombo
- Department of Neurosurgery, Clinical Neuroscience Center and University of Zürich, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zürich, ZH, Switzerland.
| | - Tim Fick
- Prinses Màxima Center, Department of Neurosurgery, Utrecht, CS, The Netherlands
| | - Giuseppe Esposito
- Department of Neurosurgery and Clinical Neuroscience Centerentrum, University Hospital of Zurich, Zürich, ZH, Switzerland
| | - Menno Germans
- Department of Neurosurgery and Clinical Neuroscience Centerentrum, University Hospital of Zurich, Zürich, ZH, Switzerland
| | - Luca Regli
- Department of Neurosurgery and Clinical Neuroscience Centerentrum, University Hospital of Zurich, Zürich, ZH, Switzerland
| | - Tristan van Doormaal
- Department of Neurosurgery and Clinical Neuroscience Centerentrum, University Hospital of Zurich, Zürich, ZH, Switzerland
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Porta M, Moreno J, Werner M, Chirife Ó, López-Rueda A. Vasos intracraneales en localización anómala en adultos. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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106
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Nicholson P, Krings T. Interventional Therapy of Brain and Spinal Arteriovenous Malformations. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00069-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Lu X, Fang X, Huang Y, Zhou P, Wang Z, Brinjikji W, Chen G. Cerebral Revascularization for the Management of Symptomatic Pure Arterial Malformations. Front Neurol 2021; 12:755312. [PMID: 34975720 PMCID: PMC8716448 DOI: 10.3389/fneur.2021.755312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Pure arterial malformations (PAMs) are extremely rare abnormalities defined as dilated, overlapping, and tortuous arteries with a coil-like appearance in the absence of venous components. Over the last half century, only seven published reports have described cases of patients with PAMs who received treatment. Methods: Here, we report two cases of women with PAMs who received surgical treatment, and we present a systematic review of the literature. We searched the PubMed, Embase, Web of Science, and Medline databases (up until October 1, 2021) for relevant publications. We performed independent-sample t-tests and Fisher's exact tests to compare continuous and categorical characteristics among the available cases. Results: Our first patient was a 43-year-old woman with PAM of the left internal carotid artery (ICA), who received an ICA-radial artery (RA)-M2 bypass. Post-operative digital subtraction angiography (DSA) revealed the disappearance of the left ICA PAM without ischemic events during follow-up. The second patient was a 53-year-old woman with PAMs of the right ICA and posterior cerebral artery. The P1 lesion was treated by proximal occlusion combined with a superficial temporal artery-P2 bypass. During the 12-month follow-up period, the size of the PAMs decreased significantly as indicated by the post-operative DSA showing the absence of hemorrhages. Our systematic review, which includes 56 PAMs, shows that the reported PAMs were more common in the anterior circulation (33/56, 58.9%) than in the posterior circulation (11/56, 19.7%). Bilateral PAMs were more likely to affect bilateral anterior cerebral arteries (ACA) (ACAbilateral vs. ACAunilateral: 63.6 vs. 26.2%, p = 0.02). In addition, PAMs involving the anterior circulation were likely to affect multiple arteries (anteriormulti vs. posteriormulti: 30.3 vs. 0%, p = 0.038). Conclusion: We found very few reports on treated PAMs; further studies with large sample sizes and long follow-up periods are required to explore the appropriate treatment strategy for PAMs.
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Affiliation(s)
- Xiaocheng Lu
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xinggen Fang
- Department of Neurosurgery, Wannan Medical College, Yijishan Hospital, Wuhu, China
| | - Yabo Huang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Peng Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Waleed Brinjikji
- Departments of Radiology, Mayo Clinic, Rochester, MN, United States
- Departments of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Gang Chen
- Department of Neurosurgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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Zhao S, Zhao Q, Jiao Y, Li H, Weng J, Huo R, Wang J, Xu H, Zhang J, Li Y, Wu Z, Wang S, Cao Y, Zhao J. Radiomics Analysis for Predicting Epilepsy in Patients With Unruptured Brain Arteriovenous Malformations. Front Neurol 2021; 12:767165. [PMID: 34975726 PMCID: PMC8714660 DOI: 10.3389/fneur.2021.767165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: To investigate the association between radiomics features and epilepsy in patients with unruptured brain arteriovenous malformations (bAVMs) and to develop a prediction model based on radiomics features and clinical characteristics for bAVM-related epilepsy.Methods: This retrospective study enrolled 176 patients with unruptured bAVMs. After manual lesion segmentation, a total of 858 radiomics features were extracted from time-of-flight magnetic resonance angiography (TOF-MRA). A radiomics model was constructed, and a radiomics score was calculated. Meanwhile, the demographic and angioarchitectural characteristics of patients were assessed to build a clinical model. Incorporating the radiomics score and independent clinical risk factors, a combined model was constructed. The performance of the models was assessed with respect to discrimination, calibration, and clinical usefulness.Results: The clinical model incorporating 3 clinical features had an area under the curve (AUC) of 0.71. Fifteen radiomics features were used to build the radiomics model, which had a higher AUC of 0.78. Incorporating the radiomics score and clinical risk factors, the combined model showed a favorable discrimination ability and calibration, with an AUC of 0.82. Decision curve analysis (DCA) demonstrated that the combined model outperformed the clinical model and radiomics model in terms of clinical usefulness.Conclusions: The radiomics features extracted from TOF-MRA were associated with epilepsy in patients with unruptured bAVMs. The radiomics-clinical nomogram, which was constructed based on the model incorporating the radiomics score and clinical features, showed favorable predictive efficacy for bAVM-related epilepsy.
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Affiliation(s)
- Shaozhi Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qi Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jiancong Weng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ran Huo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jie Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongyuan Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Junze Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yan Li
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhenzhou Wu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- *Correspondence: Yong Cao
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
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Hou K, Wang Y, Li W, Yu J. Endovascular treatment of brain arteriovenous malformations involving the anterior cerebral artery. MEDICINE INTERNATIONAL 2021; 1:22. [PMID: 36698539 PMCID: PMC9829091 DOI: 10.3892/mi.2021.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/04/2021] [Indexed: 01/28/2023]
Abstract
To date, at least to the best of our knowledge, there are only limited studies available on the endovascular treatment (EVT) of brain arteriovenous malformations (BAVMs) involving the anterior cerebral artery (ACA), thus termed ACA-BAVMs. The present study retrospectively examined 60 patients with ACA-BAVMs treated with EVT. The patients were aged between 10 and 72 years (mean age, 35.4±7.0 years) and included 28 females (46.7%, 28/60). The ACA-BAVMs were divided into three types: Type I BAVMs were those located below and in front of the corpus callosum genu, type II BAVMs were those located at the upper area of the corpus callosum from the genu to the anterior portion of corpus callosum body, and type III BAVMs were those located from the anterior portion of corpus callosum body to the splenium of the corpus callosum. There were 9 (15%, 9/60), 15 (25%, 15/60) and 36 (60%, 36/60) patients with type I, II and III ACA-BAVMs, respectively. Statistical analysis revealed that the posterior cerebral artery (PCA) tended to be involved in type II and III BAVMs. All patients were treated using EVT. During EVT, there were 3 cases of intraoperative bleeding (5%, 3/60), which tended to occur in type I and II ACA-BAVMs. The other 57 cases (95%, 57/60) had no complications and new neurological deficits. At the time of discharge, 48 (80%, 48/60) patients had a Glasgow Outcome Scale score of 5. During the clinical follow-up period, 47 patients were classified according to the modified Rankin Scale (mRS) score; 39 (83%, 39/47) patients presented with an mRS score of 0. On the whole, the present study demonstrated that EVT may be a safe treatment for ACA-BAVMs.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Yiheng Wang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Wei Li
- Department of Neurosurgery, The Second Affiliated Hospital of Xingtai Medical College, Xingtai, Hebei 054000, P.R. China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China,Correspondence to: Dr Jinlu Yu, Department of Neurosurgery, The First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, Jilin 130021, P.R. China ;
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Africk BN, Heiferman DM, Wozniak AW, Behzadi F, Ballard MS, Chazaro JM, Zsigray BM, Shanker RM, Reynolds MR, Anderson DE, Serrone JC. Angioarchitectural features amongst patients with unruptured brain arteriovenous malformations presenting with headache: findings from a single center retrospective review of 76 patients. J Headache Pain 2021; 22:122. [PMID: 34627140 PMCID: PMC8501699 DOI: 10.1186/s10194-021-01331-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/21/2021] [Indexed: 12/30/2022] Open
Abstract
Background Brain arteriovenous malformations (AVMs) consist of abnormal connections between arteries and veins via an interposing nidus. While hemorrhage is the most common presentation, unruptured AVMs can present with headaches, seizures, neurological deficits, or be found incidentally. It remains unclear as to what AVM characteristics contribute to pain generation amongst unruptured AVM patients with headaches. Methods To assess this relationship, the current study evaluates angiographic and clinical features amongst patients with unruptured brain AVMs presenting with headache. Loyola University Medical Center medical records were queried for diagnostic codes corresponding to AVMs. In patients with unruptured AVMs, we analyzed the correlation between the presenting symptom of headache and various demographic and angiographic features. Results Of the 144 AVMs treated at our institution between 1980 and 2017, 76 were unruptured and had sufficient clinical data available. Twenty-three presented with headaches, while 53 patients had other presenting symptoms. Patients presenting with headache were less likely to have venous stenosis compared to those with a non-headache presentation (13 % vs. 36 %, p = 0.044). Conclusions Our study suggests that the absence of venous stenosis may contribute to headache symptomatology. This serves as a basis for further study of correlations between AVM angioarchitecture and symptomatology to direct headache management in AVM patients.
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Affiliation(s)
- Benjamin N Africk
- Department of Pediatric Neurology, Lucile Packard Children's Hospital at Stanford, 725 Welch Road, CA, 94304, Palo Alto, USA
| | | | - Amy W Wozniak
- Clinical Research Office, Stritch School of Medicine, Loyola University Medical Center, 2160 S. First Avenue, IL, 60153, Maywood, USA
| | - Faraz Behzadi
- Loyola Stritch School of Medicine, 2160 S. First Avenue, IL, 60153, Maywood, USA
| | - Matthew S Ballard
- Loyola Stritch School of Medicine, 2160 S. First Avenue, IL, 60153, Maywood, USA
| | - Joshua M Chazaro
- Loyola Stritch School of Medicine, 2160 S. First Avenue, IL, 60153, Maywood, USA
| | - Brandon M Zsigray
- Department of Neurological Surgery, Loyola University Medical Center, 2160 S. First Avenue, IL, 60153, Maywood, USA
| | - Rachyl M Shanker
- Department of Neurological Surgery, Loyola University Medical Center, 2160 S. First Avenue, IL, 60153, Maywood, USA
| | - Matthew R Reynolds
- Department of Neurological Surgery, Loyola University Medical Center, 2160 S. First Avenue, IL, 60153, Maywood, USA
| | - Douglas E Anderson
- Department of Neurological Surgery, Loyola University Medical Center, 2160 S. First Avenue, IL, 60153, Maywood, USA.,Edward Hines Jr Veteran Administration Hospital, 5000 5th Avenue, IL, 60141, Hines, USA
| | - Joseph C Serrone
- Department of Neurological Surgery, Loyola University Medical Center, 2160 S. First Avenue, IL, 60153, Maywood, USA. .,Edward Hines Jr Veteran Administration Hospital, 5000 5th Avenue, IL, 60141, Hines, USA. .,Loyola University Medical Center, 2160 S 1st Avenue, IL, 60153, Maywood, USA.
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Abstract
Brain arteriovenous malformation (bAVM) is the most common cause of intracranial hemorrhage (ICH), particularly in young patients. However, the exact cause of bAVM bleeding and rupture is not yet fully understood. In bAVMs, blood bypasses the entire capillary bed and directly flows from arteries to veins. The vessel walls in bAVMs have structural defects, which impair vascular integrity. Mural cells are essential structural and functional components of blood vessels and play a critical role in maintaining vascular integrity. Changes in mural cell number and coverage have been implicated in bAVMs. In this review, we discussed the roles of mural cells in bAVM pathogenesis. We focused on 1) the recent advances in human and animal studies of bAVMs; 2) the importance of mural cells in vascular integrity; 3) the regulatory signaling pathways that regulate mural cell function. More specifically, the platelet-derived growth factor-B (PDGF-B)/PDGF receptor-β (PDGFR-β), EphrinB2/EphB4, and angiopoietins/tie2 signaling pathways that regulate mural cell-recruitment during vascular remodeling were discussed in detail.
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Jia Y, Li G, Song G, Ye X, Yang Y, Lu K, Huang S, Zhu S. SMASH-U aetiological classification: A predictor of long-term functional outcome after intracerebral haemorrhage. Eur J Neurol 2021; 29:178-187. [PMID: 34534389 DOI: 10.1111/ene.15111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND SMASH-U is a systematic aetiological classification system for intracerebral haemorrhage (ICH) proven to be a predictor of post-ICH haematoma expansion and mortality. However, its role in predicting functional outcome remains elusive. Therefore, we aimed to investigate whether SMASH-U is associated with long-term functional outcome after ICH and improves the accuracy of prediction when added to max-ICH score. METHODS Consecutive acute ICH patients from 2012 to 2018 from the neurology department of Tongji Hospital were enrolled. ICH aetiology was classified according to the SMASH-U system. The association of SMASH-U with 12-month functional outcome after ICH and the predictive value were evaluated. RESULTS Of 1938 ICH patients, the aetiology of 1295 (66.8%) patients were classified as hypertension, followed by amyloid angiopathy (n = 250, 12.9%), undetermined (n = 159, 8.2%), structural lesions (n = 149, 7.7%), systemic disease (n = 74, 3.8%) and medication (n = 11, 0.6%). The baseline characteristics were different among the six aetiologies. In multivariate analysis, SMASH-U was proven to be a predictor of 12-month unfavourable functional outcome. When adding the SMASH-U system, the predictive performance of max-ICH score was improved (area under the receiver operating characteristic curve from 0.802 to 0.812, p = 0.010) and the predictive accuracy was enhanced (integrated discrimination improvement [IDI]: 1.60%, p < 0.001; continuous net reclassification improvement [NRI]: 28.16%, p < 0.001; categorical NRI: 3.34%, p = 0.004). CONCLUSIONS SMASH-U predicted long-term unfavourable functional outcomes after acute ICH and improved the accuracy of prediction when added to max-ICH score. Integrating the aetiology to a score model to predict the post-ICH outcome may be meaningful and worthy of further exploration.
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Affiliation(s)
- Yuchao Jia
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guo Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guini Song
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaodong Ye
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuyan Yang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kai Lu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shanshan Huang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suiqiang Zhu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Melo-Guzman G, Mendizabal-Guerra R, Burgos-Sosa E, Nicolas-Cruz C, Lara-Torres F, Dommar-Rodriguez CJ, Sanchez-Garcia LM, Villarreal-Barrera OE, Ramirez-Rodriguez JI. Neuro-hybrid treatment for definitive resolution of unrupture cerebral arteriovenous malformations. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Mahendra Y, He M, Rouf MA, Tjakra M, Fan L, Wang Y, Wang G. Progress and prospects of mechanotransducers in shear stress-sensitive signaling pathways in association with arteriovenous malformation. Clin Biomech (Bristol, Avon) 2021; 88:105417. [PMID: 34246943 DOI: 10.1016/j.clinbiomech.2021.105417] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 06/21/2021] [Accepted: 06/21/2021] [Indexed: 02/07/2023]
Abstract
Arteriovenous malformations are congenital vascular lesions characterized by a direct and tangled connection between arteries and veins, which disrupts oxygen circulation and normal blood flow. Arteriovenous malformations often occur in the patient with hereditary hemorrhagic telangiectasia. The attempts to elucidate the causative factors and pathogenic mechanisms of arteriovenous malformations are now still in progress. Some studies reported that shear stress in blood flow is one of the factors involved in arteriovenous malformations manifestation. Through several mechanotransducers harboring the endothelial cells membrane, the signal from shear stress is transduced towards the responsible signaling pathways in endothelial cells to maintain cell homeostasis. Any disruption in this well-established communication will give rise to abnormal endothelial cells differentiation and specification, which will later promote arteriovenous malformations. In this review, we discuss the update of several mechanotransducers that have essential roles in shear stress-induced signaling pathways, such as activin receptor-like kinase 1, Endoglin, Notch, vascular endothelial growth factor receptor 2, Caveolin-1, Connexin37, and Connexin40. Any disruption of these signaling potentially causes arteriovenous malformations. We also present some recent insights into the fundamental analysis, which attempts to determine potential and alternative solutions to battle arteriovenous malformations, especially in a less invasive and risky way, such as gene treatments.
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Affiliation(s)
- Yoga Mahendra
- Key Laboratory for Biorheological Science and Technology of Ministry of Education State and Local Joint Engineering Laboratory for Vascular Implants Bioengineering College of Chongqing University, Chongqing 400030, China
| | - Mei He
- Chongqing University Cancer Hospital, Chongqing Cancer Institute, Chongqing Cancer Hospital, Chongqing, China
| | - Muhammad Abdul Rouf
- Key Laboratory for Biorheological Science and Technology of Ministry of Education State and Local Joint Engineering Laboratory for Vascular Implants Bioengineering College of Chongqing University, Chongqing 400030, China
| | - Marco Tjakra
- Key Laboratory for Biorheological Science and Technology of Ministry of Education State and Local Joint Engineering Laboratory for Vascular Implants Bioengineering College of Chongqing University, Chongqing 400030, China
| | - Longling Fan
- Key Laboratory for Biorheological Science and Technology of Ministry of Education State and Local Joint Engineering Laboratory for Vascular Implants Bioengineering College of Chongqing University, Chongqing 400030, China
| | - Yeqi Wang
- Key Laboratory for Biorheological Science and Technology of Ministry of Education State and Local Joint Engineering Laboratory for Vascular Implants Bioengineering College of Chongqing University, Chongqing 400030, China.
| | - Guixue Wang
- Key Laboratory for Biorheological Science and Technology of Ministry of Education State and Local Joint Engineering Laboratory for Vascular Implants Bioengineering College of Chongqing University, Chongqing 400030, China.
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Abstract
Intracranial vascular abnormalities rarely are encountered in primary care. Many of the pathologies are occult and prognosis varies widely between inconsequential variants of anatomy to acutely life-threatening conditions. Consequently, there often is a great deal of anxiety associated with any potential diagnosis. This article reviews anatomic intracranial vascular lesions, including vascular malformations (arteriovenous malformations/arteriovenous fistulae and cavernous malformations), structural arteriopathies (aneurysms and moyamoya), and common developmental anomalies of the vasculature. The focus includes a general overview of anatomy, pathology, epidemiology, and key aspects of evaluation for the primary care provider and a review of common questions encountered in practice.
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Current concepts and perspectives on brain arteriovenous malformations: A review of pathogenesis and multidisciplinary treatment. World Neurosurg 2021; 159:314-326. [PMID: 34339893 DOI: 10.1016/j.wneu.2021.07.106] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 11/23/2022]
Abstract
Brain arteriovenous malformations (bAVMs) are unusual vascular pathologies characterized by the abnormal aggregation of dilated arteries and veins in the brain parenchyma and for which the absence of a normal vascular structure and capillary bed leads to direct connections between arteries and veins. Although bAVMs have long been believed to be congenital anomalies that develop during the prenatal period, current studies show that inflammation is associated with AVM genesis, growth, and rupture. Interventional treatment options include microsurgery, stereotactic radiosurgery, and endovascular embolization, and management often comprises a multidisciplinary combination of these modalities. The appropriate selection of patients with brain arteriovenous malformations for interventional treatment requires balancing the risk of treatment complications against the risk of hemorrhaging during the natural course of the pathology; however, no definitive guidelines have been established for the management of brain arteriovenous malformations. In this paper, we comprehensively review the current basic and clinical studies on bAVMs and discuss the contemporary status of multidisciplinary management of bAVMs.
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Loh D, Ng V. Cerebral Arteriovenous Malformation Recurrence After Complete Surgical Excision in an Adult: Case Report and Review of the Literature. Cureus 2021; 13:e15366. [PMID: 34249522 PMCID: PMC8249148 DOI: 10.7759/cureus.15366] [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] [Accepted: 05/31/2021] [Indexed: 11/05/2022] Open
Abstract
Angiographically confirmed complete surgical excision of brain arteriovenous malformations (bAVMs) is conventionally considered curative. Recurrence in adults is rarely encountered; only 18 cases have been reported in the English literature over the past 30 years. The potential for recurrence and consequent need for routine long-term follow-up are important considerations in the management of these lesions. We report a case of a 23-year-old female with a recurrent bAVM discovered incidentally on routine imaging three years after complete surgical excision. We review the existing literature and discuss the options for surveillance and management.
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Affiliation(s)
- Daniel Loh
- Neurosurgery, National Neuroscience Institute, Singapore, SGP
| | - Vincent Ng
- Neurosurgery, National Neuroscience Institute, Singapore, SGP
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Nyirenda A, Himwaze C, Mucheleng’anga L. “Medicolegal Masquerade” a ruptured brain arteriovenous malformation mimicking homicide: A case report. FORENSIC SCIENCE INTERNATIONAL: REPORTS 2021. [DOI: 10.1016/j.fsir.2021.100186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Liew J, Feghali J, Huang J. Intracerebral and subarachnoid hemorrhage in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2021; 172:33-50. [PMID: 32768093 DOI: 10.1016/b978-0-444-64240-0.00002-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Maternal stroke occurs in around 34 out of every 100,000 deliveries and is responsible for around 5%-12% of all maternal deaths. It is most commonly hemorrhagic, and women are at highest risk for developing pregnancy-related hemorrhage during the early postpartum period through 6 weeks following the delivery. The most common causes of hemorrhagic stroke in pregnant patients are arteriovenous malformations and cerebral aneurysms. Management is similar to that for acute hemorrhagic stroke in the nonpregnant population with standard use of computed tomography and judicious utilization of intracranial vessel imaging and contrast. The optimal delivery method is evaluated on a case-by-case basis, and cesarean delivery is not always required. As most current studies are limited by retrospective design, relatively small sample sizes, and heterogeneous study term definitions, strong and comprehensive evidence-based guidelines on the management of acute hemorrhagic stroke in pregnant patients are still lacking. In the future, multicenter registries and prospective studies with uniform definitions will help improve management strategies in this complex patient population.
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Affiliation(s)
- Jason Liew
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Catapano JS, Frisoli FA, Nguyen CL, Labib MA, Cole TS, Baranoski JF, Kim H, Spetzler RF, Lawton MT. Intermediate-grade brain arteriovenous malformations and the boundary of operability using the supplemented Spetzler-Martin grading system. J Neurosurg 2021; 136:125-133. [PMID: 34171830 DOI: 10.3171/2020.11.jns203298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Supplemented Spetzler-Martin grading (Supp-SM), which is the combination of Spetzler-Martin and Lawton-Young grades, was validated as being more accurate than stand-alone Spetzler-Martin grading, but an operability cutoff was not established. In this study, the authors surgically treated intermediate-grade AVMs to provide prognostic factors for neurological outcomes and to define AVMs at the boundary of operability. METHODS Surgically treated Supp-SM intermediate-grade (5, 6, and 7) AVMs were analyzed from 2011 to 2018 at two medical centers. Worsened neurological outcomes were defined as increased modified Rankin Scale (mRS) scores on postoperative examinations. A second analysis of 2000-2011 data for Supp-SM grade 6 and 7 AVMs was performed to determine the subtypes with improved or unchanged outcomes. Patients were separated into three groups based on nidus size (S1: < 3 cm, S2: 3-6 cm, S3: > 6 cm) and age (A1: < 20 years, A2: 20-40 years, A3: > 40 years), followed by any combination of the combined supplemented grade: low risk (S1A1, S1A2, S2A1), intermediate risk (S2A2, S1A3, S3A1, or high risk (S3A3, S3A2, S2A3). RESULTS Two hundred forty-six patients had intermediate Supp-SM grade AVMs. Of these patients, 102 had Supp-SM grade 5 (41.5%), 99 had Supp-SM grade 6 (40.2%), and 45 had Supp-SM grade 7 (18.3%). Significant differences in the proportions of patients with worse mRS scores at follow-up were found between the groups, with 24.5% (25/102) of patients in Supp-SM grade 5, 29.3% (29/99) in Supp-SM grade 6, and 57.8% (26/45) in Supp-SM grade 7 (p < 0.001). Patients with Supp-SM grade 7 AVMs had significantly increased odds of worse postoperative mRS scores (p < 0.001; OR 3.7, 95% CI 1.9-7.3). In the expanded cohort of 349 Supp-SM grade 6 AVM patients, a significantly higher proportion of older patients with larger Supp-SM grade 6 AVMs (grade 6+, 38.6%) had neurological deterioration than the others with Supp-SM grade 6 AVMs (22.9%, p = 0.02). Conversely, in an expanded cohort of 197 Supp-SM grade 7 AVM patients, a significantly lower proportion of younger patients with smaller Supp-SM grade 7 AVMs (grade 7-, 19%) had neurological deterioration than the others with Supp-SM grade 7 AVMs (44.9%, p = 0.01). CONCLUSIONS Patients with Supp-SM grade 7 AVMs are at increased risk of worse postoperative neurological outcomes, making Supp-SM grade 6 an appropriate operability cutoff. However, young patients with small niduses in the low-risk Supp-SM grade 7 group (grade 7-) have favorable postoperative outcomes. Outcomes in Supp-SM grade 7 patients did not improve with surgeon experience, indicating that the operability boundary is a hard limit reflecting the complexity of high-grade AVMs.
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Affiliation(s)
- Joshua S Catapano
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
| | - Fabio A Frisoli
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
| | - Candice L Nguyen
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
| | - Mohamed A Labib
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
| | - Tyler S Cole
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
| | - Jacob F Baranoski
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
| | - Helen Kim
- 2Center for Cerebrovascular Research Department of Anesthesia and Perioperative Care, University of California, San Francisco, California
| | - Robert F Spetzler
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
| | - Michael T Lawton
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona and
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Yu JX, He C, Ye M, Li GL, Bian LS, Yang F, Zhai XD, Ling F, Zhang HQ, Hong T. The efficacy and deficiency of contemporary treatment for spinal cord arteriovenous shunts. Brain 2021; 144:3381-3391. [PMID: 34156437 DOI: 10.1093/brain/awab237] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/15/2021] [Accepted: 06/03/2021] [Indexed: 11/12/2022] Open
Abstract
Contemporary treatments for spinal cord arteriovenous shunts are only based on clinicians' treatment experiences and expertise due to its rarity. We reviewed the clinical course of the largest multi-cantered cohort to evaluate the efficacy and deficiency of contemporary interventional treatments for spinal cord arteriovenous shunts. The clinical features, treatment results and clinical outcomes of 463 spinal cord arteriovenous shunts patients were retrospectively assessed. The main outcome was the neurological deterioration that was evaluated based on the modified Aminoff and Logue scale. According to post-treatment DSA, complete obliteration was defined as disappearance of the intradural lesion, whereas partial obliteration was defined as any residual intradural lesion remaining visible and was further categorized as shunt-reduction obliteration (the nidus or shunt points was reduced) or palliative obliteration (only obliterated aneurysms or feeders). Cure rate was 40.6% for whole cohort, 58.5% after microsurgery, and 26.4% after embolization. The curative resection was associated with non-metameric lesions, lesions with a maximum diameter < 3 cm and lesions without anterior sulcal artery supply. The curative embolization was associated with fistula-type lesions, non-metameric lesions, and main drainage diameter < 1.5 mm. Permanent treatment-related neurological deficits rate was 11.2% for the whole cohort, 16.1% after microsurgery, and 5.6% after embolization. The pre-treatment clinical deterioration rate was 32.5%/year, which decreased to 9.3%/year after clinical interventions. After partial treatment, the long-term acute and gradual deterioration rate were 5.3%/year and 3.6%/year, respectively. The acute deteriorations were associated with metameric lesions, craniocervical lesions, lesions with a maximum diameter ≥2 cm and residual aneurysm. Residual aneurysm was the only predictor of acute deterioration for non-metameric spinal cord arteriovenous shunts. The gradual deteriorations were associated with palliative obliteration, absence of pre-treatment acute deterioration and intact main drainage. Although clinical risks of spinal cord arteriovenous shunts were reduced after clinical interventions, contemporary treatments for spinal cord arteriovenous shunt remains associated with considerable risks and incomplete efficacy. Individualized treatment plans should be adopted according to the angioarchitectural features and major clinical risks of specific lesions. There is a higher opportunity for complete obliteration for lesions with simple angioarchitecture. However, regarding most of spinal cord arteriovenous shunts with complex vascular anatomy, partial treatment is the only choice. For these patients, palliative obliteration targeting the aneurysms is recommended for reducing hemorrhagic risk, whereas shunt-reduction obliteration is necessary for non-haemorrhagic myelopathy. Contemporary treatment is ineffective in reducing hemorrhagic risk of incurable metameric spinal cord arteriovenous shunts.
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Affiliation(s)
- Jia-Xing Yu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Gui-Lin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Li-Song Bian
- Department of Neurosurgery, Beijing Haidian Hospital, Beijing, China
| | - Fan Yang
- Department of Neurosurgery, Beijing United Family Hospital, Beijing, China
| | - Xiao-Dong Zhai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Feng Ling
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Hong-Qi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
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Cortese J, Delaitre M, Shotar E, Lenck S, Premat K, Hasboun D, Talbi A, Grand T, Boch AL, Mathon B, Valery CA, Drir M, Sourour NA, Clarençon F. Clinical Characteristics, Angioarchitecture and Management of Tectum Mesencephali Arteriovenous Malformations : A Retrospective Case Series. Clin Neuroradiol 2021; 32:445-454. [PMID: 34152431 DOI: 10.1007/s00062-021-01047-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Tectum mesencephali arteriovenous malformations (TM-AVMs) are rare lesions deeply located close to eloquent structures making them challenging to treat. We aimed to present clinical presentation, angiographic features and treatment strategies of TM-AVMs through a single center retrospective case series. METHODS A TM-AVMs is defined as a nidus located in the parenchyma or on the pia mater of the posterior midbrain. Records of consecutive patients admitted with TM-AVMs over a 21-year period were retrospectively analyzed. Vascular anatomy of the region is also reviewed. RESULTS In this study 13 patients (1.63% of the complete cohort; 10 males), mean age 48 years, were included. All patients presented with intracranial hemorrhage and two patients (15%) died after an early recurrent bleeding. Mean size of the TM-AVMs was 10.1 ± 5 mm. Multiple arterial feeders were noted in every cases. Of the patients 11 underwent an exclusion treatment, 8 via embolization (6 via arterial access and 2 via venous access) and 4 via stereotactic radiosurgery (SRS) (1 patient received both). Overall success treatment rate was 7/11 patients (64% overall; 63% in the embolization group, 25% in the SRS group). Two hemorrhagic events led to a worsened outcome, one during embolization and one several years after SRS. All other patients remained clinically stable or improved. CONCLUSION The TM-AVMs are rare but stereotypic lesions found in a hemorrhagic context. Multiple arterial feeders are always present. Endovascular treatment seems to be an effective technique with relatively low morbidity; SRS had a low success rate but was only use in a limited number of patients.
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Affiliation(s)
- Jonathan Cortese
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | | | - Eimad Shotar
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Stéphanie Lenck
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Kévin Premat
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France.,Sorbonne University, Paris, France
| | - Dominique Hasboun
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France.,Sorbonne University, Paris, France
| | - Atika Talbi
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Téodor Grand
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Anne-Laure Boch
- APHP. Department of Neurosurgery, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Bertrand Mathon
- Sorbonne University, Paris, France.,APHP. Department of Neurosurgery, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Charles-Ambroise Valery
- APHP. Department of Neurosurgery, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Mehdi Drir
- APHP. Department of Anesthesiology and Neuro-critical Care, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Nader-Antoine Sourour
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Frédéric Clarençon
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France. .,Sorbonne University, Paris, France. .,GRC BioFast, Sorbonne University, Paris, France.
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Preradiosurgery embolization in reducing the postoperative hemorrhage rate for patients with cerebral arteriovenous malformations: a systematic review and meta-analysis. Neurosurg Rev 2021; 44:3197-3207. [PMID: 33864525 DOI: 10.1007/s10143-021-01530-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 02/10/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
Few studies have examined the postoperative hemorrhage rate of cerebral arteriovenous malformations (AVMs) treated by embolization prior to stereotactic radiosurgery. The objective of this analysis was to compare the postoperative hemorrhage rate between AVMs treated with and those treated without preradiosurgery embolization. A systematic search of the PubMed and Embase databases was performed with no restriction on the publication period. Based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies with sufficient baseline and outcome data. The analysis was performed using Comprehensive Meta-Analysis (CMA) 2.0. Eleven studies comprising 2591 patients were eligible for analysis. There was no significant difference in the postoperative hemorrhage rate between patients who had undergone embolization followed by SRS and those who had undergone SRS alone (OR 1.140, 95% CI 0.851-1.526, p = 0.38). The obliteration rate was significantly lower in the E + SRS group than in the SRS group (OR 0.586, 95% CI 0.398-0.863, p = 0.007). No significant difference in permanent neurological deficits was identified between patients who had undergone embolization followed by SRS and those who had undergone SRS alone (OR 1.175, 95% CI 0.626-2.206, p = 0.616). Available data suggested that preradiosurgery embolization did not reduce the postoperative hemorrhage rate and resulted in a significantly lower obliteration rate than treatment with SRS alone.
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Martín-Noguerol T, Concepción-Aramendia L, Lim CT, Santos-Armentia E, Cabrera-Zubizarreta A, Luna A. Conventional and advanced MRI evaluation of brain vascular malformations. J Neuroimaging 2021; 31:428-445. [PMID: 33856735 DOI: 10.1111/jon.12853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 02/14/2021] [Accepted: 03/02/2021] [Indexed: 11/26/2022] Open
Abstract
Vascular malformations (VMs) of the central nervous system (CNS) include a wide range of pathological conditions related to intra and extracranial vessel abnormalities. Although some VMs show typical neuroimaging features, other VMs share and overlap pathological and neuroimaging features that hinder an accurate differentiation between them. Hence, it is not uncommon to misclassify different types of VMs under the general heading of arteriovenous malformations. Thorough knowledge of the imaging findings of each type of VM is mandatory to avoid these inaccuracies. Conventional MRI sequences, including MR angiography, have allowed the evaluation of CNS VMs without using ionizing radiation. Newer MRI techniques, such as susceptibility-weighted imaging, black blood sequences, arterial spin labeling, and 4D flow imaging, have an added value of providing physiopathological data in real time regarding the hemodynamics of VMs. Beyond MR images, new insights using 3D printed models are being incorporated as part of the armamentarium for a noninvasive evaluation of VMs. In this paper, we briefly review the pathophysiology of CNS VMs, focusing on the MRI findings that may be helpful to differentiate them. We discuss the role of each conventional and advanced MRI sequence for VMs assessment and provide some insights about the value of structured reports of 3D printing to evaluate VMs.
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Affiliation(s)
| | | | - Cc Tchoyoson Lim
- Neuroradiology Department, National Neuroscience Institute and Duke-NUS Medical School, Singapore
| | | | | | - Antonio Luna
- MRI Unit, Radiology Department, HT Medica, Jaén, Spain
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125
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Homocysteine Level and Risk of Hemorrhage in Brain Arteriovenous Malformations. DISEASE MARKERS 2021; 2021:8862299. [PMID: 33859768 PMCID: PMC8026282 DOI: 10.1155/2021/8862299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/10/2020] [Accepted: 03/20/2021] [Indexed: 11/17/2022]
Abstract
Objective We aimed to investigate the risk factors associated with hemorrhage and clarify the relation of homocysteine (Hcy) with brain arteriovenous malformations (bAVMs). Method We retrospectively reviewed bAVM patients from Beijing Tiantan Hospital between January 2019 and December 2019. Clinical and laboratory variables were analyzed in enrolled patients with bAVMs. Potential predictors associated with hemorrhage were evaluated by logistic regression analysis. Results A total of 143 bAVM patients were identified in the study, including 69 unruptured and 74 ruptured cases. Patients with hemorrhage were less likely to have hyperhomocysteinemia (P = 0.023). Logistic regression analysis showed that increased maximum diameter of bAVM lesions (odds ratio (OR) 0.634, 95% confidence intervals (CI) 0.479-0.839; P = 0.001) and serum Hcy level (OR 0.956, 95% CI 0.920-0.993; P = 0.021) were associated with lower risk of hemorrhage in bAVMs. Conclusion The present study provided evidence regarding the association between serum Hcy and hemorrhage in patients with bAVMs. Higher Hcy level was correlated with a lower risk of rupture. Detection of factors for subsequent hemorrhage is necessary to develop therapeutic strategies for bAVMs preferably.
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Chen L, Zhou J, Deng Q, Feng J, Qiu Q, Huang W, Chen Y, Li Y. Ultrasound-visualized, site-specific vascular embolization using magnetic protein microcapsules. J Mater Chem B 2021; 9:2407-2416. [PMID: 33623935 DOI: 10.1039/d0tb02715d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Imaging-guided vascular embolization is frequently performed on patients with advanced hepatocellular carcinoma (HCC) to alleviate symptoms and extend their survival time. Current operation procedures are not only painful for patients, but are also inaccurate in tumor targeting after the release of embolic agents from the catheter, leading to injury to healthy tissues simultaneously. In this study, we developed an ultrasound-visualized, site-specific vascular embolization strategy with magnetic protein microcapsules (MPMs). MPMs were fabricated using a rapid emulsification method, giving it a smooth surface and a core-shell structure. Their diameters could be controlled within 10 μm, allowing them to pass through capillaries. The core-shell structure and loading of magnetic Fe3O4 endowed MPMs with good contrast under ultrasound imaging and magnetically inducible targeting properties, as well as aggregation response even under flowing conditions. In vitro cytotoxicity and hemolysis evaluation demonstrated good biocompatibility of the MPMs. Furthermore, mock embolization showed that cell death could be induced by aggregation of the MPMs. Such a combination of real-time monitoring using ultrasound and control on targeted vascular embolization might be a breakthrough in the treatment of advanced HCC.
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Affiliation(s)
- Lanxi Chen
- School of Biomedical Engineering, Sun Yat-sen University, Guangzhou 510006, China.
| | - Jianhua Zhou
- School of Biomedical Engineering, Sun Yat-sen University, Guangzhou 510006, China.
| | - Qiurong Deng
- School of Biomedical Engineering, Sun Yat-sen University, Guangzhou 510006, China.
| | - Jialin Feng
- Department of Chemistry, University of Cambridge, Lensfield Road, Cambridge, UK
| | - Qiong Qiu
- Department of Cardiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou 510120, China
| | - Wenwei Huang
- School of Biomedical Engineering, Sun Yat-sen University, Guangzhou 510006, China.
| | - Yin Chen
- School of Biomedical Engineering, Sun Yat-sen University, Guangzhou 510006, China.
| | - Yan Li
- School of Biomedical Engineering, Sun Yat-sen University, Guangzhou 510006, China.
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Sati L, Soygur B, Goksu E, Bassorgun CI, McGrath J. CTCFL expression is associated with cerebral vascular abnormalities. Tissue Cell 2021; 72:101528. [PMID: 33756271 DOI: 10.1016/j.tice.2021.101528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 02/06/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
CTCFL is expressed in testis, oocytes and embryonic stem cells, and is aberrantly expressed in malignant cells, and is classified as a cancer-testis gene. We have previously shown by using a tetracycline-inducible Ctcfl transgene that inappropriate expression of Ctcfl negatively impacts fetal development and causes early postnatal lethality in the mouse. The affected pups displayed severe vascular abnormalities and localized hemorrhages in the brain evocative of cerebral cavernous malformations (CCM) and arteriovenous malformations (AVM) in humans. Thus, we aim to analyze; a) the presence of CCM-related proteins CCM1/KRIT1, CCM2/malcavernin and CCM3/PDCD10 in Ctcfl transgenic animals and, b) whether there is CTCFL expression in human CCM and AVM tissues. Ctcfl transgenic animals exhibited increased CD31 expression in vascular areas of the dermis and periadnexal regions but no difference was observed for vWF and α-SMA expressions. CCM-related proteins CCM1/KRIT1, CCM2/malcavernin and CCM3/PDCD10 were aberrantly expressed in coronal sections of the head in transgenic animals. We also observed CTCFL expression in human CCMs and AVMs. The induced expression of CTCFL resulting in vascular brain malformations in mice combined with the presence of CTCFL in human vascular malformations provide new insights into the role of this gene in vascular development in humans.
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Affiliation(s)
- Leyla Sati
- Department of Histology and Embryology, Akdeniz University School of Medicine, Antalya, Turkey.
| | - Bikem Soygur
- Department of Histology and Embryology, Akdeniz University School of Medicine, Antalya, Turkey; Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Reproductive Sciences, Eli and Edythe Broad Center of Regeneration Medicine and Stem Cell Research, University of California San Francisco, San Francisco, CA, USA
| | - Ethem Goksu
- Department of Neurosurgery, Akdeniz University School of Medicine, Antalya, Turkey
| | | | - James McGrath
- Departments of Genetics and Comparative Medicine, Yale University School of Medicine, New Haven, CT, USA
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128
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Hou K, Li C, Su H, Yu J. Imaging Characteristics and Endovascular Treatment of Brain Arteriovenous Malformations Mainly Fed by the Posterior Cerebral Artery. Front Neurol 2021; 11:609461. [PMID: 33584508 PMCID: PMC7873489 DOI: 10.3389/fneur.2020.609461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/14/2020] [Indexed: 11/23/2022] Open
Abstract
Background: A BAVM that is mainly supplied by the posterior cerebral artery (PCA) lies deeply in the middle of the bilateral posterior hemispheres. Few studies have investigated the imaging characteristics and endovascular treatment (EVT) of brain arteriovenous malformations (BAVMs) in this area. Methods: A retrospective study was performed for patients who were diagnosed with PCA-BAVMs from January 2015 to December 2019. The PCA-BAVMs were divided into type I and type II according to their feeding arteries. Type I PCA-BAVMs were supplied by the posterior choroidal artery (PchA) from the PCA. They could be further subdivided into type Ia and type Ib. Type II PCA-BAVMs were supplied by the temporal or occipital branch from the PCA. They could also be further subdivided into type IIa and IIb. Targeted embolization of the risk factors was the main aim of EVT. Results: Forty-two patients were identified, with age ranging from 6 to 63 years. Twenty-four cases belonged to type I (57.1%, 24/42), including 6 Ia cases and 18 Ib cases. Eighteen cases belonged to type II (42.9%, 18/42), including 7 IIa cases and 11 IIb cases. Immediate complete or nearly complete embolization was achieved in 17 (40.5%, 17/42) cases. Partial embolization was achieved in 25 (59.5%, 25/42) cases. Two (4.8%, 2/42) patients experienced intraoperative or postoperative bleeding. The GOS scores at discharge were 3, 4, and 5 in 2 (4.8%, 2/42), 2 (4.8%, 2/42), and 38 (90.4%, 38/42) cases, respectively. There was no statistical difference between patients in type I and type II groups regarding age, BAVM rupture, SM grade, immediate extent of obliteration, and prognosis. Deep venous drainage was more common in patients of the type I group (P < 0.001). Conclusions: Our classification of the PCA-BAVMs was based on the segmentation of the PCA, which is a reasonable approach and could guide the strategy of EVT. EVT is a reasonable option for the PCA-BAVMs. The main aim of EVT is to secure the weak structures. A targeted EVT aimed at the ruptured part of the BAVM can reduce the risk of early rebleeding.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Chao Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Han Su
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
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129
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Volovici V, Schouten JW, Vajkoczy P, Dammers R, Meling TR. Unruptured Arteriovenous Malformations: Do We Have an Answer After the Final Follow-Up of ARUBA? A Bayesian Viewpoint. Stroke 2021; 52:1143-1146. [PMID: 33494639 DOI: 10.1161/strokeaha.120.032429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Brain arteriovenous malformations (bAVMs) are vascular lesions that carry significant morbidity and mortality risk upon rupture. bAVM rupture causes either intracerebral or intraventricular hemorrhage, or both. In 2014, the first results of the ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformations) were published in The Lancet, causing a paradigm shift in clinical practice and suggesting the superiority of medical treatment in terms of mortality or stroke compared with any intervention designed to obliterate the AVM. In 2020, the final results of the ARUBA trial were published. In this Viewpoint, we critically review the clinical equipoise behind the trial, highlight issues regarding external validity, and place the results of the trial in the context of other results in scientific literature of bAVMs using Bayesian inference. ARUBA is a trial of decision-making, and only proper knowledge of the nuances of its interpretation within the broader context of bAVM research can lead to proper decision-making when confronted with patients with unruptured bAVMs.
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Affiliation(s)
- Victor Volovici
- Department of Neurosurgery, Erasmus MC Stroke Center (V.V., J.W.S., R.D.), Erasmus MC Rotterdam, the Netherlands.,Center for Medical Decision Making, Department of Public Health (V.V.), Erasmus MC Rotterdam, the Netherlands
| | - Joost W Schouten
- Department of Neurosurgery, Erasmus MC Stroke Center (V.V., J.W.S., R.D.), Erasmus MC Rotterdam, the Netherlands
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité University Hospital, Berlin, Germany (P.V.)
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC Stroke Center (V.V., J.W.S., R.D.), Erasmus MC Rotterdam, the Netherlands
| | - Torstein R Meling
- Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals, Switzerland (T.R.M.).,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway (T.R.M.)
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Rodriguez-Calienes A, Bustamante-Paytan D, Camacho K, Mayoria-Vargas A, Saal-Zapata G, Rodriguez-Varela R. Early Outcomes and Complications of Endovascular Treatment of Cerebral Arteriovenous Malformations in Pediatric Patients. Pediatr Neurosurg 2021; 56:116-124. [PMID: 33601400 DOI: 10.1159/000513577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 12/03/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Arteriovenous malformations (AVMs) are the commonest cause of hemorrhagic stroke in children. Endovascular embolization is a feasible treatment modality, but cure rates are heterogenous from one series to another. We aimed to describe the immediate obliteration rates and periprocedural complications of embolization of pediatric AVMs. METHODS Between 2011 and 2019, participants below 18 years of age with AVMs treated by the same neurosurgeon at a single center were included. The clinical features, immediate angiographic results, and periprocedural complications were retrospectively collected from the clinical records. RESULTS Thirty-four embolization sessions were performed on 20 children (12 females with a mean age of 13). Intracranial hemorrhage was the most common presentation (75%), and the majority were frontal (30%) and basal ganglia (30%) lesions. An immediate complete angiographic obliteration was achieved in 9 patients (45%) with low-grade lesions (Spetzler-Martin grade I and II). NBCA was the most common embolic agent used (52.9%). Complications were reported in 3 (8.8%) out of 34 sessions. Two of them were intraoperative perforations with clinical consequences. A slight cortical hemorrhage during the procedure was observed in 1 patient without clinical repercussions. DISCUSSION This single-surgeon single-center experience suggests that endovascular treatment is a safe and efficient treatment for pediatric AVMs. Pediatric prognostic scores for a suitable selection of candidates are needed. Further studies are required to validate these results.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru, .,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru,
| | - Diego Bustamante-Paytan
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru
| | - Kiara Camacho
- Facultad de Medicina Humana, Universidad Científica del Sur, Lima, Peru
| | - Angie Mayoria-Vargas
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru
| | - Giancarlo Saal-Zapata
- Departamento de Neurocirugía, Servicio de Neurocirugía Endovascular, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Rodolfo Rodriguez-Varela
- Departamento de Neurocirugía, Servicio de Neurocirugía Endovascular, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
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131
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Giarretta I, Pola R. Arteriovenous malformations: the newest Sonic hedgehog game in the postnatal brain. Neural Regen Res 2021; 16:996-998. [PMID: 33229750 PMCID: PMC8178779 DOI: 10.4103/1673-5374.297077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Igor Giarretta
- Department of Translational Medicine and Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, School of Medicine, Rome, Italy
| | - Roberto Pola
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, School of Medicine, Rome, Italy
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Abstract
The complex development of the brain vascular system can be broken down by embryonic stages and anatomic locations, which are tightly regulated by different factors and pathways in time and spatially. The adult brain is relatively quiescent in angiogenesis. However, under disease conditions, such as trauma, stroke, or tumor, angiogenesis can be activated in the adult brain. Disruption of any of the factors or pathways may lead to malformed vessel development. In this chapter, we will discuss factors and pathways involved in normal brain vasculogenesis and vascular maturation, and the pathogenesis of several brain vascular malformations.
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Affiliation(s)
- Yao Yao
- Department of Pharmaceutical and Biomedical Sciences, University of Georgia, Athens, GA, United States
| | - Sonali S Shaligram
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, CA, United States
| | - Hua Su
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, CA, United States.
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133
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Management of Intracerebral Hemorrhage: JACC Focus Seminar. J Am Coll Cardiol 2020; 75:1819-1831. [PMID: 32299594 DOI: 10.1016/j.jacc.2019.10.066] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 10/27/2019] [Indexed: 01/12/2023]
Abstract
Intracerebral hemorrhage (ICH) accounts for a disproportionate amount of stroke-related morbidity and mortality. Although chronic hypertension and cerebral amyloid angiopathy are the underlying cerebral vasculopathies accounting for the majority of ICH, there are a broad range of potential causes, and effective management requires accurate identification and treatment of the underlying mechanism of hemorrhage. Magnetic resonance imaging and vascular imaging techniques play a critical role in identifying disease mechanisms. Modern treatment of ICH focuses on rapid stabilization, often requiring urgent treatment of mass effect, aggressive blood pressure reduction and correction of contributing coagulopathies to achieve hemostasis. We discuss management of patients with ICH who continue to require long-term anticoagulation, the interaction of ICH with neurodegenerative diseases, and our approach to prognostication after ICH. We close this review with a discussion of novel medical and surgical approaches to ICH treatment that are being tested in clinical trials.
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134
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Graffeo CS, Sahgal A, De Salles A, Fariselli L, Levivier M, Ma L, Paddick I, Regis JM, Sheehan J, Suh J, Yomo S, Pollock BE. Stereotactic Radiosurgery for Spetzler-Martin Grade I and II Arteriovenous Malformations: International Society of Stereotactic Radiosurgery (ISRS) Practice Guideline. Neurosurgery 2020; 87:442-452. [PMID: 32065836 PMCID: PMC7426190 DOI: 10.1093/neuros/nyaa004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 11/30/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND No guidelines have been published regarding stereotactic radiosurgery (SRS) in the management of Spetzler-Martin grade I and II arteriovenous malformations (AVMs). OBJECTIVE To establish SRS practice guidelines for grade I-II AVMs on the basis of a systematic literature review. METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant search of Medline, Embase, and Scopus, 1986-2018, for publications reporting post-SRS outcomes in ≥10 grade I-II AVMs with a follow-up of ≥24 mo. Primary endpoints were obliteration and hemorrhage; secondary outcomes included Spetzler-Martin parameters, dosimetric variables, and “excellent” outcomes (defined as total obliteration without new post-SRS deficit). RESULTS Of 447 abstracts screened, 8 were included (n = 1, level 2 evidence; n = 7, level 4 evidence), representing 1102 AVMs, of which 836 (76%) were grade II. Obliteration was achieved in 884 (80%) at a median of 37 mo; 66 hemorrhages (6%) occurred during a median follow-up of 68 mo. Total obliteration without hemorrhage was achieved in 78%. Of 836 grade II AVMs, Spetzler-Martin parameters were reported in 680: 377 were eloquent brain and 178 had deep venous drainage, totaling 555/680 (82%) high-risk SRS-treated grade II AVMs. CONCLUSION The literature regarding SRS for grade I-II AVM is low quality, limiting interpretation. Cautiously, we observed that SRS appears to be a safe, effective treatment for grade I-II AVM and may be considered a front-line treatment, particularly for lesions in deep or eloquent locations. Preceding publications may be influenced by selection bias, with favorable AVMs undergoing resection, whereas those at increased risk of complications and nonobliteration are disproportionately referred for SRS.
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Affiliation(s)
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Antonio De Salles
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California
| | - Laura Fariselli
- Fondazione IRCCS Istituto Neurologico Carlo Besta Milano, Unità di Radioterapia, Milan, Italy
| | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Ian Paddick
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Jean Marie Regis
- Department of Functional Neurosurgery, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - John Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota.,Department Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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135
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Song J, Li P, Tian Y, An Q, Liu Y, Yang Z, Chen L, Quan K, Gu Y, Ni W, Zhu W, Mao Y. One-Stage Treatment in a Hybrid Operation Room to Cure Brain Arteriovenous Malformation: A Single-Center Experience. World Neurosurg 2020; 147:e85-e97. [PMID: 33348099 DOI: 10.1016/j.wneu.2020.11.123] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/20/2020] [Accepted: 11/21/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report the principles and techniques of using a hybrid operation room in the treatment of brain arteriovenous malformation (BAVM). METHODS From October 1, 2016 to December 31, 2018, we treated 54 consecutive patients with nonemergent BAVM in a hybrid operation room. The clinical data, radiologic images, and outcomes were collected to establish a prospective database for evaluation. RESULTS Thirty-two male and 22 female patients were enrolled with a mean age of 32.6 ± 13.1 years (range, 10-61 years). Bleeding (n = 32, 59.3%) was the main clinical presentation, followed by headache (n = 27, 50.0%), seizures (n = 14, 25.9%), neurofunctional deficits (n = 16, 29.6%), and no symptoms (n = 2, 3.7%). Thirty-one patients (57.4%) accepted resection without intraoperative embolization, 18 (33.3%) were treated with combined embolization and resection, and 5 (9.3%) were cured with intraoperative embolization and resection was cancelled. All patients achieved total BAVM obliteration confirmed with intraoperative angiography. There were no significant differences in outcomes between low-grade (Spetzler-Martin grades I, II, and modified grade III-) and high-grade (Spetzler-Martin grades ≥IV and modified grade III+) groups, except that the high-grade group had more blood loss (667.9 ± 647.5 vs. 284.3 ± 148.6 mL; P = 0.046) and longer postoperative hospitalization (17.1 ± 9.1 vs. 10.8 ± 5.4 days; P = 0.026). At discharge, 52 patients (96.3%) had favorable outcomes (Glasgow Outcome Scale score ≥4). Forty-three patients (79.6%) received 1 year follow-up after treatment; 97.7% (n = 42) of these had ongoing favorable outcomes. However, 4 patients with low-grade BAVM had recurrence. CONCLUSIONS The hybrid operation room can ensure safe, comprehensive treatment of BAVM, offering the opportunity for a favorable curative treatment in 1 stage.
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Affiliation(s)
- Jianping Song
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Peiliang Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Yanlong Tian
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Qingzhu An
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Yingjun Liu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Zixiao Yang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Liang Chen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Kai Quan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Wei Ni
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China.
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Neurosurgical Institute of Fudan University, Shanghai, China; Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China; Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
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136
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Di Bartolomeo A, Scafa AK, Giugliano M, Dugoni DE, Ruggeri AG, Delfini R. Ruptured Brain Arteriovenous Malformations: Surgical Timing and Outcomes-A Retrospective Study of 25 Cases. J Neurosci Rural Pract 2020; 12:4-11. [PMID: 33551615 PMCID: PMC7857959 DOI: 10.1055/s-0040-1716792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background One important problem in treatment of ruptured brain arteriovenous malformations (bAVMs) is surgical timing. The aim of the study was to understand which parameters affect surgical timing and outcomes the most. Materials and Methods Between January 2010 and December 2018, 25 patients underwent surgery for a ruptured bAVM at our institute. Intracerebral hemorrhage (ICH) score was used to evaluate hemorrhage severity, while Spetzler-Martin scale for AVM architecture. We divided patients in two groups: "early surgery" and "delayed surgery." The modified Rankin Scale (mRS) evaluated the outcomes. Results Eleven patients were in the "early surgery" group: age 38 ± 18 years, Glasgow Coma Scale (GCS) 7.64 ± 2.86, ICH score 2.82 ± 0.71, hematoma volume 45.55 ± 23.21 mL. Infratentorial origin of hemorrhage was found in 27.3% cases; AVM grades were I to II in 82%, III in 9%, and IV in 9% cases. Outcome at 3 months was favorable in 36.4% cases and in 54.5% after 1 year. Fourteen patients were in the "delayed surgery" group: age 41 ± 16 years, GCS 13.21 ± 2.39, ICH score 1.14 ± 0.81, hematoma volume 29.89 ± 21.33 mL. Infratentorial origin of hemorrhage was found in 14.2% cases; AVM grades were I to II in 50% and III in 50%. Outcome at 3 months was favorable in 78.6% cases and in 92.8% after 1 year. Conclusions The early outcome is influenced more by the ICH score, while the delayed outcome by Spetzler-Martin grading. These results suggest that it is better to perform surgery after a rest period, away from the hemorrhage when possible. Moreover, this study suggests how in young patient with a high ICH score and a low AVM grade, early surgery seems to be a valid and feasible therapeutic strategy.
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Affiliation(s)
- Alessandro Di Bartolomeo
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Anthony Kevin Scafa
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Marco Giugliano
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Demo Eugenio Dugoni
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Andrea Gennaro Ruggeri
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Roberto Delfini
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
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137
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Association between draining vein diameters and intracranial arteriovenous malformation hemorrhage: a multicentric retrospective study. Neuroradiology 2020; 62:1497-1505. [PMID: 32607748 DOI: 10.1007/s00234-020-02484-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/22/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Intracranial arteriovenous malformations (AVMs) cause hemorrhage, and the role of draining vein diameters in rupture risk is controversial. The aims of the present study were to investigate the variables related with intracranial AVM rupture and to examine the association of draining vein diameters and AVM hemorrhage. METHODS Two hundred three patients were included in this study, of which 117 (57%) had unruptured AVMs, and 86 (43%) had ruptured AVMs. RESULTS In an adjusted (multivariate) analysis, the variables significantly associated with AVM hemorrhagic presentation were age (OR per year increase 0.97, 95%CI 0.95-0.99, p = 0.007), a deep nidus compared with superficial nidus (OR 3.21, 95%CI 1.13-9.06, p = 0.028), the nidus diameter (OR per each mm increase 0.95, 95%CI 0.92-0.97, p < 0.001), a single draining vein compared with multiple draining veins (OR 2.14, 95%CI 1.02-4.50, p = 0.044), the draining vein diameter (OR per mm increase 1.52, 95%CI 1.26-1.83, p < 0.001), and a draining vein diameter ≥ 5 mm compared with < 5 mm (OR 5.80, 95%CI 2.70-12.47, p < 0.001). CONCLUSION In this study, after adjusted analysis, the variables associated with intracranial AVM hemorrhagic presentation were a young age, a small nidus diameter, a deeply located nidus, a single draining vein, and large draining vein diameters. A draining vein diameter cutoff ≥ 5 mm was positively associated with the risk of AVM rupture. A large and prospective study is now necessary to confirm if draining vein diameter is a risk factor for AVM hemorrhage.
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138
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Zhang M, Feng Z, Yu W, Fu C. Artery of Percheron as a Rare Feeder of Hemorrhagic Thalamic Arteriovenous Malformation: A Case Report and Literature Review. Int J Gen Med 2020; 13:771-774. [PMID: 33116768 PMCID: PMC7547762 DOI: 10.2147/ijgm.s279226] [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: 08/28/2020] [Accepted: 09/24/2020] [Indexed: 11/23/2022] Open
Abstract
Arteriovenous malformation (AVM) fed by the artery of Percheron (AOP) is extremely rare, with only one case described in the literature to date. We herein present a case of a 43-year-old female with hemorrhagic thalamic AVM mainly supplied by the AOP, who subsequently underwent conservative management and recovered well except for mild right hemiparesis. This case highlights that the AOP is a rarely recognized but clinically significant entity and should be identified when dealing with AOP-associated neurovascular disorder as described.
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Affiliation(s)
- Mengchao Zhang
- Department of Radiology, China-Japan Union Hospital of Jilin University, Changchun, Mainland China
| | - Zheng Feng
- Department of Pediatrics, China-Japan Union Hospital of Jilin University, Changchun, Mainland China
| | - Weidong Yu
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, Mainland China
| | - Chao Fu
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, Mainland China
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139
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Montalvo-Afonso A, Delgado-López PD, Lista-Araujo MT, Rodríguez-Salazar A. Angiographically occult and spontaneously thrombosed large brain arteriovenous malformation. Neurocirugia (Astur) 2020; 32:S1130-1473(20)30102-0. [PMID: 33060023 DOI: 10.1016/j.neucir.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/05/2020] [Accepted: 08/21/2020] [Indexed: 11/16/2022]
Abstract
Treatment for brain arteriovenous malformations (AVM) include combinations of surgery, radiosurgery and embolization. Very rarely, spontaneous obliteration may occur, especially among small lesions with single superficial vein drainage and prior bleeding. We report the case of a large symptomatic AVM, without history of hemorrhage or prior treatment, in which self-obliteration was noted at surgery. Although MRI suggested the presence of an AVM, no evidence of arterial anomaly was observed in the brain angiography. At surgery, a large cortical nidus with tortuous arterial vessels, resembling that of an AVM but without blood flow, was identified. Complete resection was easily performed without relevant bleeding. The histopathologic study confirmed the diagnosis of a thrombosed AVM. Despite the low probability of recanalization, surgical resection of a suspected spontaneously obliterated AVM may be warranted, in order to reach a definitive diagnosis and to avoid the risk of an eventual bleeding, especially among younger patients.
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Affiliation(s)
- Antonio Montalvo-Afonso
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España. C/Doctor Esquerdo 46, 28009 Madrid, Spain
| | - Pedro David Delgado-López
- Servicio de Neurocirugía, Hospital Universitario de Burgos, Burgos, España, Avda Islas Baleares 3, 09006 Burgos, Spain.
| | - María Teresa Lista-Araujo
- Servicio de Anatomía Patológica, Hospital Universitario de Burgos, Burgos, España, Avda Islas Baleares 3, 09006 Burgos, Spain
| | - Antonio Rodríguez-Salazar
- Servicio de Neurocirugía, Hospital Universitario de Burgos, Burgos, España, Avda Islas Baleares 3, 09006 Burgos, Spain
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140
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Burkhardt JK, Winkler EA, Catapano JS, Spetzler RF, Lawton MT. Surgical selection and outcomes among elderly patients with brain arteriovenous malformations. Neurosurg Focus 2020; 49:E9. [PMID: 33512984 DOI: 10.3171/2020.7.focus20464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Studies of resection of brain arteriovenous malformations (AVMs) in the elderly population are scarce. This study examined factors influencing patient selection and surgical outcome among elderly patients. METHODS Patients 65 years of age and older who underwent resection of an unruptured or ruptured brain AVM treated by two surgeons at two centers were identified. Patient demographic characteristics, AVM characteristics, clinical presentation, and outcomes measured using the modified Rankin Scale (mRS) were analyzed. For subgroup analyses, patients were dichotomized into two age groups (group 1, 65-69 years old; group 2, ≥ 70 years old). RESULTS Overall, 112 patients were included in this study (group 1, n = 61; group 2, n = 51). Most of the patients presented with hemorrhage (71%), a small nidus (< 3 cm, 79%), and a low Spetzler-Martin (SM) grade (grade I or II, 63%) and were favorable surgical candidates according to the supplemented SM grade (supplemented SM grade < 7, 79%). A smaller AVM nidus was statistically significantly more likely to be present in patients with infratentorial AVMs (p = 0.006) and with a compact AVM nidus structure (p = 0.02). A larger AVM nidus was more likely to be treated with preoperative embolization (p < 0.001). Overall outcome was favorable (mRS scores 0-3) in 71% of the patients and was statistically independent from age group or AVM grading. Patients with ruptured AVMs at presentation had significantly better preoperative mRS scores (p < 0.001) and more favorable mRS scores at the last follow-up (p = 0.04) than patients with unruptured AVMs. CONCLUSIONS Outcomes were favorable after AVM resection in both groups of patients. Elderly patients with brain AVMs treated microsurgically were notable for small nidus size, AVM rupture, and low SM grades. Microsurgical resection is an important treatment modality for elderly patients with AVMs, and supplemented SM grading is a useful tool for the selection of patients who are most likely to achieve good neurological outcomes after resection. ABBREVIATIONS AVM = arteriovenous malformation; BNI = Barrow Neurological Institute; LY = Lawton-Young; mRS = modified Rankin Scale; SM = Spetzler-Martin; supp-SM = supplemented SM; UCSF = University of California, San Francisco.
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Affiliation(s)
- Jan-Karl Burkhardt
- Department of Neurosurgery, Baylor College of Medicine Medical Center, Houston, Texas
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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141
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Chen CJ, Ding D, Derdeyn CP, Lanzino G, Friedlander RM, Southerland AM, Lawton MT, Sheehan JP. Brain arteriovenous malformations: A review of natural history, pathobiology, and interventions. Neurology 2020; 95:917-927. [PMID: 33004601 DOI: 10.1212/wnl.0000000000010968] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/08/2020] [Indexed: 11/15/2022] Open
Abstract
Brain arteriovenous malformations (AVMs) are anomalous direct shunts between cerebral arteries and veins that convalesce into a vascular nidus. The treatment strategies for AVMs are challenging and variable. Intracranial hemorrhage and seizures comprise the most common presentations of AVMs. However, incidental AVMs are being diagnosed with increasing frequency due to widespread use of noninvasive neuroimaging. The balance between the estimated cumulative lifetime hemorrhage risk vs the risk of intervention is often the major determinant for treatment. Current management options include surgical resection, embolization, stereotactic radiosurgery (SRS), and observation. Complete nidal obliteration is the goal of AVM intervention. The risks and benefits of interventions vary and can be used in a combinatorial fashion. Resection of the AVM nidus affords high rates of immediate obliteration, but it is invasive and carries a moderate risk of neurologic morbidity. AVM embolization is minimally invasive, but cure can only be achieved in a minority of lesions. SRS is also minimally invasive and has little immediate morbidity, but AVM obliteration occurs in a delayed fashion, so the patient remains at risk of hemorrhage during the latency period. Whether obliteration can be achieved in unruptured AVMs with a lower risk of stroke or death compared with the natural history of AVMs remains controversial. Over the past 5 years, multicenter prospective and retrospective studies describing AVM natural history and treatment outcomes have been published. This review provides a contemporary and comprehensive discussion of the natural history, pathobiology, and interventions for brain AVMs.
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Affiliation(s)
- Ching-Jen Chen
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Dale Ding
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Colin P Derdeyn
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Giuseppe Lanzino
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Robert M Friedlander
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Andrew M Southerland
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Michael T Lawton
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Jason P Sheehan
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ.
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142
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Gorgan RM, Petrescu GED, Brehar FM. Microsurgical approach for symptomatic brain AVMs - single center experience. Neurol Res 2020; 42:1080-1084. [PMID: 32892720 DOI: 10.1080/01616412.2020.1803604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objectives: Brain arteriovenous malformations (AVMs) represent high-flow vascular lesions made up of a complex network of feeding arteries and draining veins interposed by a nidus and without a capillary bed. The management of the AVMs represents a challenge, and the optimal treatment should be considered based on the particularities of each AVM. This paper aims to provide outcome data for the cohort of patients with AVMs that underwent surgical treatment. Methods: A retrospective review of patients who presented with AVMs between 2001 and 2019 was conducted. Patients were included if they underwent surgery, preoperative and postoperative angiographic studies were available. Results: 91 patients were included. The SM grade was 1 in 16 cases (17,6%), 2 in 27 patients (29.7%), 3 in 29 patients (31,9%), 4 in 12 cases (13.2%) and grade 5 in 7 cases (7.7%). In 58 (63.7%) cases the AVMs were ruptured. Complete microsurgical resection was achieved in 82 cases (90.1%). Unruptured AVM (87.9% vs. 63.8% for ruptured AVMs; p = 0.015), low-grade AVM (86% vs. 60.4% for grade III-V AVMs; p = 0.006) and cortical location (79.5% vs. 30.8% for deep AVM; p < 0.0001) were the factors associated with a good outcome on mRS scale. Conclusions: Microsurgical resection is the curative treatment for AVMs and offers a good functional outcome if selection criteria are met.
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Affiliation(s)
- Radu M Gorgan
- Department of Neurosurgery, University of Medicine and Pharmacy "Carol Davila" , Bucahrest, Romania.,Department of Neurosurgery, "Bagdasar-Arseni" Clinical Emergency Hospital , Bucharest, Romania
| | - George E D Petrescu
- Department of Neurosurgery, University of Medicine and Pharmacy "Carol Davila" , Bucahrest, Romania.,Department of Neurosurgery, "Bagdasar-Arseni" Clinical Emergency Hospital , Bucharest, Romania
| | - Felix M Brehar
- Department of Neurosurgery, University of Medicine and Pharmacy "Carol Davila" , Bucahrest, Romania.,Department of Neurosurgery, "Bagdasar-Arseni" Clinical Emergency Hospital , Bucharest, Romania
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143
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Arthur AS, Abecassis IJ, Abi-Aad KR, Albuquerque FC, Almefty RO, Aoun RJN, Barrow DL, Bederson J, Bendok BR, Ducruet AF, Fanous AA, Fennell VS, Flores BC, Griessenauer CJ, Kim LJ, Levitt MR, Mack WJ, Mascitelli J, Min E, Mocco J, Morr S, Nerva JD, Richards AE, Schirmer CM, See AP, Snyder KV, Tian F, Walcott BP, Welz ME. Vascular. Oper Neurosurg (Hagerstown) 2020; 17:S76-S118. [PMID: 31099843 DOI: 10.1093/ons/opz088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/05/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - I Josh Abecassis
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Karl R Abi-Aad
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Rami O Almefty
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Rami James N Aoun
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Department of Otolaryngology, Mayo Clinic, Phoenix Arizona.,Department of Radiology, Mayo Clinic, Phoenix, Arizona
| | - Daniel L Barrow
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia.,Department of Ophthalmalogy, Emory University School of Medicine, Atlanta, Georgia.,Department of Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Joshua Bederson
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
| | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Department of Otolaryngology, Mayo Clinic, Phoenix Arizona.,Department of Radiology, Mayo Clinic, Phoenix, Arizona
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Andrew A Fanous
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
| | - Vernard S Fennell
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
| | - Bruno C Flores
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Christoph J Griessenauer
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System, Wilkes-Barre, Pennsylvania
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington.,Department of Radiology, University of Washington School of Medicine, Seattle, Washington
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington.,Department of Radiology, University of Washington School of Medicine, Seattle, Washington.,Department of Mechanical Engineering, University of Washington School of Medicine, Seattle, Washington
| | - William J Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Justin Mascitelli
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
| | - Elliott Min
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
| | - Simon Morr
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
| | - John D Nerva
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | | | - Clemens M Schirmer
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System, Wilkes-Barre, Pennsylvania
| | - Alfred P See
- Department of Neurosurgery, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
| | - Fucheng Tian
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Brian P Walcott
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Matthew E Welz
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
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Intracranial calcifications in childhood: Part 2. Pediatr Radiol 2020; 50:1448-1475. [PMID: 32642802 DOI: 10.1007/s00247-020-04716-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/03/2020] [Accepted: 05/12/2020] [Indexed: 02/08/2023]
Abstract
This article is the second of a two-part series on intracranial calcification in childhood. In Part 1, the authors discussed the main differences between physiological and pathological intracranial calcification. They also outlined histological intracranial calcification characteristics and how these can be detected across different neuroimaging modalities. Part 1 emphasized the importance of age at presentation and intracranial calcification location and proposed a comprehensive neuroimaging approach toward the differential diagnosis of the causes of intracranial calcification. Pathological intracranial calcification can be divided into infectious, congenital, endocrine/metabolic, vascular, and neoplastic. In Part 2, the chief focus is on discussing endocrine/metabolic, vascular, and neoplastic intracranial calcification etiologies of intracranial calcification. Endocrine/metabolic diseases causing intracranial calcification are mainly from parathyroid and thyroid dysfunction and inborn errors of metabolism, such as mitochondrial disorders (MELAS, or mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes; Kearns-Sayre; and Cockayne syndromes), interferonopathies (Aicardi-Goutières syndrome), and lysosomal disorders (Krabbe disease). Specific noninfectious causes of intracranial calcification that mimic TORCH (toxoplasmosis, other [syphilis, varicella-zoster, parvovirus B19], rubella, cytomegalovirus, and herpes) infections are known as pseudo-TORCH. Cavernous malformations, arteriovenous malformations, arteriovenous fistulas, and chronic venous hypertension are also known causes of intracranial calcification. Other vascular-related causes of intracranial calcification include early atherosclerosis presentation (children with risk factors such as hyperhomocysteinemia, familial hypercholesterolemia, and others), healed hematoma, radiotherapy treatment, old infarct, and disorders of the microvasculature such as COL4A1- and COL4A2-related diseases. Intracranial calcification is also seen in several pediatric brain tumors. Clinical and familial information such as age at presentation, maternal exposure to teratogens including viruses, and association with chromosomal abnormalities, pathogenic genes, and postnatal infections facilitates narrowing the differential diagnosis of the multiple causes of intracranial calcification.
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Zhang M, Ding X, Zhang Q, Liu J, Zhang Y, Zhang Y, Tian Z, Li W, Zhu W, Kang H, Wang Z, Wu X, Wang C, Yang X, Wang K. Exome sequencing of 112 trios identifies recessive genetic variants in brain arteriovenous malformations. J Neurointerv Surg 2020; 13:568-573. [PMID: 32848021 DOI: 10.1136/neurintsurg-2020-016469] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Brain arteriovenous malformation (BAVM) is a main cause of cerebral hemorrhage and hemorrhagic stroke in adolescents. Morphologically, a BAVM is an abnormal connection between cerebrovascular arteries and veins. The genetic etiology of BAVMs has not been fully elucidated. In this study, we aim to investigate potential recessive genetic variants in BAVMs by interrogation of rare compound heterozygous variants. METHODS We performed whole exome sequencing (WES) on 112 BAVM trios and analyzed the data for rare and deleterious compound heterozygous mutations associated with the disease. RESULTS We identified 16 genes with compound heterozygous variants that were recurrent in more than one trio. Two genes (LRP2, MUC5B) were recurrently mutated in three trios. LRP2 has been previously associated with BAVM pathogenesis. Fourteen genes (MYLK, HSPG2, PEAK1, PIEZO1, PRUNE2, DNAH14, DNAH5, FCGBP, HERC2, HMCN1, MYH1, NHSL1, PLEC, RP1L1) were recurrently mutated in two trios, and five of these genes (MYLK, HSPG2, PEAK1, PIEZO1, PRUNE2) have been reported to play a role in angiogenesis or vascular diseases. Additionally, abnormal expression of the MYLK protein is related to spinal arteriovenous malformations. CONCLUSION Our study indicates that rare recessive compound heterozygous variants may underlie cases of BAVM. These findings improve our understanding of BAVM pathology and indicate genes for functional validation.
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Affiliation(s)
- Mingqi Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Xinghuan Ding
- Department of Neurosurgery, Beijing Ditan Hospital, Capital Medical University, Beijing 100070, China
| | - Qianqian Zhang
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial Neurointerventional Engineering Research Center and Henan International Joint Laboratory of Cerebrovascular Disease, Zhengzhou 450000, Henan, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Zhongbin Tian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Wenqiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Wei Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Huibin Kang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Zhongxiao Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Xinzhi Wu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Chao Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Kun Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
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The current clinical picture of cerebral proliferative angiopathy: systematic review. Acta Neurochir (Wien) 2020; 162:1727-1733. [PMID: 32206904 DOI: 10.1007/s00701-020-04289-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/11/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cerebral proliferative angiopathy (CPA) is a rare subset of arteriovenous malformations (AVM). It has unique clinical presentation, angiographic characteristics, and pathophysiology which often brings challenges for the treatment. We aimed to define its epidemiology, pathophysiology are unknown, and best management strategies. METHODS A systematic review was conducted according to the PRISMA guidelines. MEDLINE was searched for articles regarding CPA. Extracted data included epidemiological, clinical, and angiographical characteristics, treatment, and outcomes. Treatment was classified as conservative, radiosurgery, endovascular, decompression, and indirect vascularization. A meta-analytical approach was employed for description of the data as study-size adjusted percentages or weighted means, as appropriate. RESULTS Thirty-three studies were analyzed, rendering a total 95 cases-half of which came from a single study. Patients were predominantly young (mean 23 years old) and female (60.0%) presenting with headaches (44.9%), seizures (37.1%), or transient ischemic attacks (33.7%). Hemorrhage was present in 18.0%, but rebleeding rates were as high as 67%. The majority of nidus were > 6 cm (52.5%) with hemispheric extension (73.0%). Capillary angioectatic appearance (85.7%), transdural supply (62.5%), and deep venous drainage (73.0%) were also frequent features. Most patients were treated conservatively (54.4%), followed by endovascular (34.2%). Indirect vascularization and radiosurgery were attempted in five and two patients, respectively. Mean follow-up was 110.8 patient-years. Neurological status improved in 50.7%, remained stable in 40.2%, and worsened in 9.0%. CONCLUSIONS Conservative and endovascular treatments seem adequate interventions, despite limited evidence. Complementary techniques can be used in patients throughout disease history, according to symptom-based, individualized approach. More studies are required for choosing interventions based on reliable long-term results.
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Fish JE, Flores Suarez CP, Boudreau E, Herman AM, Gutierrez MC, Gustafson D, DiStefano PV, Cui M, Chen Z, De Ruiz KB, Schexnayder TS, Ward CS, Radovanovic I, Wythe JD. Somatic Gain of KRAS Function in the Endothelium Is Sufficient to Cause Vascular Malformations That Require MEK but Not PI3K Signaling. Circ Res 2020; 127:727-743. [PMID: 32552404 PMCID: PMC7447191 DOI: 10.1161/circresaha.119.316500] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Supplemental Digital Content is available in the text. Rationale: We previously identified somatic activating mutations in the KRAS (Kirsten rat sarcoma viral oncogene homologue) gene in the endothelium of the majority of human sporadic brain arteriovenous malformations; a disorder characterized by direct connections between arteries and veins. However, whether this genetic abnormality alone is sufficient for lesion formation, as well as how active KRAS signaling contributes to arteriovenous malformations, remains unknown. Objective: To establish the first in vivo models of somatic KRAS gain of function in the endothelium in both mice and zebrafish to directly observe the phenotypic consequences of constitutive KRAS activity at a cellular level in vivo, and to test potential therapeutic interventions for arteriovenous malformations. Methods and Results: Using both postnatal and adult mice, as well as embryonic zebrafish, we demonstrate that endothelial-specific gain of function mutations in Kras (G12D or G12V) are sufficient to induce brain arteriovenous malformations. Active KRAS signaling leads to altered endothelial cell morphogenesis and increased cell size, ectopic sprouting, expanded vessel lumen diameter, and direct connections between arteries and veins. Furthermore, we show that these lesions are not associated with altered endothelial growth dynamics or a lack of proper arteriovenous identity but instead seem to feature exuberant angiogenic signaling. Finally, we demonstrate that KRAS-dependent arteriovenous malformations in zebrafish are refractory to inhibition of the downstream effector PI3K but instead require active MEK (mitogen-activated protein kinase kinase 1) signaling. Conclusions: We demonstrate that active KRAS expression in the endothelium is sufficient for brain arteriovenous malformations, even in the setting of uninjured adult vasculature. Furthermore, the finding that KRAS-dependent lesions are reversible in zebrafish suggests that MEK inhibition may represent a promising therapeutic treatment for arteriovenous malformation patients.
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Affiliation(s)
- Jason E Fish
- From the Toronto General Hospital Research Institute (J.E.F., E.B., D.G., P.V.D., Z.C.), University Health Network, Canada.,Peter Munk Cardiac Centre (J.E.F.), University Health Network, Canada.,Department of Laboratory Medicine and Pathobiology (J.E.F., D.G.), University of Toronto, Canada
| | - Carlos Perfecto Flores Suarez
- Cardiovascular Research Institute (C.P.F.S., A.M.H., M.C.G., M.C., K.B.D.R., J.D.W.), Baylor College of Medicine, Houston, TX.,Department of Molecular Physiology and Biophysics (C.P.F.S., A.M.H., M.C.G., M.C., K.B.D.R., T.S.S., C.S.W., J.D.W.), Baylor College of Medicine, Houston, TX
| | - Emilie Boudreau
- From the Toronto General Hospital Research Institute (J.E.F., E.B., D.G., P.V.D., Z.C.), University Health Network, Canada
| | - Alexander M Herman
- Cardiovascular Research Institute (C.P.F.S., A.M.H., M.C.G., M.C., K.B.D.R., J.D.W.), Baylor College of Medicine, Houston, TX.,Department of Molecular Physiology and Biophysics (C.P.F.S., A.M.H., M.C.G., M.C., K.B.D.R., T.S.S., C.S.W., J.D.W.), Baylor College of Medicine, Houston, TX
| | - Manuel Cantu Gutierrez
- Cardiovascular Research Institute (C.P.F.S., A.M.H., M.C.G., M.C., K.B.D.R., J.D.W.), Baylor College of Medicine, Houston, TX.,Department of Molecular Physiology and Biophysics (C.P.F.S., A.M.H., M.C.G., M.C., K.B.D.R., T.S.S., C.S.W., J.D.W.), Baylor College of Medicine, Houston, TX.,Graduate Program in Developmental Biology (M.C.G., J.D.W.), Baylor College of Medicine, Houston, TX
| | - Dakota Gustafson
- From the Toronto General Hospital Research Institute (J.E.F., E.B., D.G., P.V.D., Z.C.), University Health Network, Canada.,Department of Laboratory Medicine and Pathobiology (J.E.F., D.G.), University of Toronto, Canada
| | - Peter V DiStefano
- From the Toronto General Hospital Research Institute (J.E.F., E.B., D.G., P.V.D., Z.C.), University Health Network, Canada
| | - Meng Cui
- Cardiovascular Research Institute (C.P.F.S., A.M.H., M.C.G., M.C., K.B.D.R., J.D.W.), Baylor College of Medicine, Houston, TX.,Department of Molecular Physiology and Biophysics (C.P.F.S., A.M.H., M.C.G., M.C., K.B.D.R., T.S.S., C.S.W., J.D.W.), Baylor College of Medicine, Houston, TX
| | - Zhiqi Chen
- From the Toronto General Hospital Research Institute (J.E.F., E.B., D.G., P.V.D., Z.C.), University Health Network, Canada
| | - Karen Berman De Ruiz
- Cardiovascular Research Institute (C.P.F.S., A.M.H., M.C.G., M.C., K.B.D.R., J.D.W.), Baylor College of Medicine, Houston, TX.,Department of Molecular Physiology and Biophysics (C.P.F.S., A.M.H., M.C.G., M.C., K.B.D.R., T.S.S., C.S.W., J.D.W.), Baylor College of Medicine, Houston, TX
| | - Taylor S Schexnayder
- Department of Molecular Physiology and Biophysics (C.P.F.S., A.M.H., M.C.G., M.C., K.B.D.R., T.S.S., C.S.W., J.D.W.), Baylor College of Medicine, Houston, TX.,and Advanced Technology Cores (T.S.S., C.S.W.), Baylor College of Medicine, Houston, TX
| | - Christopher S Ward
- Department of Molecular Physiology and Biophysics (C.P.F.S., A.M.H., M.C.G., M.C., K.B.D.R., T.S.S., C.S.W., J.D.W.), Baylor College of Medicine, Houston, TX.,and Advanced Technology Cores (T.S.S., C.S.W.), Baylor College of Medicine, Houston, TX
| | - Ivan Radovanovic
- Krembil Research Institute (I.R.), University Health Network, Canada.,Division of Neurosurgery, Sprott Department of Surgery (I.R.), University Health Network, Canada.,Department of Surgery (I.R.), University of Toronto, Canada
| | - Joshua D Wythe
- Cardiovascular Research Institute (C.P.F.S., A.M.H., M.C.G., M.C., K.B.D.R., J.D.W.), Baylor College of Medicine, Houston, TX.,Department of Molecular Physiology and Biophysics (C.P.F.S., A.M.H., M.C.G., M.C., K.B.D.R., T.S.S., C.S.W., J.D.W.), Baylor College of Medicine, Houston, TX.,Graduate Program in Developmental Biology (M.C.G., J.D.W.), Baylor College of Medicine, Houston, TX
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148
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Fu W, Huo R, Yan Z, Xu H, Li H, Jiao Y, Wang L, Weng J, Wang J, Wang S, Cao Y, Zhao J. Mesenchymal Behavior of the Endothelium Promoted by SMAD6 Downregulation Is Associated With Brain Arteriovenous Malformation Microhemorrhage. Stroke 2020; 51:2197-2207. [PMID: 32486965 DOI: 10.1161/strokeaha.120.030046] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE In unruptured brain arteriovenous malformations (bAVMs), microhemorrhage portends a higher risk of future rupture and may represent a transitional state along the continuum of destabilization. Exploration of the molecular and cellular mechanisms of microhemorrhage will provide a possible target for medical treatment to prevent bAVM bleeding. METHODS We performed RNA sequencing analysis on 34 unruptured bAVM surgical samples. Functional pathway analysis was performed to identify potential signals associated with the microhemorrhagic phenotype. Candidate gene was then investigated in bAVM specimens by immunohistochemical staining. Several functional assays were used to investigate the effects of candidate genes on the phenotypic properties of cultured human umbilical vein endothelial cells. Then, Masson trichrome staining and immunofluorescence staining were used to evaluate the phenotypic and molecular changes in bAVM tissue. RESULTS Via RNA sequencing, we identified differential gene expression between 18 microhemorrhagic bAVMs and 16 nonmicrohemorrhagic bAVMs. TGFβ (transforming growth factor-beta)/BMP (bone morphogenetic protein) signaling was associated with the bAVM microhemorrhage group when SMAD6 (SMAD family member 6) was downregulated. Immunohistochemical staining showed that the vascular endothelium of microhemorrhagic bAVMs exhibited decreased SMAD6 expression. Functional assays revealed that SMAD6 downregulation promoted the formation of endothelial cell tubes with deficient cell-cell junctions and facilitated the acquisition of mesenchymal behavior by endothelial cells. Masson trichrome and immunofluorescence staining demonstrated that mesenchymal phenotype of endothelial cells is promoted in microhemorrhagic bAVMs. CONCLUSIONS TGFβ/BMP signaling mediated by SMAD6 in vascular endothelial cells is associated with microhemorrhagic bAVMs, and mesenchymal behavior of endothelial cells induced by SMAD6 downregulation is related with bAVM microhemorrhage.
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Affiliation(s)
- Weilun Fu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Ran Huo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Zihan Yan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Hongyuan Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Hao Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Linjian Wang
- Savaid Medical School, University of the Chinese Academy of Sciences, Beijing (L.W., J.Z.)
| | - Jiancong Weng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Jie Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,Beijing Neurosurgical Institute, Capital Medical University, China (Y.C.)
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,Savaid Medical School, University of the Chinese Academy of Sciences, Beijing (L.W., J.Z.)
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149
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Neuroimaging of Pediatric Intracerebral Hemorrhage. J Clin Med 2020; 9:jcm9051518. [PMID: 32443470 PMCID: PMC7290500 DOI: 10.3390/jcm9051518] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 01/20/2023] Open
Abstract
Hemorrhagic strokes account for half of all strokes seen in children, and the etiologies of these hemorrhagic strokes differ greatly from those seen in adult patients. This review gives an overview about incidence and etiologies as well as presentation of children with intracerebral hemorrhage and with differential diagnoses in the emergency department. Most importantly it describes how neuroimaging of children with intracerebral hemorrhage should be tailored to specific situations and clinical contexts and recommends specific imaging protocols for acute and repeat imaging. In this context it is important to keep in mind the high prevalence of underlying vascular lesions and adapt the imaging protocol accordingly, meaning that vascular imaging plays a key role regardless of modality. Magnetic resonance imaging (MRI), including advanced sequences, should be favored whenever possible at the acute phase.
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150
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Lehrer EJ, Snyder MH, Desai BD, Li CE, Narayan A, Trifiletti DM, Schlesinger D, Sheehan JP. Clinical and radiographic adverse events after Gamma Knife radiosurgery for brainstem lesions: A dosimetric analysis. Radiother Oncol 2020; 147:200-209. [PMID: 32413528 DOI: 10.1016/j.radonc.2020.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/30/2020] [Accepted: 05/08/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To analyze the association between dosvolume relationships and adverse events in brainstem lesions treated with Gamma Knife radiosurgery (GKRS). METHODS Treatment plans were generated on BrainLab Elements and GammaPlan software. Dosimetric data were analyzed as continuous variables for patients who received GKRS to brain metastases or arteriovenous malformations (AVM) within or abutting the brainstem. Adverse events were classified as clinical and/or radiographic. Logistic and cox regression were used to assess the relationship between dosimetric variables and adverse events. RESULTS Sixty-one patients who underwent single fraction GKRS for brain metastases or AVM were retrospectively analyzed. Median age was 62 years (range: 12-92 years) and the median prescription dose was 18 Gy (range: 13-25 Gy). Median follow-up was 6months. Clinical and radiographic complications were seen in ten (16.4%) and 17 (27.9%) patients, respectively. On logistic regression, increasing D05% was found to be associated with an increased probability of developing a clinical complication post-GKRS (OR: 1.18; 95% CI: 1.01-1.39; p = 0.04). Furthermore, mean brainstem dose (HR: 1.43; 95% CI: 1.05-1.94; p < 0.02), D05% (HR: 1.09; 95% CI: 1.01-1.18; p = 0.03), and D95% (HR: 2.37; 95% CI: 0.99-5.67; p = 0.05) were associated with an increased hazard of experiencing post-GKRS complications over time. CONCLUSIONS Increasing D05% to the brainstem is associated with an increased risk of developing clinical complications. Clinicians may consider this parameter in addition to fractionated stereotactic radiation therapy when well-established dose constraints are not met in this patient population. Additional data are needed to further validate these findings.
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Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - M Harrison Snyder
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Bhargav D Desai
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Chelsea E Li
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Aditya Narayan
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | | | - David Schlesinger
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
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