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Bhatia K, Lee H, Kortman H, Klostranec J, Guest W, Wälchli T, Radovanovic I, Krings T, Pereira V. Endovascular Management of Intracranial Dural Arteriovenous Fistulas: Transarterial Approach. AJNR Am J Neuroradiol 2022; 43:324-331. [PMID: 34620593 PMCID: PMC8910823 DOI: 10.3174/ajnr.a7296] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/03/2021] [Indexed: 01/02/2023]
Abstract
In this second of 3 review articles on the endovascular management of intracranial dural AVFs, we discuss transarterial treatment approaches. The treatment goal is to occlude the fistulous point, including the most distal portion of the arterial supply together with the most proximal portion of the draining vein (ie, the "foot" of the vein), which can be accomplished with liquid embolic agents via transarterial access. Anatomic factors to consider when assessing the safety and efficacy of a transarterial approach using liquid embolic agents include location, angioarchitecture, and proximity of arterial feeders to both the vasa nervosum of adjacent cranial nerves and the external carotid-internal carotid/vertebral artery anastomoses. Anatomic locations typically favorable for transarterial approaches include but are not limited to the transverse/sigmoid sinus, cerebral convexity, and superior sagittal sinus. In this review article, we discuss the technical approaches, outcomes, potential complications, and complication avoidance strategies for transarterial embolization.
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Affiliation(s)
- K.D. Bhatia
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K.),Department of Medical Imaging (K.D.B.), Sydney Children’s Hospital Network, Westmead, New South Wales, Australia,Division of Paediatrics (K.D.B.), Faculty of Medicine, University of Sydney, Camperdown, New South Wales, Australia,Division of Paediatrics (K.D.B.), Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia,Division of Medical Imaging (K.D.B.), Faculty of Medicine, Macquarie University, Macquarie Park, New South Wales, Australia
| | - H. Lee
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K.)
| | - H. Kortman
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K.)
| | - J. Klostranec
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K.)
| | - W. Guest
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K.)
| | - T. Wälchli
- Neurosurgery (T.W., I.R., T.K.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - I. Radovanovic
- Neurosurgery (T.W., I.R., T.K.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - T. Krings
- From the Divisions of Neuroradiology (K.D.B., H.L., H.K., J.K., W.G., T.K.),Neurosurgery (T.W., I.R., T.K.), Toronto Western Hospital, Toronto, Ontario, Canada
| | - V.M. Pereira
- Division of Interventional Neuroradiology (V.M.P.), St Michael’s Hospital, Toronto, Ontario, Canada
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Musmar B, Adeeb N, Ansari J, Sharma P, Cuellar HH. Endovascular Management of Hemorrhagic Stroke. Biomedicines 2022; 10:biomedicines10010100. [PMID: 35052779 PMCID: PMC8772870 DOI: 10.3390/biomedicines10010100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/20/2021] [Accepted: 12/29/2021] [Indexed: 11/24/2022] Open
Abstract
Significant advances in endovascular neurosurgery tools, devices, and techniques are changing the approach to the management of acute hemorrhagic stroke. The endovascular treatment of intracranial aneurysms emerged in the early 1990s with Guglielmi detachable coils, and since then, it gained rapid popularity that surpassed open surgery. Stent-assisted coiling and balloon remodeling techniques have made the treatment of wide-necked aneurysms more durable. With the introduction of flow diverters and flow disrupters, many aneurysms with complex geometrics can now be reliably managed. Arteriovenous malformations and fistulae can also benefit from endovascular therapy by embolization using n-butyl cyanoacrylate (NBCA), Onyx, polyvinyl alcohol (PVA), and coils. In this article, we describe the role of endovascular treatment for the most common causes of intracerebral and subarachnoid hemorrhages, particularly ruptured aneurysms and vascular malformations.
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Nico L, Magro E, Ognard J, Fahed R, Salazkin I, Gevry G, Darsaut T, Raymond J, Gentric JC. Comparing N-hexyl cyanoacrylate (Magic Glue) and N-butyl cyanoacrylate (NBCA) for neurovascular embolization using the pressure cooker technique: An experimental study in swine. J Neuroradiol 2021; 48:486-491. [PMID: 33418056 DOI: 10.1016/j.neurad.2020.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The pressure cooker (PC) technique uses a second microcatheter to produce a proximal occlusion to prevent the reflux of liquid embolic agent (LEA) injected through a more distal microcatheter, and can be used to treat arteriovenous malformations and dural arteriovenous fistulae. The liquid embolic Magic Glue (MG) (N-hexyl cyanoacrylate (NHCA)) has been introduced as an alternative to N-butyl cyanoacrylate (NBCA). Our goals were to compare the extent of embolization of rete mirabile with or without the PC technique using NBCA or MG, and to compare the proximal occlusions obtained with MG or NBCA while using the PC technique in a renal arterial model. METHODS Rete mirabile were embolized with (n = 4) and without (n = 4) the PC technique, using MG (n = 4) or NBCA (n = 4). A renal arterial model was then used to study the characteristics of the MG plug (n = 10) used for the PC technique, and resistance to catheter withdrawal as compared to NBCA (n = 4). Specimens were analyzed macro- and microscopically and compared to angiographic results. RESULTS Extent of rete embolization with CYA agents was not significantly greater when using the PC technique. Results were similar with both types of cyanoacrylate (p = 0.657). The force necessary to withdraw the microcatheter was less with MG than with NBCA (p = 0.035). CONCLUSION MG was similar to NBCA in extent of rete embolization. Less traction force was necessary to withdraw trapped non-detachable microcatheters using MG compared to NBCA.
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Affiliation(s)
- Lorena Nico
- Division of Interventional Neuroradiology, Department of Radiology, University Hospital of Brest, France
| | - Elsa Magro
- Department of Neurosurgery, University Hospital of Brest. Bd. Tanguy Prigent, 29609 Brest Cedex, France; Laboratory of Medical Information Processing - LaTIM INSERM UMR 1101, Brest, France
| | - Julien Ognard
- Division of Interventional Neuroradiology, Department of Radiology, University Hospital of Brest, France; Laboratory of Medical Information Processing - LaTIM INSERM UMR 1101, Brest, France
| | - Robert Fahed
- Department of Medicine, Division of Neurology, Ottawa Hospital, Ottawa, Canada
| | - Igor Salazkin
- Interventional Neuroradiology Laboratory, Research Centre, University of Montreal Hospital (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Guylaine Gevry
- Interventional Neuroradiology Laboratory, Research Centre, University of Montreal Hospital (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Tim Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Science Centre, Edmonton, Alberta, Canada
| | - Jean Raymond
- Interventional Neuroradiology Laboratory, Research Centre, University of Montreal Hospital (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada; Department of Radiology, University of Montreal Hospital (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Jean-Christophe Gentric
- Division of Interventional Neuroradiology, Department of Radiology, University Hospital of Brest, France; Western Brittany Thrombosis Study Group - GETBO EA3878, Brest, France.
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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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Riederer I, Bar-Ness D, Kimm MA, Si-Mohamed S, Noël PB, Rummeny EJ, Douek P, Pfeiffer D. Liquid Embolic Agents in Spectral X-Ray Photon-Counting Computed Tomography using Tantalum K-Edge Imaging. Sci Rep 2019; 9:5268. [PMID: 30918297 PMCID: PMC6437141 DOI: 10.1038/s41598-019-41737-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 03/15/2019] [Indexed: 12/26/2022] Open
Abstract
The aim was to evaluate the potential of Spectral Photon-Counting Computed Tomography (SPCCT) to differentiate between liquid embolic agents and iodinated contrast medium by using tantalum-characteristic K-edge imaging. Tubes with a concentration series of tantalum and inserts with different concentrations of iodine were scanned with a preclinical SPCCT system. Tantalum density maps (TDM) and iodine density maps (IDM) were generated from a SPCCT acquisition. Furthermore, region-of-interest (ROI) analysis was performed within the tubes in the conventional CT, the TDM and IDM. TDM and IDM enable clear differentiation between both substances. Quantitative measurements of different tantalum concentrations match well with those of actually diluted mixtures. SPCCT allows for differentiation between tantalum and iodine and may enable for an improved follow-up diagnosis in patients after vascular occlusion therapy.
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Affiliation(s)
- Isabelle Riederer
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, School of Medicine, Munich, Germany. .,Department of Diagnostic and Interventional Neuroradiology, Technical University of Munich, School of Medicine, Munich, Germany.
| | - Daniel Bar-Ness
- University Claude Bernard Lyon 1, CREATIS, CNRS UMR 5220, INSERM U1206, INSA-Lyon, France.,Department of Interventional Radiology and Cardio-vascular and Thoracic Diagnostic Imaging, Louis Pradel University Hospital, Bron, France
| | - Melanie A Kimm
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, School of Medicine, Munich, Germany
| | - Salim Si-Mohamed
- University Claude Bernard Lyon 1, CREATIS, CNRS UMR 5220, INSERM U1206, INSA-Lyon, France.,Department of Interventional Radiology and Cardio-vascular and Thoracic Diagnostic Imaging, Louis Pradel University Hospital, Bron, France
| | - Peter B Noël
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, School of Medicine, Munich, Germany
| | - Ernst J Rummeny
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, School of Medicine, Munich, Germany
| | - Philippe Douek
- University Claude Bernard Lyon 1, CREATIS, CNRS UMR 5220, INSERM U1206, INSA-Lyon, France.,Department of Interventional Radiology and Cardio-vascular and Thoracic Diagnostic Imaging, Louis Pradel University Hospital, Bron, France
| | - Daniela Pfeiffer
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, School of Medicine, Munich, Germany
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Potts MB, Zumofen DW, Raz E, Nelson PK, Riina HA. Curing arteriovenous malformations using embolization. Neurosurg Focus 2014; 37:E19. [DOI: 10.3171/2014.6.focus14228] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endovascular embolization is typically reserved as an adjuvant therapy in the management of cerebral arteriovenous malformations (AVMs), either for preoperative devascularization or preradiosurgical volume reduction. Curative embolization plays a limited role in AVM treatment but several studies have shown that it is possible, especially with later-generation liquid embolic agents. Given the complexity of AVM anatomy and the recent controversies over the role of any intervention in AVM management, it is critical that the cerebrovascular community better define the indications of each treatment modality to provide quality AVM management. In this review, the authors evaluate the role of curative AVM embolization. Important considerations in the feasibility of curative AVM embolization include whether it can be performed reliably and safely, and whether it is a durable cure. Studies over the past 20 years have begun to define the anatomical factors that are amenable to complete endovascular occlusion, including size, feeding artery anatomy, AVM morphology, and endovascular accessibility. More recent studies have shown that highly selected patients with AVMs can be treated with curative intent, leading to occlusion rates as high as 100% of such prospectively identified lesions with minimal morbidity. Advances in endovascular technology and techniques that support the efficacy and safety of curative embolization are discussed, as is the importance of superselective diagnostic angiography. Finally, the durability of curative embolization is analyzed. Overall, while still unproven, endovascular embolization has the potential to be a safe, effective, and durable curative treatment for select AVMs, broadening the armamentarium with which one can treat this disease.
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Affiliation(s)
- Matthew B. Potts
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Daniel W. Zumofen
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Eytan Raz
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Peter K. Nelson
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Howard A. Riina
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
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Abstract
Rupture of a cerebral arteriovenous malformation can result in devastating hemorrhage with a possibility of serious neurological injury or death. Endovascular embolization is an important adjunct in the treatment of cerebral arteriovenous malformations, and in a small number of cases may provide definitive treatment. Currently available embolic agents have several shortcomings, including the possibility of recanalization, adhesiveness to the endovascular microcatheter and suboptimal handling at the time of surgical resection. Onyx is an ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide that was approved by the US FDA in July 2005 as an embolic agent for brain arteriovenous malformations. Although long-term follow-up is limited, this agent appears to offer several advantages over the other available embolic agents for the endovascular management of arteriovenous malformations and other vascular lesions.
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Affiliation(s)
- Michael Ayad
- Vanderbilt University, Department of Neurological Surgery, Vanderbilt University Medical Center, MCN T-4224, Nashville, TN 37212, USA.
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Lubarsky M, Ray C, Funaki B. Embolization agents-which one should be used when? Part 2: small-vessel embolization. Semin Intervent Radiol 2011; 27:99-104. [PMID: 21359018 DOI: 10.1055/s-0030-1247891] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Michael Lubarsky
- Department of Radiology, Emory University School of Medicine, Chicago, Illinois
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9
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Carvajal LF, Gómez H, Gómez JF, Ruz MA. Malformación aneurismática de la vena de Galeno. Reporte de un caso. REVISTA COLOMBIANA DE CARDIOLOGÍA 2011. [DOI: 10.1016/s0120-5633(11)70181-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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10
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Kupfer TJ, Aumann K, Laszig R, Meckel S. [Peripheral facial palsy after embolization of a dural arteriovenous fistula with Onyx®]. HNO 2011; 59:465-9. [PMID: 21505930 DOI: 10.1007/s00106-011-2297-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Dural arteriovenous fistulas (DAVF) are intracranial vascular malformations which can cause severe complications, such as intracranial bleeding and neurological deficits. We report the case of a patient presenting with pulsatile tinnitus caused by a DAVF. The DAVF was endovascularly treated including transarterial embolization with the liquid embolic agent Onyx®. The fistula and tinnitus were cured successfully, however, the rare complication of facial nerve palsy due to reflux of Onyx® into the vasa nervorum occurred. This could be confirmed directly during surgery and by histological analysis.
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Affiliation(s)
- T J Kupfer
- HNO-Universitätsklinik Freiburg, Killianstrasse 5, 79106, Freiburg, Deutschland.
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11
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Barnett BP, Gailloud P. Assessment of EmboGel--a selectively dissolvable radiopaque hydrogel for embolic applications. J Vasc Interv Radiol 2010; 22:203-11. [PMID: 21185201 DOI: 10.1016/j.jvir.2010.10.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 08/20/2010] [Accepted: 10/19/2010] [Indexed: 10/18/2022] Open
Abstract
PURPOSE To evaluate the embolic properties of an alginate-based embolic biomaterial (EmboGel) and its solvent (EmboClear) in treatment of aneurysms. MATERIALS AND METHODS EmboGel is a mixture of iohexol and alginate that polymerizes into a hydrocoil when delivered through a coaxial catheter with a distal mixing tip, exposing alginate to a calcium chloride solution. In contrast to previously reported embolic agents, EmboGel can be selectively dissolved by EmboClear, a mixture of the enzyme alginate lyase and ethylenediaminetetraacetic acid (EDTA). The embolic and contrast properties of EmboGel were assessed in in vitro models of saccular aneurysm and an aortic aneurysm endoleak. The dissolvability of EmboGel with EmboClear was assessed further after endovascular delivery in the New Zealand white rabbit in the native aortoiliofemoral territory, a created saccular aneurysm, and the native carotid arteries. RESULTS EmboGel effectively filled aneurysm cavities in the case of stent excluded saccular and fusiform aneurysms. EmboGel was readily dissolved by EmboClear in vitro and after in vivo embolization. When the distal abdominal aorta and pelvic arteries were occluded with EmboGel, within 1 minute of EmboClear infusion, patency of the aorta and most of the pelvic circulation was regained as noted by angiography. Embolization in the subclavian artery and numerous distal branches was rapidly dissolved by EmboClear. Finally, the carotid artery occluded with EmboGel regained patency after administration of EmboClear. CONCLUSIONS EmboGel is a dissolvable alginate-based biomaterial that can be used for numerous embolic applications. EmboGel can be selectively dissolved with EmboClear, a solution of alginate lyase and EDTA.
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Affiliation(s)
- Brad P Barnett
- Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21287, USA
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12
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Endovascular treatment of a neonate with dural arteriovenous fistula and other features suggestive of cerebrofacial arteriovenous metameric syndromes. Childs Nerv Syst 2009; 25:383-7. [PMID: 19082615 DOI: 10.1007/s00381-008-0753-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Over the years, patients presented with cerebrofacial vascular malformations which occurred in clusters. The syndromic presentation suggested angio-architectural abnormality, which started to develop during embryogenesis. The segmentation of the neural tube could provide a rational explanation for such a neuropathological phenomenon. Based on this theory, cerebrofacial arteriovenous metameric syndrome (CAMS) was derived. This describes clinical association between arteriovenous malformations of the face, retina, and brain. In this case's presentation, the syndromic presentation of the patient provided further evidence to the theory. CASE REPORT The authors report a case of a male neonate presenting with heart failure at birth. He was found to have a left sigmoid dural arteriovenous fistula (dAVF), an upper lip arteriovenous malformation (AVM), and a capillary hemangioma over the nose. The neuropathological clustering of vascular lesions is suggestive of CAMS. The patient was successfully treated with endovascular treatment and showed normal development during our follow-up assessment. CONCLUSION With the evolving evidence for the embryo-developmental theory for the clustering of angio-pathological lesions, further study and development of pathophysiology should be continued in following this track of theory. The success of endovascular intervention has warranted a favorable treatment option.
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Gore P, Theodore N, Brasiliense L, Kim LJ, Garrett M, Nakaji P, Gonzalez LF, McDougall CG, Albuquerque FC. The utility of onyx for preoperative embolization of cranial and spinal tumors. Neurosurgery 2008; 62:1204-11; discussion 1211-2. [PMID: 18824987 DOI: 10.1227/01.neu.0000333292.74986.ac] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To assess the utility, technical factors, and complications associated with the use of Onyx (Micro Therapeutics, Inc., Irvine, CA) for preoperative embolization of cranial and spinal tumors. METHODS We reviewed a prospectively accumulated database for patients in whom Onyx was used for preoperative embolization of cranial and spinal tumors over a 19-month period. The patients' demographic characteristics, tumor type and location, embolic agents used, arteries catheterized, and associated complications were assessed. Specific attention was focused on technical factors associated with the use of Onyx that differed from the use of other commonly used embolic materials. RESULTS Ten patients (four female and six male; age range, 11-60 yr) underwent preoperative embolization with Onyx before cranial or spinal tumor resection. Tumors included three juvenile nasal angiofibromas, two meningiomas, two hemangioblastomas, two metastases (renal cell and thyroid), and one giant cell tumor. Onyx embolization was performed in 43 vessels over 11 treatment sessions. There were no complications related to the embolization procedures. Deep penetration of the embolic agent into the tumor was documented through preoperative imaging or surgical pathological specimens. CONCLUSION Preoperative embolization of cranial and spinal tumors can be performed safely. Specific technical advantages of Onyx included deep penetration of lesions producing extensive tumor infarction, the ability to embolize extensive portions of the tumors through fewer arterial catheterizations, and the safety of catheter withdrawal despite often substantial reflux along the embolic catheter.
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Affiliation(s)
- Pankaj Gore
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Gore P, Theodore N, Brasiliense L, Kim LJ, Garrett M, Nakaji P, Gonzalez LF, McDougall CG, Albuquerque FC. THE UTILITY OF ONYX FOR PREOPERATIVE EMBOLIZATION OF CRANIAL AND SPINAL TUMORS. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000315300.83459.5c] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Unusual Presentation of a Dural Arteriovenous Fistula of the Superior Sagittal Sinus and Single Modality Therapy with Onyx. Radiol Case Rep 2008; 3:158. [PMID: 27303511 PMCID: PMC4896129 DOI: 10.2484/rcr.v3i1.158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Superior sagittal sinus (SSS) dural arteriovenous fistulas (DAVF) are rare and present unique challenges to treatment. Complex, often bilateral, arterial supply and involvement of large volumes of eloquent cortical venous drainage may necessitate multimodality therapy. We report a case of a DAVF of the SSS in a patient who presented uniquely with increasing dizziness and disequilibrium who was treated with a single modality, endovascular embolization with ethyl vinyl alcohol co-polymer (Onyx, EV3, Irvine, CA). The patient underwent staged embolization in 2 sessions with no complications. An angiographic cure was achieved and the patient's symptoms were ameliorated. Single modality therapy with endovascular embolization of a SSS DAVF can be achieved. Careful attention to technique during embolization with Onyx is required, but complete obliteration is possible without the need for adjunctive surgical resection.
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Key Words
- ACA, anterior cerebral artery
- AVM, arteriovenous malformation
- CT, computed tomography
- DAVF, dural arteriovenous fistula
- DMSO, dimethyl-sulfoxide
- ECA, external carotid artery
- ICA, internal carotid artery
- MCA, middle cerebral artery
- MMA, middle meningeal artery, MRI, magnetic resonance imaging
- NBCA, N-butyl-cyanoacrylate
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Arat A, Inci S. Treatment of a superior sagittal sinus dural arteriovenous fistula with Onyx: technical case report. Neurosurgery 2006; 59:ONSE169-70; discussion ONSE169-70. [PMID: 16888563 DOI: 10.1227/01.neu.0000220113.34075.40] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The endovascular treatment of a complex superior sagittal sinus dural arteriovenous fistula with ethylene vinyl alcohol copolymer (Onyx) in one session is described. CLINICAL PRESENTATION A 54-year-old man presented with dizziness and a bruit. A cerebral angiogram demonstrated a superior sagittal sinus dural arteriovenous fistula with a patent superior sagittal sinus that was supplied via multiple branches of the external carotid arteries bilaterally and the left anterior and middle cerebral arteries. Drainage was mainly through the superior sagittal sinus and, only in part, retrogradely through the cortical veins. A decision was made to proceed with endovascular treatment followed by surgery. INTERVENTION Transarterial injection of one pedicle of middle meningeal artery on both sides with Onyx resulted in complete obliteration of the dural supply and some of the pial supply to the malformation without complications. The superior sagittal sinus remained patent. Based on this result, surgical treatment was cancelled. The residual pial supply had disappeared by the 10-month angiographic follow-up examination and the patient remained neurologically intact and without symptoms. CONCLUSION Definitive treatment may be attained with Onyx in dural arteriovenous fistulas. The potential of Onyx for use as a permanent embolic agent in dural arteriovenous fistulae needs to be investigated.
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Affiliation(s)
- Anil Arat
- Interventional Neuroradiology, Baylor College of Medicine, Houston, Texas, USA.
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Kim LJ, Albuquerque FC, Spetzler RF, McDougall CG. Postembolization Neurological Deficitsin Cerebral Arteriovenous Malformations: Stratification By Arteriovenous Malformation Grade. Neurosurgery 2006; 59:53-9; discussion 53-9. [PMID: 16823300 DOI: 10.1227/01.neu.0000219219.97287.91] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To stratify the risk of embolization during the treatment of cerebral arteriovenous malformations (AVMs) by grade and to assess its impact on the overall treatment risk. METHODS Patients with cerebral AVMs treated with embolization between 1995 and 2004 were retrospectively reviewed. Age, sex, AVM grade, location of lesion, number and location of embolized arteries, and number of embolization sessions were analyzed with respect to neurological or vascular complications after embolization. RESULTS Embolization was performed in 153 patients: 508 vessels were embolized during 203 sessions (mean, 3.3 vessels per patient). The mean angiographic and clinical follow-up periods were 1.7 and 2.1 years, respectively (range, 3-60 mo). The periprocedural morbidity and mortality rate was 11.8%, but at the last follow-up examination, only 2% of survivors were significantly disabled (modified Rankin score > 2). One (0.7%) patient died, and 17 patients experienced unexpected neurological deficits immediately after embolization. Five of these patients demonstrated near or total recovery during follow-up. The number of branches embolized was the only variable significantly related to neurological deficit (P < 0.017). The long-term rates of neurological deficits after embolization were 0, 5, 7, 10, and 18%, respectively, for AVM Grades I through V. Among 114 patients who underwent preoperative embolization, follow-up deficit rates of Grades I through V were 0, 5, 6, 6, and 25%, respectively. Long-term permanent deficits from embolization occurred in 8.6% of patients. CONCLUSION Endovascular treatment carries a procedural risk related to AVM grade and number of branches treated. This risk should be weighed carefully in the context of overall treatment morbidity and mortality.
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Affiliation(s)
- Louis J Kim
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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Kim LJ, Albuquerque FC, Spetzler RF, McDougall CG. POSTEMBOLIZATION NEUROLOGICAL DEFICITSIN CEREBRAL ARTERIOVENOUS MALFORMATIONS. Neurosurgery 2006. [DOI: 10.1227/01.neu.0000243283.60673.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Bristol RE, Albuquerque FC, McDougall CG. The evolution of endovascular treatment for intracranial arteriovenous malformations. Neurosurg Focus 2006; 20:E6. [PMID: 16819814 DOI: 10.3171/foc.2006.20.6.6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓ Endovascular therapy for arteriovenous malformations (AVMs) remains a relatively new approach. Beginning in the 1960s with the use of flow-directed techniques for selective embolization, hemodynamic alterations have been used to treat these lesions. In every aspect of treatment, technological advances, including catheters, embolic materials, angiography suites, and pharmacological agents, have improved outcomes while lowering the risk to patients.
In this article, the authors review the technical evolution of endovascular AVM therapy. Developments in embolic materials, beginning with foreign bodies and autografts and continuing through to highly engineered contemporary substances, are discussed. Finally, changes in treatment paradigms that have occurred over the years are traced. Within neurosurgery, this specialty has shown some of the fastest growth and development in recent decades. As minimally invasive approaches are embraced in all areas of medicine, it is clear that this treatment modality will continue to be refined.
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Affiliation(s)
- Ruth E Bristol
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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Siekmann R. Basics and Principles in the Application of Onyx LD Liquid Embolic System in the Endovascular Treatment of Cerebral Arteriovenous Malformations. Interv Neuroradiol 2005; 11:131-40. [PMID: 20584468 DOI: 10.1177/15910199050110s117] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2005] [Accepted: 07/20/2005] [Indexed: 11/16/2022] Open
Affiliation(s)
- R Siekmann
- Department of Neuroradiology, University of Giessen, Medical Center; Giessen, Germany -
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Abstract
The modern management of cerebral arteriovenous malformations (AVMs) is based on three therapeutic modalities: microneurosurgery, endovascular embolization, and stereotactic radiosurgery. Embolization facilitates subsequent radiosurgery by reducing the volume of the nidus, prepares the resection of surgically accessible AVMs, and immediately addresses the risks related to associated intra/extranidal aneurysms and arteriovenous fistulas. We discuss in this article the current state of AVM endovascular therapy.
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Affiliation(s)
- Philippe Gailloud
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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