101
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Pulli B, Chapman PH, Ogilvy CS, Patel AB, Stapleton CJ, Leslie-Mazwi TM, Hirsch JA, Carter BS, Rabinov JD. Multimodal cerebral arteriovenous malformation treatment: a 12-year experience and comparison of key outcomes to ARUBA. J Neurosurg 2020; 133:1792-1801. [PMID: 31675689 DOI: 10.3171/2019.8.jns19998] [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: 04/08/2019] [Accepted: 08/05/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Curative treatment of unruptured brain arteriovenous malformations (AVMs) remains controversial after the only randomized controlled trial, A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA), was halted prematurely because interim analysis revealed superiority of the medical management group. In contrast, meta-analyses of retrospective cohorts suggest that intervention is much safer than was found in ARUBA. METHODS The authors retrospectively analyzed 318 consecutive adult patients with brain AVMs treated at their institution with embolization, surgery, and/or proton beam radiosurgery. Analysis was performed in 142 ARUBA-eligible patients (baseline modified Rankin Scale [mRS] score 0-1, no history of hemorrhage), and results were compared to primary and secondary outcomes from ARUBA, as well as to natural history cohorts. RESULTS The annualized stroke rate (hemorrhagic or ischemic) in this cohort was 1.8%, 4.9% in the first 12 months and 0.8% after the first 12 months, which was lower than in natural history studies and the ARUBA medical management arm (p = 0.001). The primary ARUBA endpoint of symptomatic stroke was reached in 13 patients (9.2%), which compares favorably to the ARUBA intervention arm (39.6%, p = 0.0001) and is similar to the ARUBA medical management arm (9.2%, p = 1.0). The secondary ARUBA endpoint (mRS score ≥ 2 at 5 years of follow-up) was reached in 14.3% of patients, compared to 40.5% in the ARUBA intervention arm (p = 0.002) and 16.7% in the ARUBA medical management arm (p = 0.6). CONCLUSIONS This multimodal approach to the selection and treatment of patients with brain AVMs yields good clinical outcomes with key safety endpoints (stroke, death, and mRS score 0-1) better than the ARUBA intervention arm and similar to the ARUBA medical arm at 5 years of follow-up. Results compare favorably to natural history cohorts at longer follow-up times. This suggests that tertiary care centers with integrated programs, expertise in patient selection, and individualized treatment approaches may allow for better clinical outcomes than reported in ARUBA. It supports current registry studies and merits consideration of future randomized controlled trials in patients with brain AVMs.
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Affiliation(s)
- Benjamin Pulli
- 1Department of Radiology, Massachusetts General Hospital, Harvard Medical School
| | - Paul H Chapman
- 2Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | | | - Aman B Patel
- 2Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | | | - Thabele M Leslie-Mazwi
- 2Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
- 4Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joshua A Hirsch
- 1Department of Radiology, Massachusetts General Hospital, Harvard Medical School
| | - Bob S Carter
- 2Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | - James D Rabinov
- 1Department of Radiology, Massachusetts General Hospital, Harvard Medical School
- 2Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
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102
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Lefevre E, Robert T, Escalard S, Fahed R, Smajda S, Ciccio G, Desilles JP, Mazighi M, Blanc R, Piotin M. Presence of direct vertebrobasilar perforator feeders in posterior fossa arteriovenous malformations and association with poor outcomes after endovascular treatment. J Neurosurg 2020; 133:1802-1810. [PMID: 31703199 DOI: 10.3171/2019.8.jns191971] [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: 07/20/2019] [Accepted: 08/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Treatment of posterior fossa arteriovenous malformations (PFAVMs) remains controversial as it is always challenging and may lead to major complications. Nonetheless, these lesions are more likely to bleed and generate poorer outcomes than other brain AVMs. The aim of this study was to evaluate the effect of endovascular treatment on long-term outcomes and identify the patient subgroups that might benefit from endovascular treatment. METHODS The authors performed a retrospective analysis of all consecutive cases of PFAVM managed at the Fondation Rothschild Hospital between 1995 and 2018. Clinical, imaging, and treatment data were prospectively gathered; these data were analyzed with respect to long-term outcomes. RESULTS Among the 1311 patients with brain AVMs, 114 (8.7%) had a PFAVM, and 88 (77.2%) of these patients had a history of bleeding. Of the 114 PFAVMs, 101 (88.6%) were treated (83 ruptured and 18 unruptured). The mean duration of follow-up was 47.6 months (range 0-240 months). Good neurological outcome at last follow-up was achieved in 79 cases (78.2%). Follow-up angiography showed obliteration of the PFAVM in 68.3% of treated cases. The presence of direct vertebrobasilar perforator feeders was associated with neurological deterioration (OR 5.63, 95% CI 11.15-30.76) and a lower obliteration rate (OR 15.69, 95% CI 2.52-304.03) after endovascular treatment. Other predictors of neurological deterioration and obliteration rate were consistent with the Spetzler-Martin grading system. CONCLUSIONS Advances in endovascular techniques have enabled higher obliteration rates in the treatment of PFAVMs, but complication rates are still high. Subgroups of patients who might benefit from treatment must be carefully selected and the presence of direct vertebrobasilar perforator feeders must call into question the indication for endovascular treatment.
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Affiliation(s)
- Etienne Lefevre
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Thomas Robert
- 2Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Ticino, Switzerland
| | - Simon Escalard
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Robert Fahed
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Stanislas Smajda
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Gabriele Ciccio
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Jean-Philippe Desilles
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Mikael Mazighi
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Raphaël Blanc
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Michel Piotin
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
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103
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Lee S, Kim Y, Navi BB, Abdelkhaleq R, Salazar-Marioni S, Blackburn SL, Bambhroliya AB, Lopez-Rivera V, Vahidy F, Savitz SI, Medhus A, Kamel H, Grotta JC, McCullough L, Chen PR, Sheth SA. Risk of intracranial hemorrhage associated with pregnancy in women with cerebral arteriovenous malformations. J Neurointerv Surg 2020; 13:707-710. [PMID: 33229423 DOI: 10.1136/neurintsurg-2020-016838] [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: 09/08/2020] [Revised: 10/30/2020] [Accepted: 11/04/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Prior studies on rupture risk of brain arteriovenous malformations (AVMs) in women undergoing pregnancy and delivery have reported conflicting findings, but also have not accounted for AVM morphology and heterogeneity. Here, we assess the association between pregnancy and the risk of intracranial hemorrhage (ICH) in women with AVMs using a cohort-crossover design in which each woman serves as her own control. METHODS Women who underwent pregnancy and delivery were identified using DRG codes from the Healthcare Cost and Utilization Project State Inpatient Databases for California (2005-2011), Florida (2005-2014), and New York (2005-2014). The presence of AVM and ICH was determined using ICD 9 codes. Pregnancy was defined as the 40 weeks prior to delivery, and postpartum as 12 weeks after. We defined a non-exposure control period as a 52-week period prior to pregnancy. The relative risks of ICH during pregnancy were compared against the non-exposure period using conditional Poisson regression. RESULTS Among 4 022 811 women identified with an eligible delivery hospitalization (median age, 28 years; 7.3% with gestational diabetes; 4.5% with preeclampsia/eclampsia), 568 (0.014%) had an AVM. The rates of ICH during pregnancy and puerperium were 6355.4 (95% CI 4279.4 to 8431.5) and 14.4 (95% CI 13.3 to 15.6) per 100 000 person-years for women with and without AVM, respectively. In cohort-crossover analysis, in women with AVMs the risk of ICH increased 3.27-fold (RR, 95% CI 1.67 to 6.43) during pregnancy and puerperium compared with a non-pregnant period. CONCLUSIONS Among women with AVM, pregnancy and puerperium were associated with a greater than 3-fold risk of ICH.
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Affiliation(s)
- Songmi Lee
- Neurology, UTHealth McGovern Medical School, Houston, Texas, USA
| | - Youngran Kim
- Neurology, UTHealth McGovern Medical School, Houston, Texas, USA
| | - Babak B Navi
- Neurology, Weill Cornell Medical College, New York City, New York, USA
| | | | | | - Spiros L Blackburn
- Neurosurgery, UTHealth McGovern Medical School, Houston, TX, USA.,Institute for Stroke and Cerebrovascular Disease, UTHealth McGovern Medical School, Houston, TX, USA
| | | | | | - Farhaan Vahidy
- Center for Outcomes Research, Houston Methodist, Houston, Texas, USA
| | - Sean I Savitz
- Neurology, UTHealth McGovern Medical School, Houston, Texas, USA.,Institute for Stroke and Cerebrovascular Disease, UTHealth McGovern Medical School, Houston, TX, USA
| | - Annika Medhus
- Neurology, UTHealth McGovern Medical School, Houston, Texas, USA
| | - Hooman Kamel
- Neurology, Weill Cornell Medical College, New York City, New York, USA
| | - James C Grotta
- Stroke Research and Mobile Stroke Unit, Memorial Hermann Hospital-Texas Medical Center, Houston, TX, USA
| | | | - Peng Roc Chen
- Neurosurgery, UTHealth McGovern Medical School, Houston, TX, USA.,Institute for Stroke and Cerebrovascular Disease, UTHealth McGovern Medical School, Houston, TX, USA
| | - Sunil A Sheth
- Neurology, UTHealth McGovern Medical School, Houston, Texas, USA .,Institute for Stroke and Cerebrovascular Disease, UTHealth McGovern Medical School, Houston, TX, USA
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104
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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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105
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Garzelli L, Shotar E, Blauwblomme T, Sourour N, Alias Q, Stricker S, Mathon B, Kossorotoff M, Gariel F, Boddaert N, Brunelle F, Meyer P, Naggara O, Clarençon F, Boulouis G. Risk Factors for Early Brain AVM Rupture: Cohort Study of Pediatric and Adult Patients. AJNR Am J Neuroradiol 2020; 41:2358-2363. [PMID: 33122204 DOI: 10.3174/ajnr.a6824] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 08/06/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Whether architectural characteristics of ruptured brain AVMs vary across the life span is unknown. We aimed to identify angioarchitectural features associated with brain AVMs ruptured early in life. MATERIALS AND METHODS Patients with ruptured brain AVMs referred to 2 distinct academic centers between 2000 and 2018 were pooled and retrospectively analyzed. Imaging was retrospectively reviewed for angioarchitectural characteristics, including nidus size, location, Spetzler-Martin grade, venous drainage, and arterial or nidal aneurysm. Angioarchitecture variations across age groups were analyzed using uni- and multivariable models; then cohorts were pooled and analyzed using Kaplan-Meier and Cox models to determine factors associated with earlier rupture. RESULTS Among 320 included patients, 122 children (mean age, 9.8 ± 3.8 years) and 198 adults (mean age, 43.3 ± 15.7 years) were analyzed. Pediatric brain AVMs were more frequently deeply located (56.3% versus 21.2%, P < .001), with a larger nidus (24.2 versus 18.9 mm, P = .002), were less frequently nidal (15.9% versus 23.5%, P = .03) and arterial aneurysms (2.7% versus 17.9%, P < .001), and had similar drainage patterns or Spetzler-Martin grades. In the fully adjusted Cox model, supratentorial, deep brain AVM locations (adjusted relative risk, 1.19; 95% CI, 1.01-1.41; P = .03 and adjusted relative risk, 1.43; 95% CI, 1.22-1.67; P < .001, respectively) and exclusively deep venous drainage (adjusted relative risk, 1.46, 95% CI, 1.21-1.76; P < .001) were associated with earlier rupture, whereas arterial or nidal aneurysms were associated with rupture later in life. CONCLUSIONS The angioarchitecture of ruptured brain AVMs significantly varies across the life span. These distinct features may help to guide treatment decisions for patients with unruptured AVMs.
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Affiliation(s)
- L Garzelli
- From the Department of Neuroradiology (L.G., O.N., G.B.), Sainte-Anne University Hospital, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1266, Paris, France.,Departments of Neuroradiology (L.G., F.C.)
| | - E Shotar
- Department of Neuroradiology (E.S., N.S., F.C.)
| | - T Blauwblomme
- Department of Pediatric Neurosurgery (T.B., S.S.), French Center for Pediatric Stroke.,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
| | - N Sourour
- Department of Neuroradiology (E.S., N.S., F.C.)
| | - Q Alias
- Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.)
| | - S Stricker
- Department of Pediatric Neurosurgery (T.B., S.S.), French Center for Pediatric Stroke
| | - B Mathon
- Neurosurgery (B.M.), Sorbonne University, Paris, France.,Neurosurgery (B.M.), Pitié-Salpêtrière University Hospital, Public Assistance-Paris Hospitals, Paris, France.,Brain and Spine Institute (B.M.), Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1127; Centre National de la Recherche Scientifique, Unité Mixte de Recherche 7225, Paris, France
| | - M Kossorotoff
- Department of Pediatric Neurology (M.K.), French Center for Pediatric Stroke
| | - F Gariel
- Department of Neuroimaging (F.G.), Pellegrin Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - N Boddaert
- Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.).,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
| | - F Brunelle
- Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.).,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
| | - P Meyer
- Department of Anesthesiology (P.M.), Necker-Enfants Malades University Hospital, Public Assistance-Paris Hospitals, Paris, France
| | - O Naggara
- From the Department of Neuroradiology (L.G., O.N., G.B.), Sainte-Anne University Hospital, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1266, Paris, France.,Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.).,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
| | - F Clarençon
- Departments of Neuroradiology (L.G., F.C.).,Department of Neuroradiology (E.S., N.S., F.C.)
| | - G Boulouis
- From the Department of Neuroradiology (L.G., O.N., G.B.), Sainte-Anne University Hospital, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1266, Paris, France .,Department of Pediatric Imaging (Q.A., N.B., F.B., O.N., G.B.).,Université de Paris (T.B., N.B., F.B., O.N., G.B.), Paris, France
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106
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Chye CL, Wang KW, Chen HJ, Yeh SA, Tang JT, Liang CL. Haemorrhage rates of ruptured and unruptured brain arteriovenous malformation after radiosurgery: a nationwide population-based cohort study. BMJ Open 2020; 10:e036606. [PMID: 33051231 PMCID: PMC7554462 DOI: 10.1136/bmjopen-2019-036606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES The present nationwide population-based cohort study aims to assess the effectiveness of gamma knife radiosurgery (GKS) on ruptured and unruptured brain arteriovenous malformations (AVMs) by evaluating the haemorrhage rates. DESIGN A nationwide, retrospective cohort study. SETTING Taiwan National Health Insurance Research Database (NHIRD). PARTICIPANTS An observational study of 1515 patients who were diagnosed with brain AVMs between 1997 and 2013 from the Taiwan NHIRD. PRIMARY OUTCOME AND SECONDARY OUTCOME MEASURES We performed a survival analysis using the Kaplan-Meier method. Multivariate Cox proportional hazards regression models were used to explore the relationship between treatment modalities (GKS vs non-GKS) and haemorrhage, adjusted for age and sex. RESULTS The GKS and non-GKS groups included 317 and 1198 patients, respectively. Patients in the GKS group (mean±SD, 33.08±15.48 years of age) tended to be younger than those in the non-GKS group (37.40±17.62) (p<0.001). The 15-year follow-up revealed that the rate of bleeding risk was lower in the GKS group than in the non-GKRS group (adjusted HR (aHR) 0.61; 95% CI 0.40 to 0.92). The bleeding risk of ruptured AVMs was significantly lower in GKS group than in the non-GKS group (aHR 0.34; 95% CI 0.19 to 0.62). On the other hand, the bleeding risk of unruptured AVMs was higher in the GKS group than in the non-GKS group (aHR 1.95; 95% CI 1.04 to 3.65). In the unruptured AVM group, the incidence of bleeding was significantly higher among patients in the GKS group that were of >40 years of age (aHR 3.21; 95% CI 1.12 to 9.14). CONCLUSIONS GKS is safe and it reduces the risk of haemorrhage in patients with ruptured AVMs. The administration of GKS to patients with unruptured AVMs who are above the age of 40 years old male might increase the risk of haemorrhage.
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Affiliation(s)
- Cien-Leong Chye
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Kuo-Wei Wang
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Han-Jung Chen
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Shyh-An Yeh
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Radiation Oncology, E-Da Hospital, Kaohsiung, Taiwan
| | - James Taoqian Tang
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Community Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Cheng-Loong Liang
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
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107
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Rajdev K, Mehan S. Neuroprotective Methodologies of Co-Enzyme Q10 Mediated Brain Hemorrhagic Treatment: Clinical and Pre-Clinical Findings. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2020; 18:446-465. [PMID: 31187715 DOI: 10.2174/1871527318666190610101144] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 04/22/2019] [Accepted: 05/07/2019] [Indexed: 12/13/2022]
Abstract
Cerebral brain hemorrhage is associated with the highest mortality and morbidity despite only constituting approximately 10-15% of all strokes classified into intracerebral and intraventricular hemorrhage where most of the patients suffer from impairment in memory, weakness or paralysis in arms or legs, headache, fatigue, gait abnormality and cognitive dysfunctions. Understanding molecular pathology and finding the worsening cause of hemorrhage will lead to explore the therapeutic interventions that could prevent and cure the disease. Mitochondrial ETC-complexes dysfunction has been found to increase neuroinflammatory cytokines, oxidative free radicals, excitotoxicity, neurotransmitter and energy imbalance that are the key neuropathological hallmarks of cerebral hemorrhage. Coenzyme Q10 (CoQ10), as a part of the mitochondrial respiratory chain can effectively restore these neuronal dysfunctions by preventing the opening of mitochondrial membrane transition pore, thereby counteracting cell death events as well as exerts an anti-inflammatory effect by influencing the expression of NF-kB1 dependent genes thus preventing the neuroinflammation and energy restoration. Due to behavior and biochemical heterogeneity in post cerebral brain hemorrhagic pattern different preclinical autologous blood injection models are required to precisely investigate the forthcoming therapeutic strategies. Despite emerging pre-clinical research and resultant large clinical trials for promising symptomatic treatments, there are very less pharmacological interventions demonstrated to improve post operative condition of patients where intensive care is required. Therefore, in current review, we explore the disease pattern, clinical and pre-clinical interventions under investigation and neuroprotective methodologies of CoQ10 precursors to ameliorate post brain hemorrhagic conditions.
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Affiliation(s)
- Kajal Rajdev
- Department of Pharmacology, ISF College of Pharmacy, Moga-142001, Punjab, India
| | - Sidharth Mehan
- Department of Pharmacology, ISF College of Pharmacy, Moga-142001, Punjab, India
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108
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Guerrero WR, Dandapat S, Ortega-Gutierrez S. Hemorrhagic Cerebrovascular Pathology in the Pediatric Population. Front Neurol 2020; 11:1055. [PMID: 33041990 PMCID: PMC7527474 DOI: 10.3389/fneur.2020.01055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/11/2020] [Indexed: 01/10/2023] Open
Abstract
Hemorrhagic cerebrovascular disease in the pediatric population can have devastating and long-term effects. Progress in the fields of genetics, neuroimaging, pharmacology, and surgical techniques has led to improved diagnosis and management of pediatric cerebrovascular diseases. In this review we discuss the current etiologies and medical and surgical treatments of hemorrhagic cerebrovascular pathology affecting infants and children. A special emphasis is placed on neuroendovascular treatment options. Increased knowledge about this unique pathology and the medical and therapeutic options will empower practitioners to more quickly and accurately identify and accurately treat hemorrhagic diseases in the pediatric population.
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Affiliation(s)
- Waldo R Guerrero
- Department of Neurosurgery, University of South Florida Morsani College of Medicine, Tampa, FL, United States
| | - Sudeepta Dandapat
- Department of Neurology, Radiology, and Neurosurgery, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, IA, United States
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Radiology, and Neurosurgery, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, IA, United States
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109
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Naylor RM, Flemming KD, Brinjikji W, Brown RD, Chiu S, Lanzino G. Changes in Clinical Presentation and Treatment Over Time in Patients with Unruptured Intracranial Arteriovenous Malformations. World Neurosurg 2020; 141:e261-e265. [DOI: 10.1016/j.wneu.2020.05.094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 05/11/2020] [Indexed: 11/24/2022]
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110
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Jacob J, Reyns N, Valéry CA, Feuvret L, Simon JM, Mazeron JJ, Jenny C, Cuttat M, Maingon P, Pasquier D. Radiotherapy of non-tumoral refractory neurological pathologies. Cancer Radiother 2020; 24:523-533. [PMID: 32859467 DOI: 10.1016/j.canrad.2020.06.012] [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: 05/15/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 10/23/2022]
Abstract
Intracranial radiotherapy has been improved, primarily because of the development of stereotactic approaches. While intracranial stereotactic body radiotherapy is mainly indicated for treatment of benign or malignant tumors, this procedure is also effective in the management of other neurological pathologies; it is delivered using GammaKnife® and linear accelerators. Thus, brain arteriovenous malformations in patients who are likely to experience permanent neurological sequelae can be managed by single session intracranial stereotactic body radiotherapy, or radiosurgery, in specific situations, with an advantageous benefit/risk ratio. Radiosurgery can be recommended for patients with disabling symptoms, which are poorly controlled by medication, such as trigeminal neuralgia, and tremors, whether they are essential or secondary to Parkinson's disease. This literature review aims at defining the place of intracranial stereotactic body radiotherapy in the management of patients suffering from non-tumoral refractory neurological pathologies. It is clear that the multidisciplinary collaboration of experienced teams from Neurosurgery, Neurology, Neuroradiology, Radiation Oncology and Medical Physics is needed for the procedures using high precision radiotherapy techniques, which deliver high doses to locations near functional brain areas.
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Affiliation(s)
- J Jacob
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Radiation Oncology, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - N Reyns
- Centre Hospitalier Régional Universitaire de Lille, Department of Neurosurgery and Neuro-Oncology, Neurosurgery service, 2, avenue Oscar-Lambret, 59000 Lille, France; Lille University, Inserm, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, 1, avenue Oscar-Lambret, 59000 Lille, France
| | - C-A Valéry
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Neurosurgery, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - L Feuvret
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Radiation Oncology, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - J-M Simon
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Radiation Oncology, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - J-J Mazeron
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Radiation Oncology, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - C Jenny
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Medical Physics, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - M Cuttat
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Medical Physics, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - P Maingon
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Radiation Oncology, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - D Pasquier
- Centre Oscar-Lambret, Academic Department of Radiation Oncology, 3, rue Frédéric-Combemale, 59000 Lille, France; Lille University, Centre de Recherche en Informatique, Signal et Automatique de Lille, CRIStAL UMR 9189, Scientific Campus, bâtiment Esprit, avenue Henri-Poincaré, 59655 Villeneuve-d'Ascq, France
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Zhang S, Zhou C, Liu D, Piao Y, Zhang F, Hu J, Ma Z, Wei Z, Zhu W, Lv M. Is smoking a risk factor for bleeding in adult men with cerebral arteriovenous malformations? A single-center regression study from China. J Stroke Cerebrovasc Dis 2020; 29:105084. [PMID: 32807480 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105084] [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: 02/27/2020] [Revised: 04/21/2020] [Accepted: 06/21/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To assess whether smoking increases the risk of bleeding in patients with cerebral arteriovenous malformations (CAVM). MATERIAL AND METHODS According to our research plan, 385 CAVM patients admitted to Beijing Tiantan Hospital from December 2015 to January 2018 were included in this study, including 210 bleeding patients and 175 non-bleeding patients. We divided patients into three subgroups of current smokers, ex-smokers (those who quit smoking for one year or more) and non-smokers. The relationship between smoking and the risk of CAVM rupture was assessed by univariate and multivariate regression analysis. RESULTS Multivariate regression analysis showed that there was a statistically significant difference between current smoker and non-smoker (OR = 1.87, p = 0.019). Among the covariates of the multivariate regression analysis, the location, combined with blood flow-related intracranial aneurysms and size were related to the risk of CAVM bleeding. CONCLUSION Current smoking may increase the risk of CAVM bleeding; however, there was no significant correlation between ex-smoking and CAVM bleeding.
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Affiliation(s)
- Shuai Zhang
- Department of Neurosurgery, Beijing Jingmei Group General Hospital, Beijing 102300, PR China
| | - Chenguang Zhou
- Department of Neurology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, PR China
| | - Dong Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Centre for Neurological Diseases, Beijing, 100070, China
| | - Yongjun Piao
- Department of Neurosurgery, Beijing Jingmei Group General Hospital, Beijing 102300, PR China
| | - Fuqiang Zhang
- Department of Neurosurgery, Beijing Jingmei Group General Hospital, Beijing 102300, PR China
| | - Jie Hu
- Department of Neurosurgery, Beijing Jingmei Group General Hospital, Beijing 102300, PR China
| | - Zongqian Ma
- Department of Neurosurgery, Beijing Jingmei Group General Hospital, Beijing 102300, PR China
| | - Zhanyang Wei
- Department of Neurosurgery, Beijing Jingmei Group General Hospital, Beijing 102300, PR China
| | - Weisheng Zhu
- Department of Neurosurgery, Beijing Jingmei Group General Hospital, Beijing 102300, PR China.
| | - Ming Lv
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing 100070, PR China.
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Cerebral artery segmentation based on magnetization-prepared two rapid acquisition gradient echo multi-contrast images in 7 Tesla magnetic resonance imaging. Neuroimage 2020; 222:117259. [PMID: 32798680 DOI: 10.1016/j.neuroimage.2020.117259] [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: 06/05/2020] [Revised: 07/12/2020] [Accepted: 08/03/2020] [Indexed: 11/20/2022] Open
Abstract
Cerebral artery segmentation plays an important role in the direct visualization of the human brain to obtain vascular system information. On ultra-high field magnetic resonance imaging, cerebral arteries appearing hyperintense on T1 weighted (T1w) images could be segmented from brain tissues such as gray and white matter. In this study, we propose an automated method to segment the cerebral arteries using multi-contrast images including T1w images of a magnetization-prepared two rapid acquisition gradient echo (MP2RAGE) sequence at 7 T. The proposed method, termed MP2rase-CA (MP2rage based RApid SEgmentation Cerebral Artery), employed a seed-based region-growing strategy and Frangi filtering as well as our brain tissue segmentation (MP2rase Brain Tissue). Time-of-flight (TOF) magnetic resonance angiography (MRA) images were obtained as a reference to evaluate the MP2rase-CA. We successfully performed vessel segmentations, from T1w MP2RAGE images, which mostly overlapped with the segmentations of large cerebral arteries from the TOF-MRA. We also investigated the effect of the large cerebral arteries on spatial transformation of anatomical images to standard coordinate space using vessel segmentation by MP2rase-CA. As a result, the T1w image without the cerebral arteries by MP2rase-CA showed better agreement with the standard atlas compared with the T1w image containing the arteries. In addition, voxel-based morphology showed significant differences between T1w images with and without cerebral arteries in brain areas nearby large arteries. Thus, because MP2rase-CA using MP2RAGE images can obtain brain tissue anatomical information as well as relatively large cerebral artery information without need for additional structure acquisition, it is useful and time saving for functional and structural studies.
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Treatment Strategies and Related Outcomes for Brain Arteriovenous Malformations in Children: A Systematic Review and Meta-Analysis. AJR Am J Roentgenol 2020; 215:472-487. [DOI: 10.2214/ajr.19.22443] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Joud H, Peto I, Noureldine MHA, Mokin M, Agazzi S. Spontaneous Regression Followed by Rupture of an Untreated Brain Arteriovenous Malformation. World Neurosurg 2020; 143:290-294. [PMID: 32745646 DOI: 10.1016/j.wneu.2020.07.162] [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: 06/23/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Brain arteriovenous malformations (AVMs) are dynamic lesions. Unlike the recruitment of additional vessels and the growth of the nidus over time, which are well reported in the literature, spontaneous regression is much less frequent. Only a handful of cases reporting recanalization of spontaneously regressed AVMs have been published. AVMs that undergo spontaneous regression typically share structural and historical features, including previous hemorrhage, a small nidus, superficial venous drainage, and a single draining vein. Structural features and hemodynamic changes may predispose brain AVMs to spontaneous regression, and angiogenic processes are hypothesized to contribute to recanalization and hemorrhage. CASE DESCRIPTION We present the case of a 37-year-old female who had been diagnosed 12 years ago with an unruptured Spetzler-Martin grade 3 AVM in the left medial occipital lobe after a history of progressively worsening migraines. The AVM was monitored for 1 year, but the patient was lost to follow-up until 11 years later, when the AVM nidus was found to be significantly smaller in size. One month later, the patient presented with acute intraparenchymal hemorrhage due to rupture of the AVM, which was then surgically resected. CONCLUSIONS Our case is the second reported case of rupture of a spontaneously regressed AVM and the first reported case of this outcome with no history of previous hemorrhage. Close monitoring of brain AVMs may be warranted for longer periods of time than previously recommended.
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Affiliation(s)
- Hadi Joud
- University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Ivo Peto
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | | | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.
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Parr M, Patel N, Kauffmann J, Al-Mufti F, Roychowdhury S, Narayan V, Nosko M, Nanda A, Gupta G. Arteriovenous malformation presenting as traumatic subdural hematoma: A case report. Surg Neurol Int 2020; 11:203. [PMID: 32874706 PMCID: PMC7451141 DOI: 10.25259/sni_160_2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 06/11/2020] [Indexed: 12/05/2022] Open
Abstract
Background: Brain arteriovenous malformations (AVMs) are congenital aberrant connections between afferent arteries and draining veins with no intervening capillary bed or neural parenchyma. Other than seizures, the most common initial presentation of AVM is hemorrhage, which is typically intraparenchymal, subarachnoid, or intraventricular, and very rarely subdural. Case Description: This patient is a 66-year-old male with a history of atrial fibrillation, chronically anticoagulated with apixaban, who presented through emergency services after a fall. On presentation, computed tomography (CT) of the head showed a small, 6 mm right subdural hematoma, and the patient was neurologically intact. The hematoma was evacuated by burr hole craniotomy and placement of a subdural drain 12 days after the initial presentation due to worsening headaches and further hematoma expansion. Two weeks postevacuation, the patient was readmitted for seizures, and at this time, CT angiography showed no intracranial vascular lesion. Approximately 1 month later, the patient was readmitted for decreased responsiveness, and CT head at this time found right frontal intraparenchymal hemorrhage. On subsequent catheter angiography, the right frontal AVM was discovered. It was treated with preoperative embolization followed by surgical resection. Postoperatively, the patient followed commands and tracked with his eyes. There was spontaneous antigravity movement of the right upper extremity, but still no movement of the left upper or bilateral lower extremities. Conclusion: This case emphasizes the importance of maintaining a high index of suspicion for underlying vascular lesions when evaluating intracranial bleeding, even in the setting of traumatic history, particularly in cases of hematoma expansion.
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Affiliation(s)
- Matthew Parr
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nitesh Patel
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - John Kauffmann
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, United States
| | - Sudipta Roychowdhury
- Departments of Radiology, Rutgers - Robert Wood Johnson Medical School, New Brunswick, Canada
| | - Vinayak Narayan
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michael Nosko
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Anil Nanda
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gaurav Gupta
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Medical management with interventional therapy versus medical management alone for unruptured brain arteriovenous malformations (ARUBA): final follow-up of a multicentre, non-blinded, randomised controlled trial. Lancet Neurol 2020; 19:573-581. [PMID: 32562682 DOI: 10.1016/s1474-4422(20)30181-2] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/04/2020] [Accepted: 04/27/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND In A Randomized trial of Unruptured Brain Arteriovenous malformations (ARUBA), randomisation was halted at a mean follow-up of 33·3 months after a prespecified interim analysis showed that medical management alone was superior to the combination of medical management and interventional therapy in preventing symptomatic stroke or death. We aimed to study whether these differences persisted through 5-years' follow-up. METHODS ARUBA was a non-blinded, randomised trial done at 39 clinical centres in nine countries. Adults (age ≥18 years) diagnosed with an unruptured brain arteriovenous malformation, who had never undergone interventional therapy, and were considered by participating clinical centres to be suitable for intervention to eradicate the lesion, were eligible for inclusion. Patients were randomly assigned (1:1) by a web-based data collection system, stratified by clinical centre in a random permuted block design with block sizes of two, four, and six, to medical management alone or with interventional therapy (neurosurgery, embolisation, or stereotactic radiotherapy, alone or in any combination, sequence, or number). Although patients and investigators at a given centre were not masked to treatment assignment, investigators at other centres and those in the clinical coordinating centre were not informed of assignment or outcomes at any of the centres. The primary outcome was time to death or symptomatic stroke confirmed by imaging, assessed by a neurologist at each centre not involved in the management of participants' care, and monitored by an independent committee using an adaptive approach with interim analyses. Enrolment began on April 4, 2007, and was halted on April 15, 2013, after which follow-up continued until July 15, 2015. All analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, NCT00389181. FINDINGS Of 1740 patients screened, 226 were randomly assigned to medical management alone (n=110) or medical management plus interventional therapy (n=116). During a mean follow-up of 50·4 months (SD 22·9), the incidence of death or symptomatic stroke was lower with medical management alone (15 of 110, 3·39 per 100 patient-years) than with medical management with interventional therapy (41 of 116, 12·32 per 100 patient-years; hazard ratio 0·31, 95% CI 0·17 to 0·56). Two patients in the medical management group and four in the interventional therapy group (two attributed to intervention) died during follow-up. Adverse events were observed less often in patients allocated to medical management compared with interventional therapy (283 vs 369; 58·97 vs 78·73 per 100 patient-years; risk difference -19·76, 95% CI -30·33 to -9·19). INTERPRETATION After extended follow-up, ARUBA showed that medical management alone remained superior to interventional therapy for the prevention of death or symptomatic stroke in patients with an unruptured brain arteriovenous malformation. The data concerning the disparity in outcomes should affect standard specialist practice and the information presented to patients. The even longer-term risks and differences between the two therapeutic approaches remains uncertain. FUNDING National Institute of Neurological Disorders and Stroke for the randomisation phase and Vital Projects Fund for the follow-up phase.
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Winkler EA, Lu A, Morshed RA, Yue JK, Rutledge WC, Burkhardt JK, Patel AB, Ammanuel SG, Braunstein S, Fox CK, Fullerton HJ, Kim H, Cooke D, Hetts SW, Lawton MT, Abla AA, Gupta N. Bringing high-grade arteriovenous malformations under control: clinical outcomes following multimodality treatment in children. J Neurosurg Pediatr 2020; 26:82-91. [PMID: 32276243 DOI: 10.3171/2020.1.peds19487] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 01/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain arteriovenous malformations (AVMs) consist of dysplastic blood vessels with direct arteriovenous shunts that can hemorrhage spontaneously. In children, a higher lifetime hemorrhage risk must be balanced with treatment-related morbidity. The authors describe a collaborative, multimodal strategy resulting in effective and safe treatment of pediatric AVMs. METHODS A retrospective analysis of a prospectively maintained database was performed in children with treated and nontreated pediatric AVMs at the University of California, San Francisco, from 1998 to 2017. Inclusion criteria were age ≤ 18 years at time of diagnosis and an AVM confirmed by a catheter angiogram. RESULTS The authors evaluated 189 pediatric patients with AVMs over the study period, including 119 ruptured (63%) and 70 unruptured (37%) AVMs. The mean age at diagnosis was 11.6 ± 4.3 years. With respect to Spetzler-Martin (SM) grade, there were 38 (20.1%) grade I, 40 (21.2%) grade II, 62 (32.8%) grade III, 40 (21.2%) grade IV, and 9 (4.8%) grade V lesions. Six patients were managed conservatively, and 183 patients underwent treatment, including 120 resections, 82 stereotactic radiosurgery (SRS), and 37 endovascular embolizations. Forty-four of 49 (89.8%) high-grade AVMs (SM grade IV or V) were treated. Multiple treatment modalities were used in 29.5% of low-grade and 27.3% of high-grade AVMs. Complete angiographic obliteration was obtained in 73.4% of low-grade lesions (SM grade I-III) and in 45.2% of high-grade lesions. A periprocedural stroke occurred in a single patient (0.5%), and there was 1 treatment-related death. The mean clinical follow-up for the cohort was 4.1 ± 4.6 years, and 96.6% and 84.3% of patients neurologically improved or remained unchanged in the ruptured and unruptured AVM groups following treatment, respectively. There were 16 bleeding events following initiation of AVM treatment (annual rate: 0.02 events per person-year). CONCLUSIONS Coordinated multidisciplinary evaluation and individualized planning can result in safe and effective treatment of children with AVMs. In particular, it is possible to treat the majority of high-grade AVMs with an acceptable safety profile. Judicious use of multimodality therapy should be limited to appropriately selected patients after thorough team-based discussions to avoid additive morbidity. Future multicenter studies are required to better design predictive models to aid with patient selection for multimodal pediatric care, especially with high-grade AVMs.
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Affiliation(s)
| | - Alex Lu
- Departments of1Neurological Surgery
| | | | | | | | - Jan-Karl Burkhardt
- Departments of1Neurological Surgery
- 2Department of Neurosurgery, Baylor Medical Center, Houston, Texas; and
| | | | | | | | - Christine K Fox
- 4Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology; and
| | - Heather J Fullerton
- 4Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology; and
| | - Helen Kim
- 5Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, California
| | | | | | - Michael T Lawton
- Departments of1Neurological Surgery
- 7Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Nalin Gupta
- Departments of1Neurological Surgery
- 8Pediatrics
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Ramachandran S, Mukherjee D, Delf J, Bown MJ, Kandiyil N. A comparison of arterial spin labelling with catheter angiography in evaluating arteriovenous malformations: a systematic review. Br J Radiol 2020; 93:20190830. [PMID: 32208976 PMCID: PMC10993222 DOI: 10.1259/bjr.20190830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/10/2020] [Accepted: 03/12/2020] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To compare the performance of arterial spin labelling (ASL) in evaluating arteriovenous malformations (AVMs) against the current gold standard of catheter angiography. METHODS We systematically reviewed the published literature using EMBASE and Medline. We included studies that compared ASL to catheter angiography in the assessment of AVMs in three outcome domains: detection, angioarchitectural and haemodynamic features. RESULTS From 314 unique citations, 19 studies representing 289 patients with intracranial AVMs met our inclusion criteria. We did not pool data due to marked heterogeneity in study outcome measures. Seven studies showed high diagnostic performance of ASL in identifying arterial feeders, with sensitivity ranging from 84.6 to 100% and specificity ranging from 93.3 to 100%. Six studies showed strong ability in detecting arteriovenous shunting, with sensitivity ranging from 91.7 to 100% and specificity ranging from 90 to 100%. Seven studies demonstrated that ASL could identify nidal location and size as well as catheter angiography, while five studies showed relatively poorer performance in delineating venous drainage. Two studies showed 100% sensitivity of ASL in the identification of residual or obliterated AVMs following stereotactic radiosurgery. CONCLUSIONS Despite limitations in the current evidence base and technical challenges, this review suggests that ASL has a promising role in the work-up and post-treatment follow-up of AVMs. Larger scale prospective studies assessing the diagnostic performance of ASL are warranted. ADVANCES IN KNOWLEDGE ASL demonstrates overall validity in the evaluation of intracranial AVMs.
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Affiliation(s)
- Sanjeev Ramachandran
- University Hospitals of Leicester NHS Trust,
Leicester, United Kingdom
- University of Leicester,
Leicester, United Kingdom
| | - Deyashini Mukherjee
- University Hospitals of Leicester NHS Trust,
Leicester, United Kingdom
- University of Leicester,
Leicester, United Kingdom
| | - Jonathan Delf
- University Hospitals of Leicester NHS Trust,
Leicester, United Kingdom
| | - Matthew James Bown
- University Hospitals of Leicester NHS Trust,
Leicester, United Kingdom
- University of Leicester,
Leicester, United Kingdom
| | - Neghal Kandiyil
- University Hospitals of Leicester NHS Trust,
Leicester, United Kingdom
- University of Leicester,
Leicester, United Kingdom
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Vollherbst DF, Bendszus M, Möhlenbruch MA. Vascular Malformations of the Brain and Its Coverings. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:285-294. [PMID: 37502170 PMCID: PMC10370599 DOI: 10.5797/jnet.ra.2020-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/19/2020] [Indexed: 07/29/2023]
Abstract
Vascular malformations of the brain and its coverings encompass several different vascular pathologies of the brain and its coverings, which substantially differ in morphology, clinical presentation, and prognosis, reaching from incidental, asymptomatic vascular abnormalities to life-threatening diseases with high risks of morbidity, most frequently caused by intracranial hemorrhage. In this article, the most common vascular malformations of the brain with and without arteriovenous shunting of blood (e.g., arteriovenous malformations [AVMs], dural arteriovenous fistulas [DAVFs], and cavernous malformations) are explained with a focus on definition, diagnosis, classification, and management.
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Affiliation(s)
- Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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Byun J, Kwon DH, Lee DH, Park W, Park JC, Ahn JS. Radiosurgery for Cerebral Arteriovenous Malformation (AVM) : Current Treatment Strategy and Radiosurgical Technique for Large Cerebral AVM. J Korean Neurosurg Soc 2020; 63:415-426. [PMID: 32423182 PMCID: PMC7365281 DOI: 10.3340/jkns.2020.0008] [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: 01/07/2020] [Accepted: 02/29/2020] [Indexed: 11/27/2022] Open
Abstract
Arteriovenous malformations (AVMs) are congenital anomalies of the cerebrovascular system. AVM harbors 2.2% annual hemorrhage risk in unruptured cases and 4.5% annual hemorrhage risk of previously ruptured cases. Stereotactic radiosurgery (SRS) have been shown excellent treatment outcomes for patients with small- to moderated sized AVM which can be achieved in 80–90% complete obliteration rate with a 2–3 years latency period. The most important factors are associated with obliteration after SRS is the radiation dose to the AVM. In our institutional clinical practice, now 22 Gy (50% isodose line) dose of radiation has been used for treatment of cerebral AVM in single-session radiosurgery. However, dose-volume relationship can be unfavorable for large AVMs when treated in a single-session radiosurgery, resulting high complication rates for effective dose. Thus, various strategies should be considered to treat large AVM. The role of pre-SRS embolization is permanent volume reduction of the nidus and treat high-risk lesion such as AVM-related aneurysm and high-flow arteriovenous shunt. Various staging technique of radiosurgery including volume-staged radiosurgery, hypofractionated radiotherapy and dose-staged radiosurgery are possible option for large AVM. The incidence of post-radiosurgery complication is varied, the incidence rate of radiological post-radiosurgical complication has been reported 30–40% and symptomatic complication rate was reported from 8.1% to 11.8%. In the future, novel therapy which incorporate endovascular treatment using liquid embolic material and new radiosurgical technique such as gene or cytokine-targeted radio-sensitization should be needed.
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Affiliation(s)
- Joonho Byun
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kwon
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Heui Lee
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Wonhyoung Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Cheol Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Lin TM, Yang HC, Lee CC, Wu HM, Hu YS, Luo CB, Guo WY, Kao YH, Chung WY, Lin CJ. Stasis index from hemodynamic analysis using quantitative DSA correlates with hemorrhage of supratentorial arteriovenous malformation: a cross-sectional study. J Neurosurg 2020; 132:1574-1582. [PMID: 31026828 DOI: 10.3171/2019.1.jns183386] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 01/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Assessments of hemorrhage risk based on angioarchitecture have yielded inconsistent results, and quantitative hemodynamic studies have been limited to small numbers of patients. The authors examined whether cerebral hemodynamic analysis using quantitative digital subtraction angiography (QDSA) can outperform conventional DSA angioarchitecture analysis in evaluating the risk of hemorrhage associated with supratentorial arteriovenous malformations (AVMs). METHODS A cross-sectional study was performed by retrospectively reviewing adult supratentorial AVM patients who had undergone both DSA and MRI studies between 2011 and 2017. Angioarchitecture characteristics, DSA parameters, age, sex, and nidus volume were analyzed using univariate and multivariate logistic regression, and QDSA software analysis was performed on DSA images. Based on the QDSA analysis, a stasis index, defined as the inflow gradient divided by the absolute value of the outflow gradient, was determined. The receiver operating characteristic (ROC) curve was used to compare diagnostic performances of conventional DSA angioarchitecture analysis and analysis using hemodynamic parameters based on QDSA. RESULTS A total of 119 supratentorial AVM patients were included. After adjustment for age at diagnosis, sex, and nidus volume, the exclusive deep venous drainage (p < 0.01), observed through conventional angioarchitecture examination using DSA, and the stasis index of the most dominant drainage vein (p = 0.02), measured with QDSA hemodynamic analysis, were independent risk factors for hemorrhage. The areas under the ROC curves for the conventional DSA method (0.75) and QDSA hemodynamics analysis (0.73) were similar. A venous stasis index greater than 2.18 discriminated the hemorrhage group with a sensitivity of 52.6% and a specificity of 81.5%. CONCLUSIONS In QDSA, a higher stasis index of the most dominant drainage vein is an objective warning sign associated with supratentorial AVM rupture. Risk assessments of AVMs using QDSA and conventional DSA angioarchitecture were equivalent. Because QDSA is a complementary noninvasive approach without extra radiation or contrast media, comprehensive hemorrhagic risk assessment of cerebral AVMs should include both DSA angioarchitecture and QDSA analyses.
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Affiliation(s)
- Te Ming Lin
- 1Department of Radiology and
- 3School of Medicine and
| | - Huai Che Yang
- 2Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital; and
- 3School of Medicine and
| | - Cheng Chia Lee
- 2Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital; and
- 3School of Medicine and
| | - Hsiu Mei Wu
- 1Department of Radiology and
- 3School of Medicine and
| | - Yong Sin Hu
- 1Department of Radiology and
- 3School of Medicine and
| | - Chao Bao Luo
- 1Department of Radiology and
- 3School of Medicine and
| | - Wan Yuo Guo
- 1Department of Radiology and
- 3School of Medicine and
| | - Yi Hsuan Kao
- 4Department of Biomedical Imaging and Radiological Science, National Yang-Ming University, Taipei, Taiwan
| | - Wen Yuh Chung
- 1Department of Radiology and
- 2Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital; and
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Sun W, Germans MR, Sebök M, Fierstra J, Kulcsar Z, Keller A, Regli L. Outcome Comparison Between Surgically Treated Brain Arteriovenous Malformation Hemorrhage and Spontaneous Intracerebral Hemorrhage. World Neurosurg 2020; 139:e807-e811. [PMID: 32360923 DOI: 10.1016/j.wneu.2020.04.170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Case fatality and poor outcome rates are different between brain arteriovenous malformation-associated intracerebral hemorrhage (bAVM-ICH) and spontaneous intracerebral hemorrhage (SICH). These outcome rates, however, have never been compared in patients who need neurosurgical evacuation of the intracerebral hemorrhage (ICH). OBJECTIVE To compare the short- and long-term functional outcome between surgically treated patients with bAVM-ICH and SICH. METHODS We collected data from surgically treated ICH patients at the Department of Neurosurgery, University Hospital Zurich, from January 2015 to July 2018. We performed logistic regression analysis to compare the functional outcome between groups, adjusting for demographics, admission characteristics, and stroke risk factors. RESULTS A total of 26 bAVM-ICH and 115 SICH patients were included in the final analysis. Patients with bAVM-ICH were younger and less likely to have hypertension without significant differences in ICH volume, hematoma location, intraventricular hemorrhage, and other stroke risk factors. A significantly better functional outcome rate was seen in bAVM-ICH patients at short- and long-term follow-up. These differences remained significant after adjusting for confounders. CONCLUSIONS patients with a bAVM who need surgical evacuation of an ICH have a more favorable outcome than surgically treated patients with spontaneous ICH, even after correction for confounding factors, such as younger age and less premorbid hypertension.
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Affiliation(s)
- Wenhua Sun
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Menno R Germans
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland.
| | - Martina Sebök
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Jorn Fierstra
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Zsolt Kulcsar
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland; Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | - Annika Keller
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland; Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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Raper DMS, Winkler EA, Rutledge WC, Hetts SW, Abla AA. Interhemispheric Surgical Approaches for Ruptured Intraventricular Arteriovenous Malformation-Associated Aneurysms: Technical Report and Case Series. World Neurosurg 2020; 139:e618-e625. [PMID: 32339737 DOI: 10.1016/j.wneu.2020.04.066] [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: 03/12/2020] [Revised: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Aneurysms associated with brain arteriovenous malformations (AVMs) represent a hemorrhage risk in addition to that of the AVM nidus. In high-risk or unresectable cases, targeted treatment of an aneurysm causing hemorrhage may effectively decrease future hemorrhage risk. The objective of this report is to describe our series of patients with intraventricular AVM-associated aneurysms treated surgically. We highlight technical nuances of the surgical approaches to aneurysms in the lateral and third ventricles. METHODS A retrospective review was performed of patients in whom an intraventricular aneurysm rupture was responsible for hemorrhage. In each patient, the aneurysm was excluded surgically via an interhemispheric approach, including transcallosal, transchoroidal, or transcingulate corridors. Aneurysm, AVM characteristics, surgical approach, and outcomes were reviewed. RESULTS Six patients were included in the series. In 5 patients, the disease was located on the left and approached from the right. Aneurysms were located in, or projecting into, the lateral ventricle in 4 patients (transcingulate approach) and in the third ventricle in 2 patients (transchoroidal fissure approach). The aneurysm was clipped in 1 patient and resected in 5 patients. The associated AVM was resected in 2 patients. In all patients, the surgical approach allowed adequate treatment of the aneurysm without new neurologic morbidity. No patients experienced recurrent intraventricular hemorrhage during follow-up. CONCLUSIONS Ruptured intraventricular aneurysms associated with brain AVMs can be treated surgically to reduce the risk of rebleeding in patients in whom the aneurysms are not accessible to endovascular treatment and in which the AVM nidus may not be safely resected.
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Affiliation(s)
- Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California, USA.
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Zafar A, Fiani B, Hadi H, Arshad M, Cathel A, Naeem M, Parsons MS, Farooqui M, Bucklin AA, Leone MJ, Baig A, Quadri SA. Cerebral vascular malformations and their imaging modalities. Neurol Sci 2020; 41:2407-2421. [DOI: 10.1007/s10072-020-04415-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/13/2020] [Indexed: 12/19/2022]
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Nisson PL, Fard SA, Walter CM, Johnstone CM, Mooney MA, Meybodi AT, Lang M, Kim H, Jahnke H, Roe DJ, Dumont TM, Lemole GM, Spetzler RF, Lawton MT. A novel proposed grading system for cerebellar arteriovenous malformations. J Neurosurg 2020; 132:1105-1115. [PMID: 30849761 PMCID: PMC6856412 DOI: 10.3171/2018.12.jns181677] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 12/03/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the existing Spetzler-Martin (SM), Spetzler-Ponce (SP), and Lawton-Young (LY) grading systems for cerebellar arteriovenous malformations (AVMs) and to propose a new grading system to estimate the risks associated with these lesions. METHODS Data for patients with cerebellar AVMs treated microsurgically in two tertiary medical centers were retrospectively reviewed. Data from patients at institution 1 were collected from September 1999 to February 2013, and at institution 2 from October 2008 to October 2015. Patient outcomes were classified as favorable (modified Rankin Scale [mRS] score 0-2) or poor (mRS score 3-6) at the time of discharge. Using chi-square and logistic regression analysis, variables associated with poor outcomes were assigned risk points to design the proposed grading system. The proposed system included neurological status prior to treatment (poor, +2 points), emergency surgery (+1 point), age > 60 years (+1 point), and deep venous drainage (deep, +1 point). Risk point totals of 0-1 comprised grade 1, 2-3 grade 2, and 4-5 grade 3. RESULTS A total of 125 cerebellar AVMs of 1328 brain AVMs were reviewed in 125 patients, 120 of which were treated microsurgically and included in the study. With our proposed grading system, we found poor outcomes differed significantly between each grade (p < 0.001), while with the SM, SP, and LY grading systems they did not (p = 0.22, p = 0.25, and p = 1, respectively). Logistic regression revealed grade 2 had 3.3 times the risk of experiencing a poor outcome (p = 0.008), while grade 3 had 9.9 times the risk (p < 0.001). The proposed grading system demonstrated a superior level of predictive accuracy (area under the receiver operating characteristic curve [AUROC] of 0.72) compared with the SM, SP, and LY grading systems (AUROC of 0.61, 0.57, and 0.51, respectively). CONCLUSIONS The authors propose a novel grading system for cerebellar AVMs based on emergency surgery, venous drainage, preoperative neurological status, and age that provides a superior prognostication power than the formerly proposed SM, SP, and LY grading systems. This grading system is clinically predictive of patient outcomes and can be used to better guide vascular neurosurgeons in clinical decision-making.
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Affiliation(s)
- Peyton L. Nisson
- College of Medicine, University of Arizona, Tucson, Arizona
- Department of Neurosurgery, University of California, San Francisco, California
| | - Salman A. Fard
- College of Medicine, University of Arizona, Tucson, Arizona
| | | | | | - Michael A. Mooney
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael Lang
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Helen Kim
- Department of Neurosurgery, University of California, San Francisco, California
| | - Heidi Jahnke
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Denise J. Roe
- Epidemiology and Biostatistics, College of Public Health, University of Arizona, Tucson, Arizona
| | - Travis M. Dumont
- Division of Neurosurgery, Banner-University Medical Center, Tucson, Arizona
| | - G. Michael Lemole
- Division of Neurosurgery, Banner-University Medical Center, Tucson, Arizona
| | - Robert F. Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael T. Lawton
- Department of Neurosurgery, University of California, San Francisco, California
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
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Tailor C, Ashby WS, Gorassini DR, Lownie SP, Walsh K, Pelz D, Hammond RR. Embolized cerebral arteriovenous malformations: a multivariate analysis of 101 excised specimens. J Neurosurg 2020; 132:1140-1146. [PMID: 30875685 DOI: 10.3171/2018.12.jns182244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 12/12/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Endovascular approaches have evolved from a technique practiced at very few centers to a widely available option in the management of arteriovenous malformations (AVMs) of the central nervous system. Embolization can be employed as definitive therapy or as an adjunct to surgical excision. A wide variety of embolic agents have been successfully developed and used in the clinical setting. In addition to facilitating vascular occlusion, embolic agents induce a number of reactive and destructive changes in vessel walls and the surrounding tissue. However, studies examining the pathological changes induced by different embolic agents and varying times of exposure are scarce. The goal of the present study was to compare embolic agents and time of exposure on the pathology in excised specimens. METHODS The records of the Department of Pathology at the London Health Sciences Centre were searched for embolized AVMs for the 35-year period 1980-2015. All cases were reevaluated for clinical and technical variables and standardized histopathological findings. Cases were grouped by embolic agent, volume of agent used, and time to excision. RESULTS A total of 101 specimens were identified. Embolic agents were invariably associated with a range of pathological findings, some of which may affect the integrity of vessel walls or the reestablishment of flow, thrombosis, acute and chronic inflammatory changes, angionecrosis, extravasation, and recanalization. The type of embolic agent did not predict differences in the incidence or severity of histopathological changes. Larger volumes of embolic agent were associated with a greater proportion of vessels containing embolic material. AVMs excised early (< 1 week postembolization) contained more acute vasculitis, while those excised later (≥ 1 week postembolization) were more likely to exhibit recanalization and foreign body giant cell infiltrates. CONCLUSIONS Embolic agents induce a predictable range and temporal progression of pathological changes in cerebral AVMs. The embolic agents studied are indistinguishable in terms of the range and frequency of pathological reactions induced. Greater volumes of embolic agent are associated with more abundant agent within the lesion, but the proportion of vessels and vascular cross-sectional areas containing agent is small. Several changes are significantly associated with time postembolization. Acute vasculitis is a more common finding in the 1st week, while recanalization and foreign body-type granulomatous inflammation are more common at 1 week and beyond.
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Affiliation(s)
| | | | - Donald R Gorassini
- 3Department of Social Sciences, King's University College, Western University, London, Ontario, Canada
| | | | | | - David Pelz
- 4Clinical Neurological Sciences, and
- 5Medical Imaging, London Health Sciences Centre, Western University, London; and
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Silent MRA: arterial spin labeling magnetic resonant angiography with ultra-short time echo assessing cerebral arteriovenous malformation. Neuroradiology 2020; 62:455-461. [PMID: 31898767 DOI: 10.1007/s00234-019-02345-3] [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: 07/30/2019] [Accepted: 12/09/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE MR angiography using the silent MR angiography algorithm (silent MRA), which combines arterial spin labeling and an ultrashort time echo, has not been used for the evaluation of cerebral arteriovenous malformations (CAVMs). We aimed to determine the usefulness of silent MRA for the evaluation of CAVMs. METHODS Twenty-nine CAVMs of 28 consecutive patients diagnosed by 4D CT angiography or digital subtraction angiography, who underwent both time-of-flight (TOF) MRA and silent MRA, were enrolled. Two observers independently assessed the TOF-MRA and silent MRA images of CAVMs. Micro AVM was defined as AVM with a nidus diameter less than 10 mm. The detection rate, visualization of the components, and accuracy of Spetzler-Martin grade were evaluated with statistical software R. RESULTS For all 29 CAVMs, 23 (79%) lesions were detected for TOF-MRA and all for silent MRA. Of 10 micro AVMs, only 4 (40%) lesions were detectable on TOF-MRA and all (100%) on silent MRA. The visibility of the nidus and drainer was significantly better for silent MRA than TOF-MRA (p < 0.001), while there was no significant difference in the feeder between the two sequences. The accuracy rates of the Spetzler-Martin grade for the TOF and silent MRA were 38% (11/29) and 79.3% (23/29), respectively (p < 0.001). CONCLUSIONS Silent MRA is useful for evaluating CAVM components and detecting micro AVM.
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Chen CJ, Kearns KN, Ding D, Kano H, Mathieu D, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Grills IS, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for arteriovenous malformations of the basal ganglia and thalamus: an international multicenter study. J Neurosurg 2020; 132:122-131. [PMID: 30641831 DOI: 10.3171/2018.8.jns182106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 08/31/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Arteriovenous malformations (AVMs) of the basal ganglia (BG) and thalamus are associated with elevated risks of both hemorrhage if left untreated and neurological morbidity after resection. Therefore, stereotactic radiosurgery (SRS) has become a mainstay in the management of these lesions, although its safety and efficacy remain incompletely understood. The aim of this retrospective multicenter cohort study was to evaluate the outcomes of SRS for BG and thalamic AVMs and determine predictors of successful endpoints and adverse radiation effects. METHODS The authors retrospectively reviewed data on patients with BG or thalamic AVMs who had undergone SRS at eight institutions participating in the International Gamma Knife Research Foundation (IGKRF) from 1987 to 2014. Favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RICs). Multivariable models were developed to identify independent predictors of outcome. RESULTS The study cohort comprised 363 patients with BG or thalamic AVMs. The mean AVM volume and SRS margin dose were 3.8 cm3 and 20.7 Gy, respectively. The mean follow-up duration was 86.5 months. Favorable outcome was achieved in 58.5% of patients, including obliteration in 64.8%, with rates of post-SRS hemorrhage and permanent RIC in 11.3% and 5.6% of patients, respectively. Independent predictors of favorable outcome were no prior AVM embolization (p = 0.011), a higher margin dose (p = 0.008), and fewer isocenters (p = 0.044). CONCLUSIONS SRS is the preferred intervention for the majority of BG and thalamic AVMs. Patients with morphologically compact AVMs that have not been previously embolized are more likely to have a favorable outcome, which may be related to the use of a higher margin dose.
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Affiliation(s)
- Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kathryn N Kearns
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- 2Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Hideyuki Kano
- 3Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - David Mathieu
- 4Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Quebec, Canada
| | - Douglas Kondziolka
- 5Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Caleb Feliciano
- 6Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Inga S Grills
- 7Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan; and
| | - Gene H Barnett
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - L Dade Lunsford
- 3Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Hu YS, Lee CC, Wu HM, Yang HC, Lin TM, Luo CB, Guo WY, Chung WY, Lin CJ. Stagnant Venous Outflow Predicts Brain Arteriovenous Malformation Obliteration After Gamma Knife Radiosurgery Without Prior Intervention. Neurosurgery 2019; 87:338-347. [DOI: 10.1093/neuros/nyz507] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 09/10/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Gamma Knife radiosurgery (GKRS) obliterates 65% to 82% of brain arteriovenous malformations (BAVMs).
OBJECTIVE
To explore the impact of hemodynamics on GKRS outcomes.
METHODS
We retrospectively (2011-2017) included 98 patients with BAVMs who had received GKRS alone. Two evaluators, blinded to the outcomes, analyzed the pre-GKRS angiography and magnetic resonance images to obtain the morphological characteristics and quantitative digital subtraction angiography (QDSA) parameters. The venous stasis index was defined as the inflow gradient divided by the absolute value of the outflow gradient. Patients’ follow-up magnetic resonance or digital subtraction angiography images were evaluated for the presence of complete obliteration (CO). Cox regression and Kaplan–Meier analyses were conducted to determine the correlations between the parameters and outcomes.
RESULTS
Among the 98 patients, 63 (63.4%) achieved CO after GKRS at a median latency period of 31 mo. In multivariable analyses with adjustments for age and sex, increased BAVM volume (hazard ratio (HR) 0.949, P = .022) was an independent characteristic predictor, and venous stenosis (HR 2.595, P = .009), venous rerouting (HR 0.375, P = .022), and larger stasis index (HR 1.227, P = .025) were independent angiographic predictors of CO. BAVMs with a stasis index of >1.71 had a higher 36-mo probability of CO than those with a stasis index of ≤1.71 (61.1% vs 26.7%, P < .001).
CONCLUSION
BAVMs with a larger stasis index, indicating more stagnant venous outflow, may predict obliteration after GKRS. QDSA analysis may help in predicting BAVM treatment outcomes and making therapeutic decisions.
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Affiliation(s)
- Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Te-Ming Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Kato Y, Dong VH, Chaddad F, Takizawa K, Izumo T, Fukuda H, Hara T, Kikuta K, Nakai Y, Endo T, Kurita H, Xu B, Beneš V, Christian R, Pavesi G, Hodaie M, Sharma RK, Agarwal H, Mohan K, Liew BS. Expert Consensus on the Management of Brain Arteriovenous Malformations. Asian J Neurosurg 2019; 14:1074-1081. [PMID: 31903343 PMCID: PMC6896626 DOI: 10.4103/ajns.ajns_234_19] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Brain arteriovenous malformations (bAVMs) are complex, heterogeneous, and uncommon intracranial lesions. They can be treated by one or a combination of the following treatment modalities, namely embolization, radiosurgery, or microsurgical resection. In Spetzler-Martin Grade 4 and 5 arteriovenous malformations (AVMs), conservative management may be the best option. A group of experts in the management of AVMs of different disciplines gathered in January 2019 in Hanoi to compile the “Expert Consensus on the Management of Brain Arteriovenous Malformations”.
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Affiliation(s)
- Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Van He Dong
- Department of Neurosurgery, VietDuc University Hospital, Hoan Kiem, Hanoi, Vietnam
| | - Feres Chaddad
- Department of Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Katsumi Takizawa
- Department of Neurosurgery, Japanese Red Cross Asahikawa Hospital, Asahikawa, Japan
| | - Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto, Nagasaki, Japan
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kochi University Hospital, Nankoku, Kochi, Japan
| | - Takayuki Hara
- Department of Neurosurgery, Toranomon Hospital, MinatoKu, Tokyo, Japan
| | | | - Yasunobu Nakai
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Toshiki Endo
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryo Aoba, Sendai, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Bin Xu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Vladimír Beneš
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University, Military University Hospital, Prague, Czech Republic
| | - Raftopoulos Christian
- Department of Neurosurgery, Cliniques Universitaires SaintLuc Bruxelles, Brussels, Belgium
| | - Giacomo Pavesi
- Department of Neurosurgery, Sant'Agostino Estense Hospital, Modena, Italy
| | - Mojgan Hodaie
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rajan Kumar Sharma
- Department of Neurosurgery, Bir Hospital, National Academy of Medical Sciences, Kathmandu, Nepal
| | | | - Krishna Mohan
- Department of Neurosurgery, SVIMS, Tirupathi, Andhra Pradesh, India
| | - Boon Seng Liew
- Department of Neurosurgery, Hospital Sungai Buloh, Selangor, Malaysia
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Neyazi B, Stein KP, Wilkens L, Maslehaty H, Dumitru CA, Sandalcioglu IE. Age-dependent changes of collagen alpha-2(IV) expression in the extracellular matrix of brain arteriovenous malformations. Clin Neurol Neurosurg 2019; 189:105589. [PMID: 31837516 DOI: 10.1016/j.clineuro.2019.105589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 10/31/2019] [Accepted: 11/04/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Brain arteriovenous malformations (bAVM) are rare vascular lesions. Recent observations challenge the congenital nature of these lesions. The underlying cellular and molecular mechanisms associated with dynamic changes of bAVM still remain unclear. The objective of this study was to explore the potential role of COL4A2 (Collagen alpha-2(IV)) in the pathophysiology of bAVM. PATIENTS AND METHODS Expression and localization of COL4A2 were analyzed on tissue microarrays from bAVM patients (n = 60) by immunohistochemistry. Correlations between COL4A2 levels and clinical parameters were examined with Pearson's test for normally- distibuted or Spearman's Rho for not normally distributed data. Comparison between different clinical parameters was performed using t-test, non-parametric Mann-Whitney U test or Kruskal- Wallis test. Fisher's exact test was used for categorical data. RESULTS COL4A2 was mainly expressed beneath the endothelium of vessels in the tunica media of bAVM. This pattern of expression indicates the basement membrane of the vessel walls. High levels of COL4A2 expression correlated with the age at surgery of patients (p = 0.005; R = 0.393; Spearman's Rho). The age at surgery in young (17-25 years) and old patients (55-76 years) showed a linear correlation; a greater variance of COL4A2 expression was observed in the age group between 26-54 years. CONCLUSION This study reports for the first time the expression of COL4A2 in bAVM and suggests a potential role of COL4A2 in bAVM pathophysiology. These findings contribute to a better understanding of the microenvironment of bAVM and may foster the development of improved therapeutic strategies for this disease.
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Affiliation(s)
- Belal Neyazi
- Department of Neurosurgery, Otto-von-Guericke University, Magdeburg, Germany.
| | - Klaus-Peter Stein
- Department of Neurosurgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Ludwig Wilkens
- Department of Pathology, Nordstadt Hospital, Hanover, Germany
| | | | - Claudia A Dumitru
- Department of Neurosurgery, Otto-von-Guericke University, Magdeburg, Germany
| | - I Erol Sandalcioglu
- Department of Neurosurgery, Otto-von-Guericke University, Magdeburg, Germany
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Schuss P, Hadjiathanasiou A, Ilic I, Brandecker S, Güresir Á, Vatter H, Güresir E. Risk of Rebleeding in Patients Suffering From Ruptured Brain Arteriovenous Malformations Undergoing Subacute Treatment: A Single-Center Series and Systematic Review of the Literature. World Neurosurg 2019; 134:e610-e615. [PMID: 31678312 DOI: 10.1016/j.wneu.2019.10.148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The optimal timing for treatment of ruptured brain arteriovenous malformation (BAVM) is still controversial. The present study aims to determine safety of subacute BAVM management in clinically stable patients by identifying the rate of rebleeding. METHODS Patients presenting from 2000 to 2018 with ruptured BAVM who were scheduled for BAVM treatment at least 4 weeks after initial hemorrhage were included in the present study. After neurological rehabilitation of the patient and decreased hemorrhage-induced brain swelling, subacute treatment for the ruptured BAVM was carried out. Primary outcome of the present series was defined as treatment failure resulting from rehemorrhage caused by the ruptured BAVM in patients previously labeled eligible for subacute BAVM treatment. Additionally, we performed a systematic review of the contemporary peer-reviewed literature concerning treatment strategy in patients with ruptured BAVM. RESULTS Fifty-five patients suffering from ruptured BAVM were considered eligible for subacute BAVM treatment at our institution. No patient suffered from early rebleeding before definitive BAVM treatment in our institutional group. Our own patient data were then pooled with data from the literature, resulting in 166 patients suffering from ruptured BAVM who underwent subacute BAVM treatment. Of these, 1 patient (0.6%) suffered from rehemorrhage during the recovery period 130 days after initial BAVM rupture. CONCLUSIONS The present series and systematic review revealed a rehemorrhage rate of 0.6% in patients suffering from ruptured BAVM who underwent subacute treatment. Therefore, subacute treatment of patients with ruptured BAVM seems safe after application of rigorous treatment algorithms to sort out patients with higher risk for rehemorrhage.
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Affiliation(s)
- Patrick Schuss
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany.
| | | | - Inja Ilic
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Simon Brandecker
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Ági Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
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Gallardo F, Martin C, Chang L, Diaz JF, Bustamante J, Rubino P. Utilidad de las Escalas de Gradación en el Tratamiento Quirúrgico de Malformaciones Arteriovenosas Cerebrales. Surg Neurol Int 2019; 10:S46-S57. [PMID: 32300491 PMCID: PMC7159054 DOI: 10.25259/sni_454_2019] [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: 08/13/2019] [Accepted: 09/02/2019] [Indexed: 11/26/2022] Open
Abstract
Introducción: Las malformaciones arteriovenosas (MAVs) cerebrales comprenden una compleja pato-logía responsable de hasta el 38% de las hemorragias en pacientes de entre 15-45 años, acarreando cada episodio de sangrado un 25-50% de morbilidad y un 10-20% de mortalidad. La decisión terapéu-tica en un paciente con una MAV debe tener en cuenta la comparación entre los riesgos propios de la intervención y los de la historia natural de esta enfermedad. Objetivo: Evaluar la utilidad de predecir riesgo quirúrgico de diferentes escalas de gradación de MAV cerebrales según nuestra experiencia en una serie de casos. Material y Métodos: Se realizó un análisis bibliográfico de escalas de gradación de riesgo quirúrgico de MAV cerebrales utilizando como motor de búsqueda Pubmed incluyendo como palabras clave “malformación arteriovenosa cerebral”y “scala de gradación” (brain arteriovenous and malfor- mation grading scale). Se analizaron de forma retrospectiva aquellos pacientes intervenidos quirúrgi-camente por MAV en este hospital público, se las clasificó acorde a las escalas analizadas y se compa-raron los resultados obtenidos con los previstos en ellas. Resultados: Se analizaron 90 pacientes intervenidos quirúrgicamente por MAV, sin tratamiento coad-yuvante. De forma retrospectiva se los agrupó acorde a las escalas de Spetzler Martin (SM), Spetzler-Ponce (SP) y suplementaria de Lawton. Las MAV grado 3 se subclasificaron según las escalas de Lawton y de de Oliveira. Considerando buenos resultados aquellos con Rankin modificado (mRs) igual o menor a 2. Con un rango de seguimiento de 12 a 48 meses, encontramos buenos resultados en el 100% de MAV SM grado 1, 91.7% de las grado 2, 80% en grado 3 y 42.9% en grado 4. Utilizando la escala SP, 93.7% de buenos resultados en tipo A, 80% en tipo B y 42.9% en tipo C. Subclasifican-do las MAV SM 3 acorde a las escalas de de Oliveira y Lawton, 84% de buenos resultados en el tipo 3A, 71.3% en las 3B, 92% en MAV tipo 3-, 72.1% en el tipo 3+, 60% en tipo 3. Utilizando la escala suplementaria de Lawton combinada con SM, buen resultado en 100% grados II y III, 85,7% grado IV, 87,6 grado V, 80% grado VI, 75% grado VII y 66,6% grado VIII. Conclusión: Reafirmamos en esta serie, la utilidad de estimar riesgo quirúrgico con las escalas SM, SP, y la subclasificación de las MAV grado 3 propuesta por Lawton. Y principalmente el utilizar la escala suplementaria de Lawton-Young al considerar el tratamiento quirúrgico de los pacientes con MAV que sangraron.
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Zhong J, Press RH, Olson JJ, Oyesiku NM, Shu HKG, Eaton BR. The use of Hypofractionated Radiosurgery for the Treatment of Intracranial Lesions Unsuitable for Single-Fraction Radiosurgery. Neurosurgery 2019; 83:850-857. [PMID: 29718388 DOI: 10.1093/neuros/nyy145] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 03/22/2018] [Indexed: 11/15/2022] Open
Abstract
Stereotactic radiosurgery (SRS) is commonly used in the treatment of brain metastases, benign tumors, and arteriovenous malformations (AVM). Single-fraction radiosurgery, though ubiquitous, is limited by lesion size and location. In these cases, hypofractionated radiosurgery (hfSRS) offers comparable efficacy and toxicity. We review the recent literature concerning hfSRS in the treatment of brain metastases, benign tumors, and AVMs that are poorly suited for single-fraction SRS. Published retrospective analyses suggest that local control rates for brain metastases and benign tumors, as well as the rates of AVM obliteration, following hfSRS treatment are comparable to those reported for single-fraction SRS. Additionally, the toxicities from hypofractionated treatment appear comparable to those seen with single-fractioned SRS to small lesions.
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Affiliation(s)
- Jim Zhong
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Robert H Press
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | | | - Hui-Kuo G Shu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Abstract
BACKGROUND Brain arteriovenous malformations (AVMs) are the single most common cause of intracerebral haemorrhage in young adults. Brain AVMs also cause seizure(s) and focal neurological deficits (in the absence of haemorrhage, migraine or an epileptic seizure); approximately one-fifth are incidental discoveries. Various interventions are used in an attempt to eradicate brain AVMs: neurosurgical excision, stereotactic radiosurgery, endovascular embolization, and staged combinations of these interventions. This is an update of a Cochrane Review first published in 2006, and last updated in 2009. OBJECTIVES To determine the effectiveness and safety of the different interventions, alone or in combination, for treating brain AVMs in adults compared against either each other, or conservative management, in randomized controlled trials (RCTs). SEARCH METHODS The Cochrane Stroke Group Information Specialist searched the Cochrane Stroke Group Trials Register (last searched 7 January 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1) in the Cochrane Library, MEDLINE Ovid (1980 to 14 January 2019), and Embase OVID (1980 to 14 January 2019). We searched international registers of clinical trials, the contents pages of relevant journals, and bibliographies of relevant articles (November 2009). We also contacted manufacturers of interventional treatments for brain AVMs (March 2005). SELECTION CRITERIA We sought RCTs of any intervention for brain AVMs (used alone or in combination), compared against each other or against conservative management, with relevant clinical outcome measures. DATA COLLECTION AND ANALYSIS One author screened the results of the updated searches for potentially eligible RCTs for this updated review. Both authors independently read the potentially eligible RCTs in full and confirmed their inclusion according to the inclusion criteria. We resolved disagreement by discussion. We assessed the risk of bias in included studies and applied GRADE. MAIN RESULTS We included one trial with 226 participants: A Randomized trial of Unruptured Brain Arteriovenous Malformations (ARUBA), comparing intervention versus conservative management for unruptured brain AVMs (that had never bled). The quality of evidence was moderate because we found just one trial that was at low risk of bias other than a high risk of performance bias due to participants and treating physicians not being blinded to allocated treatment. Data on functional outcome and death at a follow-up of 12 months were provided for 218 (96%) of the participants in ARUBA. In this randomized controlled trial (RCT), intervention compared to conservative management increased death or dependency (modified Rankin Scale score ≥ 2, risk ratio (RR) 2.53, 95% confidence interval (CI) 1.28 to 4.98; 1 trial, 226 participants; moderate-quality evidence) and the proportion of participants with symptomatic intracranial haemorrhage (RR 6.75, 95% CI 2.07 to 21.96; 1 trial, 226 participants; moderate-quality evidence), but there was no difference in the frequency of epileptic seizures (RR 1.14, 95% CI 0.63 to 2.06; 1 trial, 226 participants; moderate-quality evidence). Three RCTs are ongoing. AUTHORS' CONCLUSIONS We found moderate-quality evidence from one RCT including adults with unruptured brain AVMs that conservative management was superior to intervention with respect to functional outcome and symptomatic intracranial haemorrhage over one year after randomization. More RCTs will help to confirm or refute these findings.
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Affiliation(s)
- Susanna M Zuurbier
- Amsterdam University Medical CentersDepartment of NeurologyAmsterdamNetherlands1105 AZ
| | - Rustam Al‐Shahi Salman
- University of EdinburghCentre for Clinical Brain SciencesFU303i, First floor, Chancellor's Building49 Little France CrescentEdinburghMidlothianUKEH16 4SB
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Karlsson B, Johansson AV, Yang HC, Jokura H, Yamamoto M, Martínez-Álvarez R, Kawagishi J, Guo WY, Beute G, Pan DHC, Chung WY, Söderman M, Aiyama H, Yeo TT. A novel method to determine the natural course of unruptured brain arteriovenous malformations without the need for follow-up information. J Neurosurg 2019; 129:10-16. [PMID: 30544301 DOI: 10.3171/2018.7.gks181278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/11/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThere is a strong clinical need to accurately determine the average annual hemorrhage risk in unruptured brain arteriovenous malformations (AVMs). This need motivated the present initiative to use data from a uniquely large patient population and design a novel methodology to achieve a risk determination with unprecedented accuracy. The authors also aimed to determine the impact of sex, pregnancy, AVM volume, and location on the risk for AVM rupture.METHODSThe present study does not consider any specific management of the AVMs, but only uses the age distribution for the first hemorrhage, the shape of which becomes universal for a sufficiently large set of patients. For this purpose, the authors collected observations, including age at first hemorrhage and AVM size and location, in 3425 patients. The average annual risk for hemorrhage could then be determined from the simple relation that the number of patients with their first hemorrhage at a specific age equals the risk for hemorrhage times the number of patients at risk at that age. For a subset of the patients, the information regarding occurrence of AVM hemorrhage after treatment of the first hemorrhage was used for further analysis of the influence on risk from AVM location and pregnancy.RESULTSThe age distribution for the first AVM hemorrhage was used to determine the average annual risk for hemorrhage in unruptured AVMs at adult ages (25-60 years). It was concluded to be 3.1% ± 0.2% and unrelated to AVM volume but influenced by its location, with the highest risk for centrally located AVMs. The hemorrhage risk was found to be significantly higher for females in their fertile years.CONCLUSIONSThe present methodology allowed the authors to determine the average annual risk for the first AVM hemorrhage at 3.1% ± 0.2% without the need for individual patient follow-up. This methodology has potential also for other similar types of investigations. The conclusion that centrally located AVMs carry a higher risk was confirmed by follow-up information. Follow-up information was also used to conclude that pregnancy causes a substantially greater AVM hemorrhage risk. The age distribution for AVM hemorrhage is incompatible with AVMs present at birth having the same hemorrhage risk as AVMs in adults. Plausibly, they instead develop in the early years of life, possibly with a lower hemorrhage risk during that time period.
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Affiliation(s)
- Bengt Karlsson
- 1Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Arne V Johansson
- 2Department of Mechanics, KTH Royal Institute of Technology, Stockholm, Sweden
| | | | - Hidefumi Jokura
- 4Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki, Japan
| | | | | | - Jun Kawagishi
- 4Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Osaki, Japan
| | - Wan-Yuo Guo
- 9Radiology, Veterans General Hospital, Taipei, Taiwan
| | - Guus Beute
- 7ETZ Elizabeth, Tilburg, The Netherlands; and
| | | | | | | | | | - Tseng Tsai Yeo
- 1Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
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Alexander MD, Hippe DS, Cooke DL, Hallam DK, Hetts SW, Kim H, Lawton MT, Sekhar LN, Kim LJ, Ghodke BV. Targeted Embolization of Aneurysms Associated With Brain Arteriovenous Malformations at High Risk for Surgical Resection: A Case-Control Study. Neurosurgery 2019; 82:343-349. [PMID: 28419337 DOI: 10.1093/neuros/nyx167] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 03/10/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND High-risk components of brain arteriovenous malformations (BAVMs) can be targeted to reduce the risk of lesion rupture. OBJECTIVE To evaluate targeted embolization of aneurysms against other means of treatment with a case-control analysis; we previously investigated this approach associated with BAVMs. METHODS Retrospective analysis of patients with BAVMs was performed, identifying patients treated with intention to occlude only an aneurysm associated with a BAVM. For each targeted aneurysm embolization (TAE) patient identified, 4 control patients were randomly selected, controlling for rupture status, age, and Spetzler-Martin plus Lawton-Young supplemental score. Analysis was performed to compare rates of adverse events (hemorrhage, new seizure, and death) between the 2 groups. RESULTS Thirty-two patients met inclusion criteria, and 128 control patients were identified, out of 1103 patients treated during the study period. Thirty-four adverse events occurred (15 ruptures, 15 new seizures, and 11 deaths) during the follow-up period (mean 1157 d for the TAE cohort and 1036 d for the non-TAE cohort). Statistically lower associations were noted for the TAE group for any adverse event (hazard ratio 0.28, P = .037) and the composite outcome of hemorrhage or new seizure (hazard ratio 0.20, P = .029). CONCLUSION For BAVMs at high risk for surgical resection, TAE can be performed safely and effectively. Patients treated with TAE had better outcomes than matched patients undergoing other combinations of treatment. TAE can be considered for BAVMs with high operative risk prior to radiosurgery or when no other treatment options are available.
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Affiliation(s)
- Matthew D Alexander
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Daniel S Hippe
- Uni-versity Washington, Department of Radiology, Seattle, Washington
| | - Daniel L Cooke
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Danial K Hallam
- Uni-versity Washington, Department of Radiology, Seattle, Washington
| | - Steven W Hetts
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Helen Kim
- Univer-sity of California San Francisco, Depart-ment of Anesthesia and Perioperative Care, San Francisco, California
| | - Michael T Lawton
- University of California San Francisco, Department of Neurological Surgery, San Francisco, California
| | - Laligam N Sekhar
- University Washington, De-partment of Neurological Surgery, Seattle, Washington
| | - Louis J Kim
- University Washington, De-partment of Neurological Surgery, Seattle, Washington
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Mascitelli JR, Yoon S, Cole TS, Kim H, Lawton MT. Does eloquence subtype influence outcome following arteriovenous malformation surgery? J Neurosurg 2019; 131:876-883. [PMID: 30497229 PMCID: PMC6800816 DOI: 10.3171/2018.4.jns18403] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 04/12/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although numerous arteriovenous malformation (AVM) grading scales consider eloquence in risk assessment, none differentiate the types of eloquence. The purpose of this study was to determine if eloquence subtype affects clinical outcome. METHODS This is a retrospective review of a prospectively collected clinical database of brain AVMs treated with microsurgery in the period from 1997 to 2017. The only inclusion criterion for this study was the presence of eloquence as defined by the Spetzler-Martin grading scale. Eloquence was preoperatively categorized by radiologists. Poor outcome was defined as a modified Rankin Scale (mRS) score 3-6, and worsening clinical status was defined as an increase in the mRS score at follow-up. Logistic regression analyses were performed. RESULTS Two hundred forty-one patients (49.4% female; average age 33.9 years) with eloquent brain AVMs were included in this review. Of the AVMs (average size 2.7 cm), 54.4% presented with hemorrhage, 46.2% had deep venous drainage, and 17.0% were diffuse. The most common eloquence type was sensorimotor (46.1%), followed by visual (27.0%) and language (22.0%). Treatments included microsurgery alone (32.8%), microsurgery plus embolization (51.9%), microsurgery plus radiosurgery (7.9%), and all three modalities (7.5%). Motor mapping was used in 9% of sensorimotor AVM cases, and awake speech mapping was used in 13.2% of AVMs with language eloquence. Complications occurred in 24 patients (10%). At the last follow-up (average 24 months), 71.4% of the patients were unchanged or improved and 16.6% had a poor outcome. There was no statistically significant difference in the baseline patient and AVM characteristics among the different subtypes of eloquence. In a multivariate analysis, in comparison to visual eloquence, both sensorimotor (OR 7.4, p = 0.004) and language (OR 6.5, p = 0.015) eloquence were associated with poor outcomes. Additionally, older age (OR 1.31, p = 0.016) and larger AVM size (OR 1.37, p = 0.034) were associated with poor outcomes. CONCLUSIONS Unlike visual eloquence, sensorimotor and language eloquence were associated with worse clinical outcomes after the resection of eloquent AVMs. This nuance in AVM eloquence demands consideration before deciding on microsurgical intervention, especially when numerical grading systems produce a score near the borderline between operative and nonoperative management.
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Affiliation(s)
- Justin R. Mascitelli
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Seungwon Yoon
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Tyler S. Cole
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Helen Kim
- Center for Cerebrovascular Research, University of California, San Francisco, California
| | - Michael T. Lawton
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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Zaki Ghali MG, Kan P, Britz GW. Curative Embolization of Arteriovenous Malformations. World Neurosurg 2019; 129:467-486. [DOI: 10.1016/j.wneu.2019.01.166] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
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Volume-Staged Gamma Knife Radiosurgery for Large Brain Arteriovenous Malformation. World Neurosurg 2019; 132:e604-e612. [PMID: 31442655 DOI: 10.1016/j.wneu.2019.08.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Large brain arteriovenous malformations (AVMs) pose a management dilemma because of the limited success of any single treatment modality by itself. Surgery alone is associated with significant morbidity and mortality. Similarly, embolization alone has limited efficacy. Volume-staged Gamma Knife radiosurgery (VSGR) has been developed for the treatment of large AVMs to increase the efficacy and improve safety of treatment of these lesions. The aim of this study was to assess the efficacy and safety of VSGR technique for the treatment of large brain AVMs. METHODS The study included patients treated by VSGR between May 2009 and July 2015. All patients had large AVMs (>10 mL). There were 29 patients. RESULTS Twenty-four patients completed radiographic follow-up, with 15 obliteration cases (62.5%). A total of 56 sessions were performed. The mean AVM volume was 16 mL (range, 10.1-29.3 mL). The mean prescription dose was 18 Gy (range, 14-22 Gy). The mean follow-up duration was 43 months (range, 21-73 months). One patient died during follow-up of an unrelated cause. Two patients had hemorrhage during follow-up. Symptomatic edema developed in 5 patients (17%). The factors affecting obliteration were smaller total volume, higher dose/stage, nondeep location, compact AVM, AVM score <3, >18 Gy dose, and <15 mL total volume. The factors affecting symptomatic edema were smaller total volume and shorter time between first and last sessions (P = 0.012). T2 image changes were affected by Spetzler-Martin grade ≥3 (P = 0.013) and AVM score ≥3 (P = 0.014). CONCLUSIONS VSGR provides an effective and safe treatment option for large brain AVMs. Smaller AVM volume is associated with higher obliteration rate.
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Wild E, Barry J, Sun H. Targeted Stereotactic Radiosurgery for Arteriovenous Malformation Downgrading Followed by Microsurgical Resection: A Case Report and Review of the Literature. World Neurosurg 2019; 131:82-86. [PMID: 31369878 DOI: 10.1016/j.wneu.2019.07.170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND An unruptured brain arteriovenous malformation (bAVM) is a complex pathological entity with the potential to lead to disabling or fatal intracranial hemorrhage. The treatment approaches for these lesions have included microsurgical resection, endovascular embolization, stereotactic radiosurgery (SRS), and medical management or any combination of these modalities. However, the optimal treatment approach for unruptured bAVMs has not yet been determined. In the present case, we used SRS strategically to downgrade an AVM to allow for improved resectability. CASE DESCRIPTION A 28-year-old woman had presented with 10 years of headaches and was found to have a Spetzler-Martin grade IV AVM not amenable to resection. She underwent targeted SRS only of the deep portions of the AVM, resulting in a decrease of the AVM to grade III. Subsequent microsurgical resection was successful in complete removal of the AVM. At the 1-year follow-up examination she had no deficits. CONCLUSIONS We have proposed a protocol of using focused SRS to eliminate the portions of the AVM that confer an increased surgical risk. SRS, followed by microsurgical resection, could represent an optimal treatment strategy for high-grade AVMs with difficult surgical anatomy.
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Affiliation(s)
- Elizabeth Wild
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - James Barry
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.
| | - Hai Sun
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
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Tam KY, Lim K, Zhu CXL, Chan KY, Poon WS, Poon D, Kam M, Cheung M, Wong KCG. Long-term outcomes of ruptured cerebral arteriovenous malformations in the paediatric population: A retrospective review in a regional hospital in Hong Kong. J Clin Neurosci 2019; 66:66-70. [DOI: 10.1016/j.jocn.2019.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022]
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Shaligram SS, Winkler E, Cooke D, Su H. Risk factors for hemorrhage of brain arteriovenous malformation. CNS Neurosci Ther 2019; 25:1085-1095. [PMID: 31359618 PMCID: PMC6776739 DOI: 10.1111/cns.13200] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 07/09/2019] [Accepted: 07/11/2019] [Indexed: 12/16/2022] Open
Abstract
Patients with brain arteriovenous malformation (bAVM) are at risk of intracranial hemorrhage (ICH). Overall, bAVM accounts for 25% of hemorrhagic strokes in adults <50 years of age. The treatment of unruptured bAVMs has become controversial, because the natural history of these patients may be less morbid than invasive therapies. Available treatments include observation, surgical resection, endovascular embolization, stereotactic radiosurgery, or combination thereof. Knowing the risk factors for bAVM hemorrhage is crucial for selecting appropriate therapeutic strategies. In this review, we discussed several biological risk factors, which may contribute to bAVM hemorrhage.
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Affiliation(s)
- Sonali S Shaligram
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative care, University of California, San Francisco, California
| | - Ethan Winkler
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Daniel Cooke
- Department of Radiology, University of California, San Francisco, California
| | - Hua Su
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative care, University of California, San Francisco, California
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145
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Sappenfield EC, Jha RT, Agazzi S, Ros S. Cerebral arteriovenous malformation rupture in pregnancy. BMJ Case Rep 2019; 12:e225811. [PMID: 31340940 PMCID: PMC6663161 DOI: 10.1136/bcr-2018-225811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2019] [Indexed: 11/04/2022] Open
Abstract
A 30-year-old nulliparous woman at 38 5/7 weeks of gestation developed a sudden, severe headache at work and subsequent loss of consciousness. She underwent evaluation in the emergency department. CT and CT angiogram head revealed a large intraparenchymal haematoma with intraventricular extension secondary to ruptured cerebral arteriovenous malformation (cAVM). She was intubated and transferred to a tertiary care centre. The patient underwent caesarean section followed by partial embolisation of the cAVM with planned second embolisation and resection 1 week later. Due to drowsiness and headache, the planned repeat embolisation and cAVM resection were performed 3 days earlier. The patient had a full recovery. Emergency medicine physicians and obstetrician-gynaecologists should be familiar with differential diagnosis of sudden headache in pregnancy and signs of a ruptured cAVM to facilitate early diagnosis, multidisciplinary team approach and timely treatment. Early diagnosis and management of ruptured cAVM are important due to associated morbidity and mortality.
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Affiliation(s)
| | - R Tushar Jha
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Siviero Agazzi
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Stephanie Ros
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, USA
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146
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Hasegawa H, Hanakita S, Shin M, Sugiyama T, Kawashima M, Takahashi W, Ishikawa O, Nakatomi H, Saito N. Re-Evaluation of the Size Limitation in Single-Session Stereotactic Radiosurgery for Brain Arteriovenous Malformations: Detailed Analyses on the Outcomes with Focusing on Radiosurgical Doses. Neurosurgery 2019; 86:685-696. [DOI: 10.1093/neuros/nyz280] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 04/16/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Single-session stereotactic radiosurgery (SRS) for large arteriovenous malformations (AVMs) ≥10 mL remains controversial, which is considered as the current size limitation.
OBJECTIVE
To reconsider the size limitation of SRS for AVMs by profoundly analyzing dose-volume relationship.
METHODS
Data on 610 consecutive patients with AVM treated with SRS using regular (18-22 Gy) or low (<18 Gy) prescription doses were retrospectively analyzed. AVMs were classified into 4 groups: small (<5 mL), medium (≥5 and <10 mL), medium-large (≥10 and <15 mL), and large (≥15 mL). The maximum volumes were 22.5 mL (regular-dose group) and 23.5 mL (low-dose group).
RESULTS
When treated with regular doses, the cumulative 6-yr obliteration rates for each of the 4 AVM groups were 86%, 80%, 87%, and 79%, respectively; the cumulative 10-yr significant neurological event (SNE) rates were 2.6%, 3.9%, 6.8%, and 5.3%, respectively. Regarding large AVMs, regular-dose SRS resulted in marginally better obliteration rate (6-yr cumulative rate, 79% vs 48%, P = .111) and significantly lower SNE (5-yr cumulative rate, 5% vs 31%, P = .038) and post-SRS hemorrhage rate (8-yr cumulative rate, 0% vs 54%, P = .002) compared to low-dose SRS. Multivariate analyses revealed that regular-dose SRS significantly contributed to increase in the obliteration rate and decrease in SNEs and hemorrhage.
CONCLUSION
The outcomes for large AVMs were generally favorable when treated with ablative doses. Single-session SRS could be acceptable for AVMs up to ≈20 mL if treated with ablative doses.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Shunya Hanakita
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
- Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Wataru Takahashi
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Osamu Ishikawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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147
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Bass DI, Walker M, Ferreira M, Ghodke B. A case report of an unruptured tectal AVM presenting with obstructive hydrocephalus that resolved upon spontaneous obliteration of the venous varix. J Clin Neurosci 2019; 65:157-160. [DOI: 10.1016/j.jocn.2019.03.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 03/25/2019] [Indexed: 11/26/2022]
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148
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Jhaveri A, Amirabadi A, Dirks P, Kulkarni AV, Shroff MM, Shkumat N, Krings T, Pereira VM, Rea V, Muthusami P. Predictive Value of MRI in Diagnosing Brain AVM Recurrence after Angiographically Documented Exclusion in Children. AJNR Am J Neuroradiol 2019; 40:1227-1235. [PMID: 31248861 DOI: 10.3174/ajnr.a6093] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/18/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE MRI is routinely performed following brain AVM after treatment in children. Our aim was to determine the predictive values of contrast-enhanced MR imaging and TOF-MRA for brain AVM recurrence in children, compared with conventional angiography and the role of 3D rotational angiography-MR imaging fusion in these cases. MATERIALS AND METHODS We included all pediatric patients with brain AVMs during an 18-year period with angiographically documented obliteration after treatment. Patients underwent 3T MR imaging, including contrast-enhanced MR imaging, TOF-MRA, and conventional angiography, with a subset undergoing 3D rotational angiography. The predictive values of contrast-enhanced MR imaging and TOF-MRA for brain AVM recurrence were determined. CTA sections reconstructed from 3D rotational angiography were coregistered with and fused to 3D-T1WI for analysis. RESULTS Thirty-nine children (10.8 ± 3.9 years of age; range, 2-17 years; male/female ratio, 19:20; mean Spetzler-Martin grade, 1.9 ± 0.6) met the inclusion criteria. Of these, 13 had angiographically confirmed brain AVM recurrence, 8 following surgery and 5 following embolization. Sensitivity, specificity, and positive and negative predictive values for recurrence were the following: contrast-enhanced MR imaging: 84.6%, 38.5%, 40.7%, 81.8%; TOF-MRA: 50.0%, 96.1%, 85.7%, 79.3%; both: 75.0%, 90.9%, 85.7%, 83.3%. 3D rotational angiography-MR imaging fused images confirmed or excluded recurrence in all available cases (13/13). Embolization-only treatment was a significant predictor of recurrence (OR = 32.4, P = .006). MR imaging features predictive of recurrence included a tuft of vessels on TOF-MRA and nodular juxtamural/linear enhancement with a draining vein on contrast-enhanced MR imaging. CONCLUSIONS MR imaging is useful for surveillance after brain AVM treatment in children, but conventional angiography is required for definitive diagnosis of recurrence. TOF-MRA and contrast-enhanced MR imaging provide complementary information for determining brain AVM recurrence and should be interpreted in conjunction. 3D rotational angiography-MR imaging fusion increases the diagnostic confidence regarding brain AVM recurrence and is therefore suited for intraoperative neuronavigation.
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Affiliation(s)
- A Jhaveri
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - A Amirabadi
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - P Dirks
- Division of Neurosurgery (P.D., A.V.K.), Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - A V Kulkarni
- Division of Neurosurgery (P.D., A.V.K.), Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - M M Shroff
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - N Shkumat
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - T Krings
- Divisions of Neuroradiology and Neurosurgery (T.K.,V.M.P.), Departments of Medical Imaging and Surgery, University of Toronto, and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - V M Pereira
- Divisions of Neuroradiology and Neurosurgery (T.K.,V.M.P.), Departments of Medical Imaging and Surgery, University of Toronto, and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - V Rea
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
| | - P Muthusami
- From Pediatric Neuroradiology and Image Guided Therapy (A.J., A.A., M.M.S., N.S., V.R., P.M.), Diagnostic Imaging
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149
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Abstract
Background and Purpose- The management of unruptured brain arteriovenous malformations remains unclear. Using a large cohort to determine risk factors predictive of hemorrhagic presentation of arteriovenous malformations, this study aims to develop a predictive tool that could guide hemorrhage risk stratification. Methods- A database of 789 arteriovenous malformation patients presenting to our institution between 1990 and 2017 was used. A hold-out method of model validation was used, whereby the data was randomly split in half into training and validation data sets. Factors significant at the univariable level in the training data set were used to construct a model based on multivariable logistic regression. Model performance was assessed using receiver operating curves on the training, validation, and complete data sets. The predictors and the complete data set were then used to derive a risk prediction formula and a practical scoring system, where every risk factor was worth 1 point except race, which was worth 2 points (total score varies from 0 to 6). The factors are summarized by R2eD arteriovenous malformation (acronym: R2eD AVM). Results- In 755 patients with complete data, 272 (36%) presented with hemorrhage. From the training data set, a model was derived containing the following risk factors: nonwhite race (odds ratio [OR]=1.8; P=0.02), small nidus size (OR=1.47; P=0.14), deep location (OR=2.3; P<0.01), single arterial feeder (OR=2.24; P<0.01), and exclusive deep venous drainage (OR=2.07; P=0.02). Area under the curve from receiver operating curve analysis was 0.702, 0.698, and 0.685 for the training, validation, and complete data sets, respectively. In the entire study population, the predicted probability of hemorrhagic presentation increased in a stepwise manner from 16% for patients with no risk factors (score of 0) to 78% for patients having all the risk factors (score of 6). Conclusions- The final model derived from this study can be used as a predictive tool that supplements clinical judgment and aids in patient counseling.
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Affiliation(s)
- James Feghali
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wuyang Yang
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Risheng Xu
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jason Liew
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Cameron G McDougall
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Justin M Caplan
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rafael J Tamargo
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Judy Huang
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
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150
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Michelozzi C, Cognard C. [The role of interventional neuroradiology in treatment of hemorrhagic stroke]. Presse Med 2019; 48:684-695. [PMID: 31153680 DOI: 10.1016/j.lpm.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 05/02/2019] [Indexed: 11/15/2022] Open
Abstract
Treatment of hemorrhagic strokes necessitates hospitalization in an accommodated hospital offering the possibility of a multidisciplinary approach. In this setting, over recent years interventional radiology has become increasingly important from the diagnostic as well as the therapeutic standpoint. In the context of subarachnoid hemorrhage by intracranial aneurysm rupture, the NICE (National Institute for Health and Clinical Excellence) and ASA (American Stroke Academy) recommendations suggest that endovascular coiling should be considered as an alternative to surgical clipping (class I, level of evidence B). As stenting is associated with increased morbidity and mortality in the ruptured aneurysms, it should be avoided (class III, level of evidence C). The patient's clinical status on presentation should be taken into account when deciding on therapeutic management and determining prognosis. Long-term clinical outcome depends on several factors: clinical status on arrival, comorbidities, age, occurrence of operative complications and complications of subarachnoid hemorrhage such as hydrocephaly, vasospasm and delayed cerebral ischemia, as well as complications stemming from prolonged bed rest. In the event of vasospasm refractory to maximal medical therapy, endovascular treatment by intra-arterial injection of Nimodipine and angioplasty can be envisioned. In the event of intracerebral hemorrhage (ICH) by rupture cerebral dural arteriovenous fistula, once the diagnosis has been confirmed, and given the exceedingly high risk of rebleeding, first-line treatment will consist in emergency endovascular embolization. In the event of intracerebral hemorrhage (ICH) by arteriovenous rupture, treatment is decided on during a multidisciplinary meeting and either carried out immediately or delayed according to several factors: clinical conditions, age of the patient, angioarchitecture and ICH location.
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Affiliation(s)
- Caterina Michelozzi
- CHU Toulouse, hôpital Pierre Paul Riquet, service de neuroradiologie, 1, place du Dr Baylac, 31059 Toulouse cedex 9, France.
| | - Christophe Cognard
- CHU Toulouse, hôpital Pierre Paul Riquet, service de neuroradiologie, 1, place du Dr Baylac, 31059 Toulouse cedex 9, France
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