1
|
Borges de Almeida G, Pamplona J, Baptista M, Carvalho R, Conceição C, Lopes da Silva R, Sagarribay A, Reis J, Fragata I. Endovascular Treatment of Brain Arteriovenous Malformations in Pediatric Patients: A Single Center Experience and Review of the Literature. J Neurol Surg A Cent Eur Neurosurg 2024; 85:361-370. [PMID: 37494960 DOI: 10.1055/s-0043-1770356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND Brain arteriovenous malformations (bAVMs) are abnormal vascular connections with direct arteriovenous shunts, generally symptomatic in the adult life. However, a small number of bAVMs may manifest in pediatric patients, with higher bleeding risk and mortality rates when compared to adults. The purpose of this study is to review our experience with endovascular treatment of bAVMs in pediatric patients. METHODS This is a retrospective analysis of all bAVMs in pediatric patients (0-18 years) who underwent diagnostic digital subtraction angiography (DSA) at our institution from January 2010 to June 2021. RESULTS Twenty-six patients met the inclusion criteria, of which 12 underwent endovascular treatment. Treated patients had a mean age of 10.25 years and 58% were females. Complete angiographic exclusion was achieved in five (42%) patients with endovascular treatment. Five patients with residual bAVM after embolization needed adjuvant therapy with surgery (n = 3) or stereotactic radiosurgery (SRS; n = 2). Two patients are still undergoing embolization sessions. Procedure-related complications occurred in two patients (17%) and included small vessel perforation and an occipital ischemic stroke. Two patients showed bAVM recurrence on follow-up (17%) and subsequently underwent SRS (n = 1) or surgery (n = 1), both resulting in complete bAVM exclusion. All patients had a modified Rankin scale (mRS) score of 0 to 2 on follow-up. CONCLUSION Our experience supports the effectiveness and safety of endovascular treatment of bAVM in selected pediatric patients. A multidisciplinary approach combining surgery and SRS is warranted to achieve higher complete bAVM obliteration rates. Long-term follow-up is important as these lesions may show recurrence over time, especially in the pediatric population.
Collapse
Affiliation(s)
| | - Jaime Pamplona
- Department of Neuroradiology, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Portugal
| | - Mariana Baptista
- Department of Neuroradiology, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Portugal
| | - Rui Carvalho
- Department of Neuroradiology, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Portugal
| | - Carla Conceição
- Department of Neuroradiology, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
| | - Rita Lopes da Silva
- Department of Pediatric Neurology, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
| | - Amets Sagarribay
- Department of Neurosurgery, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
| | - João Reis
- Department of Neuroradiology, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Portugal
| |
Collapse
|
2
|
Puthuran M, Gravino G, Babatola F, Pullicino R, Masri S, Biswas S, Chapot R, Chandran A. Primary endovascular embolisation of intracranial arteriovenous malformations (AVM)-UK single centre experience. Neuroradiology 2024; 66:227-236. [PMID: 37999787 DOI: 10.1007/s00234-023-03258-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/19/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE Intracranial arteriovenous malformations (AVMs) treated at our institution with modern techniques of endovascular intervention were analysed for the rate of complete occlusion, associated morbidity, and mortality. To our knowledge, this is the first series from the UK evaluating the effectiveness of endovascular embolisation as a primary treatment for selected cases. METHODS All newly referred AVMs between January 2017 and June 2022 were reviewed and those treated with primary endovascular intervention were identified. Details of the endovascular procedures were retrospectively reviewed. RESULTS In 5½ years, 41.1% of AVMs referred to our institution have been triaged for primary endovascular intervention. Sixty-eight AVMs were embolised and followed-up: 44 ruptured and 24 unruptured. Spetzler-Martin grading varied from I to III, and a single AVM was grade IV. The approach was arterial in 73.5%, solely venous in 7.4%, and combined in 19.1%. The mean follow-up was 18 months for imaging and 26 months for clinical assessment. Complete obliteration was achieved in 95.6%. Ruptured AVM cohort: The rate of functional deterioration was 13.6%. Unruptured AVM cohort: The rate of functional deterioration secondary to complications from embolisation was 4.2%. CONCLUSIONS Endovascular embolisation may be a favourable option for primary AVM treatment in carefully selected patients. However, selection criteria need to be better delineated for more specialists to consider this as a primary therapy.
Collapse
Affiliation(s)
- Mani Puthuran
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Gilbert Gravino
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK.
| | - Feyi Babatola
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | | | - Souhyb Masri
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | | | | | - Arun Chandran
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| |
Collapse
|
3
|
Rodriguez-Calienes A, Vivanco-Suarez J, Borjas-Calderón NF, Chavez-Ecos FA, Fernández DEM, Malaga M, Basilio Flores JE, Ortega-Gutierrez S, Saal-Zapata G. Curative embolization of ruptured pediatric cerebral arteriovenous malformations. Clin Neurol Neurosurg 2023; 227:107663. [PMID: 36868088 DOI: 10.1016/j.clineuro.2023.107663] [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: 11/28/2022] [Revised: 02/23/2023] [Accepted: 02/25/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION Embolization with the intention to cure has not been well studied in ruptured arteriovenous malformations (AVMs). Furthermore, the role of primary curative embolization of pediatric AVMs is uncertain. Hence, we aimed to characterize the safety and efficacy of curative embolization of ruptured pediatric AVMs and assess predictors of obliteration and complications. METHODS A retrospective analysis of all pediatric (≤18 years) patients who underwent curative embolization of ruptured AVMs was conducted in two institutions between 2010 and 2022. The efficacy (complete angiographic obliteration after the last embolization session), recurrence (radiological recurrence of the lesion after confirmed obliteration in follow-up imaging), and safety (procedure-related complications and mortality) of the procedure were evaluated. RESULTS Sixty-eight patients (38 females; mean age 12.4 ± 3.4 years) underwent a total of 109 embolization sessions. Median follow-up time was 18 months after embolization (ranged from 2 to 47 months). Complete angiographic obliteration was achieved in 42 patients (62%). In 30 patients (44%) the AVM was occluded with a single embolization session. Recurrence of a totally embolized lesion occurred in 9 patients (13%). Thirteen complications (11.9% of procedures) were observed, and no deaths were reported. A nidus size > 2 cm was the only independent predictor of complete obliteration (OR = 0.16; 95% CI 0.03 - 0.77; p = 0.030). CONCLUSION Embolization of pediatric ruptured AVMs with curative intent can achieve acceptable obliteration rates. However, recurrence after complete obliteration and procedure-related complications of curative embolization of these lesions cannot be ignored. Ruptured AVMs ≤ 2 cm are adequate to achieve complete obliteration with curative endovascular management.
Collapse
Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA; Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru.
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Nagheli Fernanda Borjas-Calderón
- Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru; Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru
| | - Fabian A Chavez-Ecos
- Sociedad Científica de Estudiantes de Medicina de Ica, Universidad Nacional San Luis Gonzaga, Ica, Peru; Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
| | | | - Marco Malaga
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service. Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, Lima, Peru; Departament of Neurosurgery, Clinica Angloamericana, Lima, Peru.
| |
Collapse
|
4
|
Pepper J, Lamin S, Thomas A, Walsh AR, Rodrigues D, Lo WB, Solanki GA. Clinical features and outcome in pediatric arteriovenous malformation: institutional multimodality treatment. Childs Nerv Syst 2022; 39:975-982. [PMID: 36580118 DOI: 10.1007/s00381-022-05800-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 12/09/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE Intracranial arteriovenous-malformation (AVM) is a relatively rare condition in pediatrics, yet is a major cause of spontaneous intracranial hemorrhage with a risk of fatal hemorrhage reported to be between 4 and 29%. Little is known about vessel morphology and optimum treatment modalities including multimodality combination therapy and prognosis in children. METHODS A retrospective review of all children presenting to our institution from 2006 to 2020 that had an AVM was undertaken. RESULTS A total of 50 children were identified with median age of 11 (range 1-16) years. The mean follow-up was 7.6 years. Forty-one children presented as an emergency and of those, 40 had hemorrhage identified on initial brain imaging. The average nidus size was 25 mm, drainage was superficial in 51% of cases, and located in eloquent cortex in 56%. The supplemental Spetzler-Martin grading indicated 78% (39/50) were grade 4 and above (moderate to high risk). Primary treatment modalities included embolization in 50% (25) or SRS in 30% (15) and surgery in 20% (10).The AVM was obliterated on follow-up DSA in 66% children. Three children had post-treatment hemorrhage, two related to embolization and one the day following SRS, giving a re-bleed rate of 6%. The GOSE was available for 32 children at long term follow and 94% had a good outcome (GOSE 5-8). Two children died due to acute hemorrhage (4%). CONCLUSION The majority of children with AVM present with hemorrhage. The rebleed rate during definitive treatment is low at 6% over the study period. The selective use of the 3 modalities of treatment has significantly reduced mortality and severe disability.
Collapse
Affiliation(s)
- Joshua Pepper
- Birmingham Women's & Children's Hospital, Birmingham, UK.
| | - Saleh Lamin
- Birmingham Women's & Children's Hospital, Birmingham, UK.,Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Allan Thomas
- Birmingham Women's & Children's Hospital, Birmingham, UK.,Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, UK
| | | | | | - William B Lo
- Birmingham Women's & Children's Hospital, Birmingham, UK
| | | |
Collapse
|
5
|
Jha VC, Alam MS, Sinha VS. Comparative outcome of endovascular embolization with microsurgery in managing acute spontaneous cerebral hemorrhage in pediatric patients, an institutional experience. Childs Nerv Syst 2022; 39:963-974. [PMID: 36571597 DOI: 10.1007/s00381-022-05785-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/06/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES A few previous studies have reported the role of embolization with curative intent in the treatment of the early phase of a spontaneous cerebral hemorrhage in pediatric patients, and its efficacy needs to be compared with surgery at the same time risk factors for hemorrhage following early embolization in such patients need to be evaluated. METHODS From a pool of 80 pediatric (< 18 years) who had undergone treatment for ruptured AVM with hemorrhage at our center between July 2018 and July 2022, we identified 36 patients with spontaneous bleeding due to AVM. Out of which, 20 were treated solely by embolization (group 1), while the remaining patients were treated surgically (with and without adjuvant embolization) (group 2). RESULT Spetzler-Martin's grading of the lesion suggested seven lesions < 3 and 13 lesions ≥ 3 in the embolization group. Similarly, seven lesions were < 3 and nine ≥ 3 Spetzler-Martin grade in the surgery group. Incomplete embolization was associated with hemorrhage in two patients treated with curative intent and four patients treated with embolization as adjuvant in the surgery group (p = 0.01). On follow-up, 18 patients in the embolization group and 12 in the surgery group had Glasgow outcome scores ≥ 4 (p = 0.273). CONCLUSION In the pediatric age group, incomplete embolization is the significant risk factor for hemorrhage in AVMs treated after a hemorrhagic stroke. Embolization with curative intent is as effective as surgery in treating such lesions as adjuvant embolization with careful patient selection.
Collapse
Affiliation(s)
- Vikas Chandra Jha
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India.
| | | | - Vivek Sharan Sinha
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India
| |
Collapse
|
6
|
Fang W, Yang Z, Liu Y, Yu J, Sun P, Zhao Z, He Y, Zhang T, Deng J. Peri-procedure efficacy and safety of one-stop hybrid surgery for the treatment of brain arteriovenous malformations: A single-center preliminary experience. Front Neurol 2022; 13:1052882. [PMID: 36408526 PMCID: PMC9671923 DOI: 10.3389/fneur.2022.1052882] [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: 09/24/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
Abstract
Background Some deficiencies and shortcomings in treatment strategies of brain arteriovenous malformation (bAVM) remain. It is worth exploring whether the one-stop hybrid surgical platform can play a positive role in the treatment of bAVM. Objective This study investigated short clinical and angiographic results of one-stop hybrid surgery for the treatment of bAVM. Methods All patients with bAVM treated with one-stop hybrid surgery were reviewed from February 2017 to December 2021. Data including demographic information, clinical conditions, characteristics of AVM, procedure details, and clinical and angiographic results were collected. Result In total, 150 cerebral bAVM patients received one-stop hybrid surgery; among them, 122 received surgical resection assisted by intraoperative DSA, and 28 were treated with combination surgical resection and endovascular embolization. Complete angiographic obliteration of the AVM was achieved in 136 patients (90.7%), and procedure-related death and neurological deficit rates were 7.3%. Of all relevant variables, logistic regression analysis showed that the Spetzler & Martin (S&M) score was the only factor related to the cure rate (P < 0.001) and endpoint complication rate (P = 0.007). Conclusions In our preliminary experience, one-stop hybrid surgery for the treatment of brain AVMs achieves a high angiographic total occlusion rate, with acceptable peri-procedure morbidity and mortality. For S&M 4 and 5 lesions, more cases and further study are needed to investigate the effects and safety of hybrid surgery.
Collapse
Affiliation(s)
- Wei Fang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Zijian Yang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Yufeng Liu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Jia Yu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Peng Sun
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Zhenwei Zhao
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Yue He
- Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Zhang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
- Tao Zhang
| | - Jianping Deng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
- *Correspondence: Jianping Deng
| |
Collapse
|
7
|
Chowdhury SS, See AP, Eriksson LP, Boulouis G, Lehman LL, Hararr DB, Zabih V, Dlamini N, Fox C, Waak M. Closing the Gap in Pediatric Hemorrhagic Stroke: A Systematic Review. Semin Pediatr Neurol 2022; 43:101001. [PMID: 36344021 DOI: 10.1016/j.spen.2022.101001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 09/07/2022] [Accepted: 09/12/2022] [Indexed: 10/14/2022]
Abstract
Pediatric hemorrhagic stroke (HS) accounts for a large proportion of childhood strokes, 1 of the top 10 causes of pediatric deaths. Morbidity and mortality lead to significant socio-economic and psychosocial burdens. To understand published data on recognizing and managing children with HS, we conducted a systematic review of the literature presented here. We searched PubMed, Embase, CINAHL and the Cochrane Library databases limited to English language and included 174 studies, most conducted in the USA (52%). Terminology used interchangeably for HS included intraparenchymal/intracranial hemorrhage, spontaneous ICH, and cerebrovascular accident (CVA). Key assessments informing prognosis and management included clinical scoring (Glasgow coma scale), and neuroimaging. HS etiologies reported were systemic coagulopathy (genetic, acquired pathologic, or iatrogenic), or focal cerebrovascular lesions (brain arteriovenous malformations, cavernous malformations, aneurysms, or tumor vascularity). Several scales were used to measure outcome: Glasgow outcome score (GOS), Kings outcome score for head injury (KOSCHI), modified Rankin scale (mRS) and pediatric stroke outcome measure (PSOM). Most studies described treatments of at-risk lesions. Few studies described neurocritical care management including raised ICP, seizures, vasospasm, or blood pressure. Predictors of poor outcome included ethnicity, comorbidity, location of bleed, and hematoma >2% of total brain volume. Motor and cognitive outcomes followed independent patterns. Few studies reported on cognitive outcomes, rehabilitation, and transition of care models. Interdisciplinary approach to managing HS is urgently needed, informed by larger cohort studies targeting key clinical question (eg development of a field-guide for the clinician managing patients with HS that is reproducible internationally).
Collapse
Affiliation(s)
| | | | | | | | | | | | - Veda Zabih
- The Hospital for Sick Children, Toronto, Canada
| | | | | | - Michaela Waak
- The University of Queensland, Australia; Children's Health Queensland Hospital, Brisbane, Australia
| |
Collapse
|
8
|
Ghatge S, Itti P. Curative Embolization of Small Brain Arteriovenous Malformations by Ethyl Vinyl Alcohol Copolymer: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e27219. [PMID: 36035052 PMCID: PMC9399823 DOI: 10.7759/cureus.27219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2022] [Indexed: 11/30/2022] Open
Abstract
The right choice in treating small (Spetzler-Ponce grade A) brain arteriovenous malformations (AVMs) is a matter of debate with varying views from neurology, neurosurgery, and interventional neuroradiology points of view. The Spetzler-Martin 1 and 2 brain AVMs, especially those in eloquent and deep areas that are difficult to access by micro-neurosurgery, are most suitable for a complete cure by endovascular embolization with ethyl vinyl alcohol (EVOH)-based agents. A literature search was done with keywords such as endovascular embolization of small brain AVM. Data from 13 articles are included in the study based on predetermined inclusion and exclusion criteria. Meta-analysis for the complete cure rate was done, publication bias was removed, and regression analysis showed a 76% cure rate with a 95% confidence interval (CI). Major complications were hemorrhage and neurological deficit, which ranged from 0-20% and 0-16% with a mean proportion of 0.11 and 0.09, respectively. Long-term (3-6 months) follow-up data showed 0-4% recurrence at three months, 0-8% recurrence at six months, and 2-10% permanent disability. The mortality rate ranged from 3% to 4%. Three illustrative cases with data from the author’s institute are included in the article. To conclude, endovascular embolization for small brain AVMs is a satisfactory treatment modality, however, prospective registries and randomized controlled trials involving embolization versus neurosurgery and/or stereotactic radiosurgery (SRS) may validate the role of embolization in small brain AVMs as curative treatment.
Collapse
|
9
|
Curative Embolization for Pediatric Spetzler-Martin Grade III Cerebral Arteriovenous Malformations. World Neurosurg 2022; 160:e494-e500. [PMID: 35074545 DOI: 10.1016/j.wneu.2022.01.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Spetzler-Martin (SM) grade III arteriovenous malformations (AVMs) represent a gray zone due to their high variability in location, size, and angioarchitecture. In addition, there is a lack of information on curative embolization in the pediatric population, especially in this subgroup of lesions. Here we present our experience treating grade III AVMs by curative embolization in pediatric patients. METHODS Clinical and angiographic data from pediatric patients with grade III SM AVMs were retrospectively collected between 2011 and 2020 in a referral institution. We grouped the AVMs into subtypes according to size (S), venous drainage (V), and eloquence (E) and obtained subtypes: IIIA (S1V1E1), IIIB (S2V1E0), IIIC (S2V0E1), and IIID (S3V0E0). RESULTS A total of 61 embolization sessions were performed in 35 pediatric patients. There were 25 females (64%), and the mean age was 12.2 years (range 5-18). Complete angiographic occlusion was achieved in 16 patients (47%). In 13 patients (37%), the AVM was occluded with a single embolization session and most (12/13) had small lesions (IIIA subtype). Among the 19 patients with incomplete occlusion, most (58%) had large lesions (IIIB, IIIC, and IIID). Large AVMs (IIIB, IIIC, and IIID) underwent 36 sessions; however, only 3 patients (21%) achieved complete occlusion in 11 sessions. Eight intraoperative complications (13% procedures) occurred mainly in ruptured AVMs (7/8) and eloquent zones (7/8). CONCLUSIONS Curative embolization for SM grade III AVMs in children carries a high complication rate, especially in small, ruptured, and eloquent lesions. In addition, acceptable immediate complete angiographic occlusion rates were achieved, especially in small AVMs.
Collapse
|
10
|
Rodriguez-Calienes A, Bustamante-Paytan D, Camacho-Caballero K, Mayoria-Vargas A, Rodríguez-Varela R, Saal-Zapata G. Single-center experience with endovascular treatment of cerebral arteriovenous malformations with intent to cure in pediatric patients. Childs Nerv Syst 2022; 38:343-351. [PMID: 34605999 DOI: 10.1007/s00381-021-05376-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/01/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE This study aimed to report the incidence of technical complications and immediate complete angiographic occlusion, identify associated factors with failure of complete occlusion and identify predictors of technical complications in a single-center experience of pediatric arteriovenous malformations (AVM) treated with endovascular treatment with intent to cure. METHODS Patients between 1 and 18 years of age undergoing endovascular embolization between 2011 and 2020 were included. RESULTS A total of 120 embolizations were performed in 69 patients. The most frequent clinical presentation was intracerebral hemorrhage (76.8%). Immediate obliteration of the malformations was achieved in 40 (58%) cases. The technical complication rate was 15%. AVM nidus size between 3 and 6 cm (OR: 3.91; 95% CI 1.1-13.85; p = 0.035) and the presence of multiple feeders (OR: 5.08; 95% CI 1.41-18.28; p = 0.074) were predictive of failure of immediate complete occlusion. The location of the temporal lobe (OR: 7.83; p = 0.048), deep venous drainage (OR: 4.67; p = 0.112), and the presence of an intranidal aneurysm (OR: 3.58; p = 0.134) were predictors of technical complications. CONCLUSIONS Embolization of pediatric AVMs with intent to cure shows a high rate of technical complications and acceptable immediate occlusion rates. Nidus size and the presence of multiple feeders were predictive of failure of complete occlusion, while temporal lobe location, deep venous drainage, and the presence of an intranidal aneurysm were predictors of technical complications. Further studies are needed to determine the best therapeutic approach in the pediatric population.
Collapse
Affiliation(s)
- Aaron Rodriguez-Calienes
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Alameda del Corregidor 1531, La Molina 15024, Lima, Peru
| | - Diego Bustamante-Paytan
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru. .,Facultad de Medicina Humana, Universidad de San Martín de Porres, Alameda del Corregidor 1531, La Molina 15024, Lima, Peru.
| | - Kiara Camacho-Caballero
- Facultad de Medicina Humana, Universidad Científica del Sur, Lima, Peru.,CHANGE, Research Working Group, Carrera de Medicina Humana, Universidad Cientifica del Sur, Lima, Peru
| | - Angie Mayoria-Vargas
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Alameda del Corregidor 1531, La Molina 15024, Lima, Peru
| | - Rodolfo Rodríguez-Varela
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| |
Collapse
|
11
|
Steinberg JA, Brandel MG, Kang KM, Rennert RC, Pannell JS, Olson SE, Gonda DD, Khalessi AA, Levy ML. Arteriovenous malformation surgery in children: the Rady Children's Hospital experience (2002-2019). Childs Nerv Syst 2021; 37:1267-1277. [PMID: 33404725 DOI: 10.1007/s00381-020-04994-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Compared to adult AVMs, there is a paucity of data on the microsurgical treatment of pediatric AVMs. We report our institutional experience with pediatric AVMs treated by microsurgical resection with or without endovascular embolization and radiation therapy. METHODS We retrospectively reviewed all patients ≤ 18 years of age with cerebral AVMs that underwent microsurgical resection at Rady Children's Hospital 2002-2019. RESULTS Eighty-nine patients met inclusion criteria. The mean age was 10.3 ± 5.0 years, and 56% of patients were male. In total, 72 (81%) patients presented with rupture. Patients with unruptured AVMs presented with headache (n = 5, 29.4%), seizure (n = 9, 52.9%), or incidental finding (n = 3, 17.7%). The mean presenting mRS was 2.8 ± 1.8. AVM location was lobar in 78%, cerebellar/brainstem in 15%, and deep supratentorial in 8%. Spetzler-Martin grade was I in 28%, II in 45%, III in 20%, IV in 6%, and V in 1%. Preoperative embolization was utilized in 38% of patients and more frequently in unruptured than ruptured AVMs (62% vs. 32%, p = 0.022). Radiographic obliteration was achieved in 76/89 (85.4%) patients. Complications occurred in 7 (8%) patients. Annualized rates of delayed rebleeding and recurrence were 1.2% and 0.9%, respectively. The mean follow-up was 2.8 ± 3.1 years. A good neurological outcome (mRS score ≤ 2) was obtained in 80.9% of patients at last follow-up and was improved relative to presentation for 75% of patients. CONCLUSIONS Our case series demonstrates high rates of radiographic obliteration and relatively low incidence of neurologic complications of treatment or AVM recurrence.
Collapse
Affiliation(s)
- Jeffrey A Steinberg
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Michael G Brandel
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Keiko M Kang
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Robert C Rennert
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - J Scott Pannell
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Scott E Olson
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - David D Gonda
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA.,Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA, USA
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA
| | - Michael L Levy
- Department of Neurosurgery, University of California-San Diego, San Diego, CA, USA. .,Division of Pediatric Neurosurgery, Rady Children's Hospital, San Diego, CA, USA.
| |
Collapse
|
12
|
Rodriguez-Calienes A, Bustamante-Paytan D, Camacho K, Mayoria-Vargas A, Saal-Zapata G, Rodriguez-Varela R. Early Outcomes and Complications of Endovascular Treatment of Cerebral Arteriovenous Malformations in Pediatric Patients. Pediatr Neurosurg 2021; 56:116-124. [PMID: 33601400 DOI: 10.1159/000513577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 12/03/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Arteriovenous malformations (AVMs) are the commonest cause of hemorrhagic stroke in children. Endovascular embolization is a feasible treatment modality, but cure rates are heterogenous from one series to another. We aimed to describe the immediate obliteration rates and periprocedural complications of embolization of pediatric AVMs. METHODS Between 2011 and 2019, participants below 18 years of age with AVMs treated by the same neurosurgeon at a single center were included. The clinical features, immediate angiographic results, and periprocedural complications were retrospectively collected from the clinical records. RESULTS Thirty-four embolization sessions were performed on 20 children (12 females with a mean age of 13). Intracranial hemorrhage was the most common presentation (75%), and the majority were frontal (30%) and basal ganglia (30%) lesions. An immediate complete angiographic obliteration was achieved in 9 patients (45%) with low-grade lesions (Spetzler-Martin grade I and II). NBCA was the most common embolic agent used (52.9%). Complications were reported in 3 (8.8%) out of 34 sessions. Two of them were intraoperative perforations with clinical consequences. A slight cortical hemorrhage during the procedure was observed in 1 patient without clinical repercussions. DISCUSSION This single-surgeon single-center experience suggests that endovascular treatment is a safe and efficient treatment for pediatric AVMs. Pediatric prognostic scores for a suitable selection of candidates are needed. Further studies are required to validate these results.
Collapse
Affiliation(s)
- Aaron Rodriguez-Calienes
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru, .,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru,
| | - Diego Bustamante-Paytan
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru
| | - Kiara Camacho
- Facultad de Medicina Humana, Universidad Científica del Sur, Lima, Peru
| | - Angie Mayoria-Vargas
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru
| | - Giancarlo Saal-Zapata
- Departamento de Neurocirugía, Servicio de Neurocirugía Endovascular, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Rodolfo Rodriguez-Varela
- Departamento de Neurocirugía, Servicio de Neurocirugía Endovascular, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| |
Collapse
|
13
|
Abstract
Cerebral arteriovenous malformations (AVMs) are a complex and heterogeneous pathology which require an understanding of the natural history of these lesions, as well as the potential treatment options in order to manage them safely. While treatment is the agreed upon strategy for most ruptured AVMs, the management of unruptured AVMs continues to be debated. More recently, this debate has been fueled by the A Randomized Trial of Unruptured Arteriovenous Malformations (ARUBA) trial which attempts to define the natural history and treatment risk of AVMs. However, the trial has significant shortcomings which limit its broad applicability. In addition, the breadth, efficacy, and safety of potential treatment options continue to improve. This review focuses on defining the natural history of cerebral AVMs, an overview of the ARUBA trial, and the most current treatment paradigm for cerebral AVMs.
Collapse
|
14
|
Hani U, Bari ME, Bukhari SS. Arteriovenous malformation with associated multiple flow-related distal anterior cerebral artery aneurysms: A case report with poor outcomes. Surg Neurol Int 2020; 11:232. [PMID: 32874735 PMCID: PMC7451175 DOI: 10.25259/sni_27_2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 07/06/2020] [Indexed: 11/04/2022] Open
Abstract
Background Low-grade arteriovenous malformations (AVMs) associated with multiple flow-related distal anterior cerebral artery (DACA) aneurysms are rare occurrences. Here, we present a case of a frontal AVM with three associated DACA aneurysms arising from a single feeder. Case Description A 36-year-old male presented to us in the ER with acute-onset dysphasia and altered mental status. Head computed tomography and angiogram showed a spontaneous intracerebral hemorrhage with intraventricular extension and revealed a Spetzler Martin Grade II AVM, being fed by two feeders, with the major feeder from the DACA bearing three flow-related aneurysms. As the patient awaited digital subtraction angiography, his Glasgow Coma Scale dropped and he underwent emergency embolization with Onyx. This was followed by external ventricular drainage. The patient's neurological status did not improve, and he died following a complicated clinical course. Conclusion Multiple DACA aneurysms are a case of both clinical and anatomical rarity and to avoid complications in the clinical course, one must be judicious about the time spent between symptom onset and embolization.
Collapse
Affiliation(s)
- Ummey Hani
- Sindh Medical College, Jinnah Sindh Medical University, Sindh, Pakistan
| | - Muhammad Ehsan Bari
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Sindh, Pakistan
| | - Syed Sarmad Bukhari
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Sindh, Pakistan
| |
Collapse
|
15
|
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]
|
16
|
Lu VM, Wahood W, Rinaldo L, Ahn ES, Daniels DJ. Long-term functional outcome after intervention for pediatric intracranial arteriovenous malformations: A systematic review and meta-analysis. Clin Neurol Neurosurg 2020; 191:105707. [PMID: 32018117 DOI: 10.1016/j.clineuro.2020.105707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 11/15/2019] [Accepted: 01/29/2020] [Indexed: 10/25/2022]
Abstract
Intervention (surgery, embolization, and radiosurgery) is critical in maximizing outcomes of pediatric arteriovenous malformations (pAVMs). Although short-term functional outcomes following intervention have been stablished to be favorable, long-term outcomes have yet to be thoroughly consolidated. Searches of 7 electronic databases from inception to April 2019 were conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Favorable functional were modified Rankin Scale (mRS) scores ranging from 0 to 2, and the incidences were extracted and pooled by random-effects meta-analysis of proportions. Fourteen pertinent studies were identified describing outcomes of 699 pAVM patients, with median 75 % presenting with hemorrhage. Surgery, embolization and radiosurgery use were reported by 12 (86 %), 14 (100 %) and 10 (71 %) studies respectively. By median study follow-up time of 4.1 years, a favorable functional outcome was estimated to occur in 87 % (95 % CI, 82-91 %) of subjects respectively. Hemorrhagic versus non-hemorrhagic presentations did not statistically differ in incidence of this long-term outcome, 78 % (95 % CI, 67-87 %) and 91 % (95 % CI, 80-98 %) respectively. This study demonstrates that favorable long-term functional outlook of pAVM subjects after intervention can persist for many years after initial intervention. The certainty of achieving this outcome is moderate, irrespective of hemorrhagic presentation or intervention modality. Long-term functional deficit risk should not be the sole factor in deciding if intervention should be pursued.
Collapse
Affiliation(s)
- Victor M Lu
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States.
| | - Waseem Wahood
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Lorenzo Rinaldo
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Edward S Ahn
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - David J Daniels
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States.
| |
Collapse
|
17
|
Lv X, Jiang C, Wang J. Pediatric intracranial arteriovenous shunts: Advances in diagnosis and treatment. Eur J Paediatr Neurol 2020; 25:29-39. [PMID: 31996298 DOI: 10.1016/j.ejpn.2019.12.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/24/2019] [Accepted: 12/29/2019] [Indexed: 02/07/2023]
Abstract
Pediatric intracranial arteriovenous shunts (IAVSs) comprise a wide range of lesions, including pial arteriovenous malformation (AVM) and arteriovenous fistula (AVF), dural arteriovenous fistula (DAVF) and vein of Galen aneurysmal malformation (VGAM). We provide an overview of pediatric IAVSs, encompassing both diagnosis and endovascular treatment. We include references from pertinent literature and representative cases from our hospital. Pediatric IAVS are frequently associated two broader conditions, such as capillary malformation-arteriovenous malformation (CM-AVM) and hereditary hemorrhagic telangiectasia (HHT). These conditions and the associated genetic mutations have only recently been described. Their impact on the brain will be different in the prenatal period, in neonates, in infants, and in children, with variable symptoms according to each age group and the current strategies of endovascular treatment in the management of these vascular lesions will be discussed. This review could improve the understanding of pediatric IAVSs and their diagnosis and treatment.
Collapse
Affiliation(s)
- Xianli Lv
- Neurosurgery Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
| | - Chuhan Jiang
- Neurosurgery Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - James Wang
- Neurosurgery Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| |
Collapse
|
18
|
Wu EM, El Ahmadieh TY, McDougall CM, Aoun SG, Mehta N, Neeley OJ, Plitt A, Shen Ban V, Sillero R, White JA, Batjer HH, Welch BG. Embolization of brain arteriovenous malformations with intent to cure: a systematic review. J Neurosurg 2020; 132:388-399. [PMID: 30717053 DOI: 10.3171/2018.10.jns181791] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/01/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Endovascular embolization has been established as an adjuvant treatment strategy for brain arteriovenous malformations (AVMs). A growing body of literature has discussed curative embolization for select lesions. The transition of endovascular embolization from an adjunctive to a definitive treatment modality remains controversial. Here, the authors reviewed the literature to assess the lesional characteristics, technical factors, and angiographic and clinical outcomes of endovascular embolization of AVMs with intent to cure. METHODS Electronic databases-Ovid MEDLINE, Ovid Embase, and PubMed-were searched for studies in which there was evidence of AVMs treated using endovascular embolization with intent to cure. The primary outcomes of interest were angiographic obliteration immediately postembolization and at follow-up. The secondary outcomes of interest were complication rates. Descriptive statistics were used to calculate rates and means. RESULTS Fifteen studies with 597 patients and 598 AVMs treated with intent-to-cure embolization were included in this analysis. Thirty-four percent of AVMs were Spetzler-Martin grade III. Complete obliteration immediately postembolization was reported in 58.3% of AVMs that had complete treatment and in 45.8% of AVMs in the entire patient cohort. The overall clinical complication rate was 24.1%. The most common complication was hemorrhage, occurring in 9.7% of patients. Procedure-related mortality was 1.5%. CONCLUSIONS While endovascular embolization with intent to cure can be an option for select AVMs, the reported complication rates appear to be increased compared with those in studies in which adjunctive embolization was the goal. Given the high complication rate related to a primary embolization approach, the risks and benefits of such a treatment strategy should be discussed among a multidisciplinary team. Curative embolization of AVMs should be considered an unanticipated benefit of such therapy rather than a goal.
Collapse
Affiliation(s)
- Eva M Wu
- 1Department of Neurological Surgery, University of Texas Southwestern, School of Medicine; and
| | | | | | | | - Nikhil Mehta
- 3Neurointerventional Radiology, University of Texas Southwestern, Zale Lipshy Hospital, Dallas, Texas
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Alias Q, Boulouis G, Blauwblomme T, Benichi S, Beccaria K, Gariel F, Garzelli L, Meyer P, Kossorotoff M, Boddaert N, Brunelle F, Naggara O. First Line Onyx Embolization in Ruptured Pediatric Arteriovenous Malformations : Safety and Efficacy. Clin Neuroradiol 2019; 31:155-163. [PMID: 31802150 DOI: 10.1007/s00062-019-00861-6] [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: 09/16/2019] [Accepted: 11/18/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Brain arteriovenous malformations (bAVM) are the main cause of pediatric intracerebral hemorrhage (pICH). Embolization with Onyx (ev3, Irvine, CA, USA) in children with ruptured bAVM has been infrequently reported. The aim of this study was to assess the safety and efficacy profile of Onyx embolization as first line endovascular treatment of ruptured pediatric bAVMs. METHODS Children with non-traumatic pICH due to bAVM rupture at a pediatric quaternary care center were prospectively enrolled in a registry and retrospectively analyzed between 2013 and 2018. Clinical and demographic data, treatment modalities and clinical imaging follow-up were retrieved, and detailed procedural data were retrospectively assessed by two investigators. The safety (procedural morbidity and mortality) and efficacy (obliteration and interval rebleeding) were evaluated. RESULTS In this study 29 children treated for a bAVM by Onyx embolization were included (14 girls, 48%; median age 11.1 years, interquartile range, IQR 8.1-12.7 years) with a total of 72 endovascular sessions (median of 2 sessions per patient IQR 1-3). The AVMs were deeply located in 23 patients (79%). No systemic complications occurred, and no child experienced embolization-related persistent neurological deficits. Non-clinically relevant complications were observed during five procedures, unrelated to Onyx. After a mean follow-up of 31 months from rupture complete obliteration rates were 100%, 89%, 29%, 14% in bAVM Spetzler Martin grades I, II, III and IV-V, respectively. CONCLUSION It was found that Onyx embolization is safe and represents a good option for an initial treatment approach, in a sequential treatment strategy for pediatric ruptured brain AVMs. Younger age may not be an argument to deny Onyx embolization.
Collapse
Affiliation(s)
- Quentin Alias
- Pediatric Radiology, Necker Children Hospital, Paris, France
| | - Grégoire Boulouis
- Pediatric Radiology, Necker Children Hospital, Paris, France.,INSERM UMR 1266 IMA-BRAIN, Department of Neuroradiology, CHSA, Université de Paris, Paris, France
| | - Thomas Blauwblomme
- Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France
| | - Sandro Benichi
- Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France
| | - Kevin Beccaria
- Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France
| | - Florent Gariel
- Pediatric Radiology, Necker Children Hospital, Paris, France.,INSERM UMR 1266 IMA-BRAIN, Department of Neuroradiology, CHSA, Université de Paris, Paris, France.,Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France.,Department of Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | | | - Philippe Meyer
- Pediatric Neuro ICU, Necker Children Hospital, APHP, Paris, France
| | - Manoelle Kossorotoff
- Department of Pediatric Neurology, French Centre for Pediatric Stroke, APHP University Necker Children Hospital, Paris, France
| | | | | | - Olivier Naggara
- Pediatric Radiology, Necker Children Hospital, Paris, France. .,INSERM UMR 1266 IMA-BRAIN, Department of Neuroradiology, CHSA, Université de Paris, Paris, France.
| |
Collapse
|
20
|
Targeted endovascular treatment for ruptured brain arteriovenous malformations. Neurosurg Rev 2019; 43:1509-1518. [DOI: 10.1007/s10143-019-01205-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/08/2019] [Accepted: 10/29/2019] [Indexed: 11/26/2022]
|
21
|
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]
|
22
|
Fang YB, Byun JS, Liu JM, Krings T, Pereira VM, Brinjikji W. Transvenous embolization of brain arteriovenous malformations: a systematic review and meta-analysis. J Neurosurg Sci 2019; 63:468-472. [DOI: 10.23736/s0390-5616.18.04342-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
23
|
Ai X, Ye Z, Xu J, You C, Jiang Y. The factors associated with hemorrhagic presentation in children with untreated brain arteriovenous malformation: a meta-analysis. J Neurosurg Pediatr 2019; 23:343-354. [PMID: 30544349 DOI: 10.3171/2018.9.peds18262] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 09/06/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Rupture of arteriovenous malformations (AVMs) would result in high mortality and prevalence of disability in pediatric patients. Decisions regarding the treatment of AVMs need to weigh the risk of rupture over the course of their natural history against the possibility of creating a lesion during treatment. Multiple factors have been proposed to predict hemorrhagic presentation of pediatric patients with AVMs. The aim of this meta-analysis was to evaluate the predictors of hemorrhagic presentation in pediatric patients with AVMs. METHODS The authors searched the PubMed and EMBASE databases. Studies reporting the predictors of hemorrhagic presentation in children with untreated brain AVMs were included. The predictive ability of identified predictors was assessed by odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS A higher risk of hemorrhagic presentation was found in AVMs with smaller size (< 3 cm, OR 2.97, 95% CI 1.94–4.54, p < 0.00001), deep venous drainage (OR 2.28, 95% CI 1.55–3.36, p < 0.0001), a single draining vein (OR 2.23, 95% CI 1.27–3.92, p = 0.005), a single feeder (OR 3.72, 95% CI 1.31–10.62, p = 0.01), a deep location (OR 1.82, 95% CI 1.22–2.72, p = 0.004), an infratentorial location (OR 2.25, 95% CI 1.19–4.26, p = 0.01), and diffuse morphology (OR 8.94, 95% CI 3.01–26.55, p < 0.0001). In addition, the AVMs with draining vein ectasia (OR 0.35, 95% CI 0.13–0.97, p = 0.04) and high Spetzler-Martin (SM) grade (OR 0.53, 95% CI 0.36–0.78, p = 0.001) had a lower risk of hemorrhagic presentation in pediatric patients. CONCLUSIONS Smaller AVMs, deep venous drainage, a single draining vein, a single feeder, deep/infratentorial location, diffuse morphology, and high SM grade were identified as positive predictors for hemorrhagic presentation. Particularly, patients with diffuse AVMs have a higher risk of hemorrhagic presentation than other factors and may need active treatments. However, factors such as age, sex, draining vein stenosis, and associated aneurysms were not associated with hemorrhagic presentation. ABBREVIATIONS AVM = arteriovenous malformation; CI = confidence interval; NOS = Newcastle-Ottawa Scale; OR = odds ratio; SM = Spetzler-Martin.
Collapse
Affiliation(s)
| | | | | | | | - Yan Jiang
- 2Nursing Department, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
24
|
Flores BC, See AP, Weiner GM, Jankowitz BT, Ducruet AF, Albuquerque FC. Use of the Apollo detachable-tip microcatheter for endovascular embolization of arteriovenous malformations and arteriovenous fistulas. J Neurosurg 2019; 130:963-971. [PMID: 29570006 DOI: 10.3171/2017.9.jns17397] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 09/11/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Liquid embolic agents have revolutionized endovascular management of arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs). Nonetheless, since 2005, the US FDA has received more than 100 reports of microcatheter breakage or entrapment related to Onyx embolization, including 9 deaths. In 2014, the Apollo detachable-tip microcatheter became the first of its kind available in the US. Since then, few reports on its safety have been published. METHODS The authors conducted a retrospective review of endovascular cases by searching the patient databases at 2 tertiary cerebrovascular centers (Barrow Neurological Institute and University of Pittsburgh Medical Center). Patients who underwent endovascular embolization of an AVM or AVF using the Apollo microcatheter were identified. Patient demographics and lesion characteristics were collected. The authors analyzed Apollo-specific endovascular variables, such as number of microcatheterizations, sessions, and pedicles embolized; microcatheter tip detachment status; obliteration rate; and endovascular- and microcatheter-related morbidity and mortality. RESULTS From July 2014 to October 2016, a total of 177 embolizations using the Apollo microcatheter were performed in 61 patients (mean age 40.3 years). The most frequent presentation was hemorrhage (22/61, 36.1%). Most lesions were AVMs (51/61, 83.6%; mean diameter 30.6 mm). The mean Spetzler-Martin grade was 2.4. Thirty-nine (76.5%) of 51 patients with AVMs underwent resection. Microcatheterization was successful in 172 pedicles. Most patients (50/61, 82%) underwent a single embolization session. The mean number of pedicles per session was 2.5 (range 1-7). Onyx-18 was used in 103 (59.9%), N-butyl cyanoacrylate (NBCA) in 44 (25.6%), and Onyx-34 in 25 (14.5%) of the 172 embolizations. In 45.9% (28/61) of the patients, lesion obliteration of 75% or greater was achieved. Tip detachment occurred in 19.2% (33/172) of microcatheters. Fifty-three (86.9%) of the 61 patients who underwent embolization with the Apollo microcatheter had good functional outcomes (modified Rankin Scale score 0-2). No unintended microcatheter fractures or related morbidity was observed. One patient died of intraprocedural complications unrelated to microcatheter selection. In the univariate analysis, microcatheter tip detachment (p = 0.12), single embolized pedicles (p = 0.12), and smaller AVM nidus diameter (p = 0.17) correlated positively with high obliteration rates (> 90%). In the multivariate analysis, microcatheter tip detachment was the only independent variable associated with high obliteration rates (OR 9.5; p = 0.03). CONCLUSIONS The use of the Apollo detachable-tip microcatheter for embolization of AVMs and AVFs is associated with high rates of successful catheterization and obliteration and low rates of morbidity and mortality. The microcatheter was retrieved in all cases, even after prolonged injections in distal branch pedicles, often with significant reflux. This study represents the largest case series on the application of the Apollo microcatheter for neurointerventional procedures.
Collapse
Affiliation(s)
- Bruno C Flores
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Alfred P See
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Gregory M Weiner
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian T Jankowitz
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew F Ducruet
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Felipe C Albuquerque
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| |
Collapse
|
25
|
Al-Smadi AS, Ansari SA, Shokuhfar T, Malani A, Sattar S, Hurley MC, Potts MB, Jahromi BS, Alden TD, Dipatri AJ, Shaibani A. Safety and outcome of combined endovascular and surgical management of low grade cerebral arteriovenous malformations in children compared to surgery alone. Eur J Radiol 2019; 116:8-13. [PMID: 31153578 DOI: 10.1016/j.ejrad.2019.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/17/2019] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To evaluate the outcomes of combined preoperative embolization and microsurgical resection in comparison with microsurgical resection alone as the current standard of care for low-grade cerebral arteriovenous malformations (AVM) in the pediatric population. MATERIALS & METHODS We performed a single-center retrospective study of pediatric patients presenting with Spetzler-Martin (SM) grade I and II cerebral AVMs at a high-volume tertiary pediatric hospital between January 2005 and September 2016. Low grade AVM patients were divided into two groups: pre-operative embolization with subsequent microsurgical resection or microsurgical resection alone. Patient demographics, clinical and imaging presentations, AVM morphological characteristics, post-operative complications, and mid to long-term clinical outcomes were studied. Post-embolization and post-surgical outcomes were assessed prior to and after treatment, at 3 months and at final follow-up using the modified Rankin Scale (mRS) to compare both final independent (mRS 0-2) and favorable (no change or improved mRS) clinical outcomes for comparison between study groups. Statistical associations of patient demographics, AVM characteristics/SM grading, and treatment modality group with post-operative complications were performed using univariate logistic regression analysis. RESULTS Thirty-four patients with low grade cerebral AVMs met the study inclusion criteria (mean age 10.6 ± 3.4 years; range 3-16 years, 22M:12 F). Twenty patients (59%) presented with ruptured AVMs. Twenty-five patients (73.5%) underwent combined treatment with embolization and microsurgical resection, while 9/34 (26.5%) underwent microsurgical resection alone. A total of 35 embolization procedures performed in 25 patients (Mode, 1; Range, 1-7) were associated with two minor post-embolization and 7 subsequent post-surgical (28%) complications, resulting in clinical deterioration in a single patient. Microsurgical resection alone was associated with 3 post-surgical complications (33%), resulting in permanent neurological disability in a single patient. There was no significance association of post-operative complications with either treatment modality group, combined treatment versus surgical resection alone [OR:1.13; 95% CI:0.23-5.62; p-value 0.88]. SM Grade II and eloquent locations were found to be significantly associated with post-surgical complications of low grade pediatric cerebral AVMs [OR 13.2 and OR 8 respectively, p-value 0.004 and 0.005). On mean follow-up time of 35.7 months, final clinical outcome was favorable in the majority of both treatment arms with no dependent (mRS>2) patients in the combined endovascular and surgical cohort. Two patients in the surgical cohort failed to achieve independent functional status, primarily due to a pre-operative morbid status (p-value 0.015). However, there was no significant difference in favorable outcomes between the treatment groups [p-value 0.14]. CONCLUSION Our study suggests equivalent safety and favorable clinical outcomes related to combined endovascular embolization and microsurgical resection of low grade pediatric cerebral AVMs in comparison to microsurgical resection alone. On long term clinical follow-up, the vast majority of patients achieved an independent and favorable functional status irrespective of pre-operative embolization.
Collapse
Affiliation(s)
- Anas S Al-Smadi
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Sameer A Ansari
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Tahaamin Shokuhfar
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Aresha Malani
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Saadia Sattar
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Michael C Hurley
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Matthew B Potts
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Babak S Jahromi
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Tord D Alden
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Arthur J Dipatri
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Ali Shaibani
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States.
| |
Collapse
|
26
|
Onyx embolization of a ruptured anterior inferior cerebellar artery in a neonate. Childs Nerv Syst 2019; 35:373-378. [PMID: 30203392 PMCID: PMC7257924 DOI: 10.1007/s00381-018-3968-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 08/31/2018] [Indexed: 10/28/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is rare in neonates. The authors present a unique report of a neonate with SAH from anterior inferior cerebellar artery (AICA) aneurysm rupture that was successfully treated with Onyx embolization. This case report demonstrates the utility of Onyx embolization for posterior circulation aneurysms in neonates and the successful management of SAH in this population.
Collapse
|
27
|
Zaki Ghali G, Zaki Ghali MG, Zaki Ghali E. Transvenous embolization of arteriovenous malformations. Clin Neurol Neurosurg 2018; 178:70-76. [PMID: 30731326 DOI: 10.1016/j.clineuro.2018.08.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/06/2018] [Accepted: 08/12/2018] [Indexed: 10/28/2022]
Abstract
Embolization of arteriovenous malformations is characteristically used as part of a multimodal treatment approach, pre-operatively to facilitate microsurgical resection or as a preradiosurgical adjunct. The concept of AVM cure via embolization alone has gained popularity in recent years. Embolization of AVMs has been most commonly performed transarterially, with the transvenous route traditionally eschewed given concern over precipitating premature venous occlusion and consequent hemorrhage. However, the transvenous approach in treating AVMs offers several distinct advantages compared to the transarterial route and can be used in instances when the latter is not feasible, with several series having proven its efficacy and safety. Conceptually, AVM embolization performed via the transvenous route achieves complete obliteration by directly and facilely targeting the nidus. Nidal embolisate penetration is facilitated by control of arterial inflow via systemic or local hypotension. Innovation in endovascular strategies has led to significantly improved obliteration rates. The experience with transvenous AVM embolization is reviewed and discussed.
Collapse
Affiliation(s)
- George Zaki Ghali
- United States Environmental Protection Agency, Arlington, VA 22202, USA; Department of Toxicology, Purdue University, West Lafayette, IN 47907, USA
| | - Michael George Zaki Ghali
- Department of Neurological Surgery, Houston Methodist Hospital, 6560 Fannin Street, Houston, 77030, TX, United States; Deptartment of Neurological Surgery, Baylor College of Medicine, Houston, TX 77030, US.
| | - Emil Zaki Ghali
- Department of Medicine, Inova Alexandria Hospital, Alexandria 22304, USA; Department of Urological Surgery, El Gomhoureya General Hospital, Alexandria, Egypt
| |
Collapse
|
28
|
Endovascular Therapy for Brainstem Arteriovenous Malformations. World Neurosurg 2018; 125:481-488. [PMID: 30149173 DOI: 10.1016/j.wneu.2018.08.099] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/11/2018] [Accepted: 08/13/2018] [Indexed: 11/21/2022]
Abstract
Brainstem arteriovenous malformations (AVMs) represent ∼5% of all intracranial AVMs and carry a higher risk of hemorrhage than their supratentorial counterparts. There is a high and near-uniform mortality with initial and recurrent episodes of hemorrhage. Brainstem AVMs may also present symptomatically with focal neurologic deficits or hydrocephalus. Treatment is indicated for ruptured and symptomatic brainstem AVMs, as well as those possessing high-risk angioarchitectural features. Microsurgical resection and stereotactic radiosurgery are ideal therapeutic options when feasible. Embolization is most commonly used as adjunctive treatment before surgery or stereotactic radiosurgical irradiation. Preoperative embolization facilitates microsurgical resection and reduces intraoperative and postoperative hemorrhage rates. Use of embolization preradiosurgically helps to reduce nidal size, transforming a large lesion to a size amenable to radiosurgical intervention, increasing the probability of obliteration, decreasing procedural hemorrhage risk, stabilizing the lesion until radiotherapeutic effect achieves obliteration, and providing interval symptomatic resolution. Embolization may also be used effectively as stand-alone monotherapy for small lesions with 1 or 2 arterial feeders not supplying eloquent parenchyma. Although an extensive evidence base exists for clinical usefulness of stereotactic radiosurgery as monotherapy or in combination with other therapeutic modalities, only a few studies have reported specifically on obliteration and complication rates with monotherapeutic embolization in the treatment of brainstem AVMs. The potential role of embolization as monotherapy for brainstem AVMs is reviewed and discussed.
Collapse
|
29
|
Elewa MK. Cerebral arteriovenous malformations in the era of embolization for angiographic cure: a single-center experience in Egypt. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2018; 54:12. [PMID: 29780232 PMCID: PMC5954783 DOI: 10.1186/s41983-018-0003-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 03/23/2018] [Indexed: 11/10/2022] Open
Abstract
Background Embolization for cerebral arteriovenous malformations (AVMs) has evolved in the last decade with evolution in both equipment and material. Embolization targets have expanded to include angiographic cure. Methods To discuss the technical and management outcomes of our first cerebral AVM case series treated with embolization. The clinical, angiographic, treatment, and outcome variables of consecutive cerebral arteriovenous malformation cases, treated with curative embolization, between January 2011 and June 2017 in one regional center, were retrospectively analyzed. Results In 21 patients, 21 AVMs were identified, and 13 patients (61.9%) were males. The mean of the age was 34.24 ± 12.99. Fifteen patients (71.4%) had a history of intracranial hemorrhage, and 10 (47.6%) patients had seizures. Sixteen patients (76.2%) were at grade 1 of modified Rankin Scale (mRS) at admission. The median for modal Spetzler-Martin grade was 2. The average number of arterial feeders was 3. Direct arteriovenous fistulas were found in 4 cases (19.0%). Venous aneurysms were found in 4 cases (19.0%). Seventeen AVMs (80.9%) were considered high bleeding risk lesions. Forty-three embolization sessions were done. Early hemorrhage occurred in 3 sessions (7.0%). Vessel perforation occurred 1 session (2.3%). Poor outcome occurred in 1 patient that was discharged at grade 3 mRS. Angiographic cure was achieved in 9 patients (42.9%). The average size reduction was 65%. Conclusions Onyx embolization could serve as a curative option for AVM treatment with accepted morbidity and mortality.
Collapse
Affiliation(s)
- Mohamed K Elewa
- Neurology Department, Ain Shams University, 38 El-Abbasia, Cairo, 11566 Egypt
| |
Collapse
|
30
|
Jin H, Liu Z, Chang Q, Chen C, Ge H, Lv X, Li Y. A challenging entity of endovascular embolization with ONYX for brainstem arteriovenous malformation: Experience from 13 cases. Interv Neuroradiol 2017; 23:497-503. [PMID: 28614989 PMCID: PMC5624407 DOI: 10.1177/1591019917711679] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective Brainstem arteriovenous malformations (AVMs) are rare lesions with a high risk of intracranial hemorrhage and are challenging to treat. We present our experience of endovascular embolization with Onyx in these aggressive lesions. Materials and methods Between 2007 and 2016, 13 patients with brainstem AVMs were embolized with Onyx at our center. Twelve patients presented with intracranial hemorrhage and one with headache. Retrospective examinations of patient demographics, clinical presentation, angiographic features, treatment modalities, postoperative complications and outcomes were carried out. Results The AVMs were in the midbrain in 10 patients (one anterior and nine posterior or dorsal), in the posterior pons in two and pontomedullary in one. Complete occlusion was achieved in three patients. Gamma knife radiosurgery was performed in six patients who were near-completely or partially embolized. Postoperative complications, including five cases of ischemia and one case of hemorrhage, resulted in four cases of neurological deterioration and two deaths. Clinical follow-up was obtained in 10 patients at a mean period of 45.2 months (range 3 to 93 months). During the follow-up, good clinical outcomes were observed in seven patients with posterior or dorsal midbrain AVMs, and one patient with a posterior pons AVM that was partially occluded died of intracranial hemorrhage. Conclusion Endovascular embolization for brainstem AVM with Onyx is a technical challenge and the reflux of Onyx may cause severe complications. Individualized treatment is needed based on the specific subtype of brainstem AVM.
Collapse
Affiliation(s)
- Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, China
- Beijing Engineering Research Center for Interventional Neuroradiology, China
| | - Zhan Liu
- Department of Neurosurgery, Traditional Chinese Medicine Hospital of Laiwu City, China
| | - Qing Chang
- Department of Neurosurgery, Weifang Yidu Hospital, Qingzhou, China
| | - Chang Chen
- Department of Neurosurgery, Xintai Hospital of Traditional Chinese Medicine, China
| | - Huijian Ge
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, China
- Beijing Engineering Research Center for Interventional Neuroradiology, China
| | - Xianli Lv
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, China
- Beijing Engineering Research Center for Interventional Neuroradiology, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, China
- Beijing Engineering Research Center for Interventional Neuroradiology, China
- Youxiang Li, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, No. 6, Tiantan Xili, Dongcheng, Beijing, 100050, P.R. China.
| |
Collapse
|
31
|
Viana DC, de Castro-Afonso LH, Nakiri GS, Monsignore LM, Trivelato FP, Colli BO, Abud DG. Extending the indications for transvenous approach embolization for superficial brain arteriovenous malformations. J Neurointerv Surg 2017; 9:1053-1059. [PMID: 28600483 DOI: 10.1136/neurintsurg-2017-013113] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 05/13/2017] [Accepted: 05/16/2017] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Transarterial embolization is the standard endovascular treatment strategy for intracranial arteriovenous malformations (AVMs). The transvenous approach has been indicated for the embolization of deep AVMs meeting a set of strict eligibility criteria. The present study aims to assess the safety and efficacy of the transvenous approach for superficial AVMs. METHODS A retrospective series of 12 patients presenting with cortical AVMs were treated by endovascular embolization using a transvenous approach with a curative intent. RESULTS Nine patients (75%) had ruptured AVMs at admission. The mean nidus size was 1.9 cm, six patients (50%) had a nidus in eloquent areas and the median Spetzler-Martin grade was 2. The rate of immediate angiographic occlusion of the AVMs was 91.6% (11/12). One patient in whom immediate angiographic occlusion was not achieved showed spontaneous occlusion at the 6-month follow-up. No procedural or clinical complications were observed. The mean and median modified Rankin scale (mRS) scores at discharge were 1.7 and 2 (range 0-3, SD=0.96), and the mean and median mRS scores at 6 months were 1.6 and 2 (0-3, 1.16). Nine patients (75%) were independent (mRS ≤2) at discharge and 11 patients (91.6%) were independent (mRS ≤2) at the 6-month follow-up. CONCLUSIONS The curative transvenous embolization of superficial intracranial AVMs is feasible and appears safe and effective when strict anatomical selection is respected. This technique extends the current indications for transvenous embolization of intracranial AVMs and may improve cure rates while reducing embolization-related complications.
Collapse
Affiliation(s)
- Dinark Conceição Viana
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Luis Henrique de Castro-Afonso
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Guilherme Seizem Nakiri
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Lucas Moretti Monsignore
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Felipe Padovani Trivelato
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Benedicto Oscar Colli
- Division of Neurosurgery, Department of Surgery, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Daniel Giansante Abud
- Division of Interventional Neuroradiology, Department of Internal Medicine, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| |
Collapse
|
32
|
Chen K, Paramasivam S, Berenstein A. Pediatric neurointervention: collimation on radiation exposure-associated lifetime excess tumor risk. J Neurointerv Surg 2016; 9:895-898. [DOI: 10.1136/neurintsurg-2016-012477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/26/2016] [Accepted: 07/29/2016] [Indexed: 12/24/2022]
Abstract
BackgroundIntracranial vascular malformations in children are being addressed through a variety of treatment modalities including open surgery, external beam radiation, and image-guided neuroendovascular procedures. These patients often receive multiple treatments and incur serial exposures to ionizing radiation which has been linked to tumor development in population-based data.ObjectiveThis study quantifies the effect of collimation on exposures from single procedures and over patient lifetimes to estimate excess risk of lifetime tumor development.Methods215 patients aged 0–21 years from a single center took part in the study. Radiation exposure from neuroendovascular procedures was tabulated and converted to brain doses using modeled data and extrapolated to risk ratios using results of population-based estimates found in the literature.ResultsLifetime and per procedure risk was highest in patients with brain arteriovenous malformations, brain arteriovenous fistulas, and vein of Galen malformations, a reflection of our institutional referral patterns. Across all pathologies the per procedure excess relative risk decreased from 13.4 to 2.3 when full collimation was employed. Lifetime excess relative risk decreased from 49.0 to 7.7 for full collimation.ConclusionsThis is the first study to quantify the effect of collimation on lifetime and per procedure risk of tumor development in a pediatric population. In addition to collimation, technical and operator-based aspects of the neurointerventional suite are discussed to further reduce patient exposure without sacrificing image quality.
Collapse
|