Novel Multimodality Imaging Techniques for Diagnosis and Evaluation of Arteriovenous Malformations

Congenital Intracranial Vascular Malformations in Children : Radiological Overview

Prompt medical attention is crucial for congenital intracranial vascular malformations in children and newborns due to potential severe outcomes. Imaging is pivotal for accurate identification, given the diverse risks and treatment strategies. This article aims to enhance the identification and understanding of congenital intracranial vascular abnormalities including arteriovenous malformation, arteriovenous fistula, cavernous malformation, capillary telangiectasia, developmental venous anomaly, and sinus pericranii in pediatric patients.

How Reliable Is the Intraoperative Computed Tomography Angiography in Assessing Complete Surgical Resection of Cerebral Arteriovenous Malformations?

BACKGROUND

Digital subtraction angiography (DSA) is still considered the gold standard test to evaluate arteriovenous malformation's (AVM) residual after microsurgical resection.

OBJECTIVE

To evaluate the safety and reliability of intraoperative computed tomography angiography (iCTA) as an immediate method of evaluating the surgical results of AVM resection.

METHODS

We performed a retrospective review for all cases of cerebral AVMs at our institute from January 2015 to April 2020 who underwent surgical resection of cerebral AVM and had iCTA. All included patients underwent a postoperative DSA, and the results were compared with iCTA.

RESULTS

Twenty-eight cases were included. All cases showed complete resection (100%) in the iCTA, and the results were consistent with the postoperative DSA results. The sensitivity of iCTA was 100%. The added operative time ranged from 25 to 30 min. There were no complications related to the use of iCTA.

CONCLUSION

Intraoperative assessment of AVMs surgical results with an iCTA is safe and reliable. The sensitivity of iCTA following AVM resection merits further investigations.

ACR Appropriateness Criteria® Cerebrovascular Disease

Diseases of the cerebral vasculature represent a heterogeneous group of ischemic and hemorrhagic etiologies, which often manifest clinically as an acute neurologic deficit also known as stroke or less commonly with symptoms such as headache or seizures. Stroke is the fourth leading cause of death and is a leading cause of serious long-term disability in the United States. Eighty-seven percent of strokes are ischemic, 10% are due to intracerebral hemorrhage, and 3% are secondary to subarachnoid hemorrhage. The past two decades have seen significant developments in the screening, diagnosis, and treatment of ischemic and hemorrhagic causes of stroke with advancements in CT and MRI technology and novel treatment devices and techniques. Multiple different imaging modalities can be used in the evaluation of cerebrovascular disease. The different imaging modalities all have their own niches and their own advantages and disadvantages in the evaluation of cerebrovascular disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Effect of treatment period on outcomes after stereotactic radiosurgery for brain arteriovenous malformations: an international multicenter study

OBJECTIVE

The role of and technique for stereotactic radiosurgery (SRS) in the management of arteriovenous malformations (AVMs) have evolved over the past four decades. The aim of this multicenter, retrospective cohort study was to compare the SRS outcomes of AVMs treated during different time periods.

METHODS

The authors selected patients with AVMs who underwent single-session SRS at 8 different centers from 1988 to 2014 with follow-up ≥ 6 months. The SRS eras were categorized as early (1988-2000) or modern (2001-2014). Statistical analyses were performed to compare the baseline characteristics and outcomes of the early versus modern SRS eras. Favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RICs).

RESULTS

The study cohort comprised 2248 patients with AVMs, including 1584 in the early and 664 in the modern SRS eras. AVMs in the early SRS era were significantly smaller (p < 0.001 for maximum diameter and volume), and they were treated with a significantly higher radiosurgical margin dose (p < 0.001). The obliteration rate was significantly higher in the early SRS era (65% vs 51%, p < 0.001), and earlier SRS treatment period was an independent predictor of obliteration in the multivariate analysis (p < 0.001). The rates of post-SRS hemorrhage and radiological, symptomatic, and permanent RICs were not significantly different between the two groups. Favorable outcome was achieved in a significantly higher proportion of patients in the early SRS era (61% vs 45%, p < 0.001), but the earlier SRS era was not statistically significant in the multivariate analysis (p = 0.470) with favorable outcome.

CONCLUSIONS

Despite considerable advances in SRS technology, refinement of AVM selection, and contemporary multimodality AVM treatment, the study failed to observe substantial improvements in SRS favorable outcomes or obliteration for patients with AVMs over time. Differences in baseline AVM characteristics and SRS treatment parameters may partially account for the significantly lower obliteration rates in the modern SRS era. However, improvements in patient selection and dose planning are necessary to optimize the utility of SRS in the contemporary management of AVMs.

Neuroimaging of headaches associated with vascular disorders

Headaches from vascular causes need to be differentiated from primary headaches because a misdiagnosis may lead to dire consequences for the patient. Neuroimaging is critical in identifying patients with vascular headaches and identifying the nature of the pathologic disorder causing these headaches. In addition, the imaging findings guide the physician regarding the optimal treatment modality for these lesions. This review summarizes the nuances of differentiating patients with secondary headaches related to vascular disease and discusses pertinent neuroimaging studies.