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Orscelik A, Musmar B, Matsukawa H, Ismail M, Elawady SS, Assad S, Cunningham C, Sowlat MM, Spiotta AM. Optimal Timing of Microsurgical Treatment for Ruptured Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2024:00006123-990000000-01230. [PMID: 38912816 DOI: 10.1227/neu.0000000000003043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/19/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The timing of microsurgical treatment (MST) for ruptured brain arteriovenous malformations (bAVM) is a contentious issue in the literature. This study aimed to investigate the impact of MST timing on outcomes in patients with ruptured bAVMs, considering MST with and without preoperative endovascular treatment (EVT). METHOD Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, a comprehensive search was conducted across multiple databases, yielding 15 studies meeting the inclusion criteria. The timing was defined as the duration from the rupture of bAVM to the MST. The patients were divided into 4 different groups based on MST timing: <48 hours, <1 week, <2 weeks, and <1 month. The primary outcome was favorable outcome defined as a modified Rankin Scale score of 0 to 2 or a Glasgow Outcome Scale score of 4 to 5 in the last clinical follow-up. Secondary outcomes included periprocedural mortality and complete excision. RESULTS MST time >48 hours were associated with a significantly higher favorable outcome rate (odds ratio: 9.71, 95% Cl: 3.09-30.57, P < .01) and a lower mortality rate (OR: 0.15, 95% Cl: 0.02-0.88, P = .04) compared with MST timing ≤48 hours. After exclusion of patients who underwent MST with preoperative EVT, MST time >48 hours had a significantly higher rate of favorable outcome (OR: 9.39, 95% CI: 2.53-34.89, P < .01). CONCLUSION This meta-analysis suggests that delayed surgical intervention beyond 48 hours may be associated with improved favorable outcomes in patients who underwent MST with and without preoperative EVT for ruptured bAVMs.
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Affiliation(s)
- Atakan Orscelik
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Basel Musmar
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Mustafa Ismail
- College of Medicine, University of Baghdad, Baghdad, Iraq
| | - Sameh Samir Elawady
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Salman Assad
- Department of Neurology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Conor Cunningham
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mohamed Mahdi Sowlat
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Zhang H, Han H, Ma L, Li R, Li Z, Li A, Yuan K, Zhu Q, Wang C, Zhang Y, Zhang H, Gao D, Guo G, Kang S, Ye X, Li Y, Sun S, Wang H, Hao Q, Chen Y, Wang R, Chen X, Zhao Y. A comprehensive analysis of patients with cerebral arteriovenous malformation with headache: assessment of risk factors and treatment effectiveness. J Headache Pain 2024; 25:72. [PMID: 38714978 PMCID: PMC11075233 DOI: 10.1186/s10194-024-01774-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 04/16/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Due to the high mortality and disability rate of intracranial hemorrhage, headache is not the main focus of research on cerebral arteriovenous malformation (AVM), so research on headaches in AVM is still scarce, and the clinical understanding is shallow. This study aims to delineate the risk factors associated with headaches in AVM and to compare the effectiveness of various intervention treatments versus conservative treatment in alleviating headache symptoms. METHODS This study conducted a retrospective analysis of AVMs who were treated in our institution from August 2011 to December 2021. Multivariable logistic regression analysis was employed to assess the risk factors for headaches in AVMs with unruptured, non-epileptic. Additionally, the effectiveness of different intervention treatments compared to conservative management in alleviating headaches was evaluated through propensity score matching (PSM). RESULTS A total of 946 patients were included in the analysis of risk factors for headaches. Multivariate logistic regression analysis identified that female (OR 1.532, 95% CI 1.173-2.001, p = 0.002), supply artery dilatation (OR 1.423, 95% CI 1.082-1.872, p = 0.012), and occipital lobe (OR 1.785, 95% CI 1.307-2.439, p < 0.001) as independent risk factors for the occurrence of headaches. There were 443 AVMs with headache symptoms. After propensity score matching, the microsurgery group (OR 7.27, 95% CI 2.82-18.7 p < 0.001), stereotactic radiosurgery group(OR 9.46, 95% CI 2.26-39.6, p = 0.002), and multimodality treatment group (OR 8.34 95% CI 2.87-24.3, p < 0.001) demonstrate significant headache relief compared to the conservative group. However, there was no significant difference between the embolization group (OR 2.24 95% CI 0.88-5.69, p = 0.091) and the conservative group. CONCLUSIONS This study identified potential risk factors for headaches in AVMs and found that microsurgery, stereotactic radiosurgery, and multimodal therapy had significant benefits in headache relief compared to conservative treatment. These findings provide important guidance for clinicians when developing treatment options that can help improve overall treatment outcomes and quality of life for patients.
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Affiliation(s)
- Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Ma
- Center for Cerebrovascular Research, University of California, San Francisco, CA, USA
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anqi Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qinghui Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chengzhuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yukun Zhang
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Hongwei Zhang
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Dezhi Gao
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Geng Guo
- Department of Emergency, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Shuai Kang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Shibin Sun
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qiang Hao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Rong Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Yuanli Zhao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Yindeedej V, Duangprasert G, Noiphithak R, Nimmannitya P, Punyarat P, Tantongtip D, Thamwongskul C. Bleeding pediatric AVM with negative pre-operative angiography: the first case report. Childs Nerv Syst 2023; 39:3327-3331. [PMID: 37380926 DOI: 10.1007/s00381-023-06055-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 06/22/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Pediatric arteriovenous malformation (pAVM) is one of the most common vascular entities in non-traumatic intracerebral hemorrhage (ICH) in children. To diagnose arteriovenous malformation (AVM), digital subtraction angiography (DSA) is the gold standard investigation because it can provide sufficient dynamic information about the AVM. In extremely rare occasions, angiography is unable to detect an AVM because the AVM is spontaneously occluded. All reported cases found by authors in the literature had already been diagnosed with AVM by angiography or other vascular studies before the AVM occlusion. CASE PRESENTATION We present a case of a 4-year-old girl who presented with left occipital ICH with atypical calcification. Based on history and investigation, pAVM was the most likely diagnosis. However, preoperative angiography was negative for pAVM and for shunting. Bleeding tumor was then suspected instead. After resection, pathological diagnosis confirmed pAVM. CONCLUSION Our case demonstrates that DSA, despite being considered the gold standard, cannot always diagnose pAVM. The mechanism of spontaneous AVM occlusion remains unknown.
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Affiliation(s)
- Vich Yindeedej
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand.
| | - Gahn Duangprasert
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Raywat Noiphithak
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Pree Nimmannitya
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Prachya Punyarat
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Dilok Tantongtip
- Division of Neurosurgery, Department of Surgery, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Chatchai Thamwongskul
- Department of Pathology, Thammasat University Hospital, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
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Mehta TI, Arun A, Heiberger C, Cognetti D, Ray TR, Amans MR, Fargen K, Huisman TAGM, Hui F. Venous Pathologies and Interventions of the Head. Semin Neurol 2023; 43:439-453. [PMID: 37562454 DOI: 10.1055/s-0043-1771512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Intracranial venous pathologies are a historically underrecognized group of disorders that can have a devastating impact on patients. Despite advancements in peripheral venous disorders and arterial neurointerventions, intracranial venous pathologies have received comparatively little attention. Understanding the anatomy, physiology, clinical relevance, and treatment options of intracranial venous pathologies is fundamental to evolving therapies and research priorities. This article provides an overview of major intracranial venous pathologies, the respective pathophysiologies, and treatment options.
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Affiliation(s)
- Tej Ishaan Mehta
- The United States Air Force Medical Corps, Falls Church, Virginia
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Anirudh Arun
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Caleb Heiberger
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - David Cognetti
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Tyler R Ray
- Department of Mechanical Engineering, University of Hawai'i at Mānoa, Honolulu, Hawaii
- Department of Cellular and Molecular Biology, John A. Burns School of Medicine, University of Hawai'i at Mānoa, Honolulu, Hawaii
| | - Matthew R Amans
- Department of Radiology, University of California San Francisco, San Francisco, California
- Department of Neurosurgery, University of California San Francisco, San Francisco, California
| | - Kyle Fargen
- Department of Neurosurgery, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
| | - Thierry A G M Huisman
- Department of Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Ferdinand Hui
- Department of Radiology, The Queen's Medical Center, Honolulu, Hawaii
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Barros G, Sen RD, McGrath M, Nistal D, Sekhar LN, Kim LJ, Levitt MR. Frailty predicts postoperative functional outcomes after microsurgical resection of ruptured brain arteriovenous malformations in older patients. World Neurosurg 2022; 164:e844-e851. [DOI: 10.1016/j.wneu.2022.05.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 10/18/2022]
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Parenrengi MA, Suryaningtyas W, Fauza J. Endovascular embolization for cases of 'hidden' pediatric cerebral arteriovenous malformations: A diagnostic & therapeutic challenge. Int J Surg Case Rep 2021; 86:106347. [PMID: 34481131 PMCID: PMC8416958 DOI: 10.1016/j.ijscr.2021.106347] [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: 06/17/2021] [Revised: 08/22/2021] [Accepted: 08/22/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Ruptured arteriovenous malformations (AVM) hold a larger proportion as the cause of spontaneous intracranial hemorrhage in children compared to those in adults. Although surgical excision still remains as the gold standard therapy for arteriovenous malformations, some smaller ones are reported to resolve from embolization alone. However, difficulty arises when small arteriovenous malformations are not detected on certain diagnostic modalities such as Computed Tomography Angiography (CTA), giving rise to false negatives, which may compromise appropriate management of patients. Endovascular embolization can be used as alternative options as diagnostic and therapy for invisible arteriovenous malformation in children. We report two cases of ruptured paediatrics arteriovenous malformations with a complication of hydrocephalus, managed with endovascular embolization and a cerebrospinal fluid diversionary procedure. CASE DESCRIPTION We report 2 case in from Dr. Soetomo academic general hospital in 2021, the first case was a fully conscious 6-year-old-female child with sudden left-sided weakness and severe headache in January, and the second case a 9-year-old female came with decreased consciousness in May. Both had evidence of intracerebral hemorrhage, intraventricular hemorrhage, and hydrocephalus on head radiological examination, but no visible vascular malformations on Computed Tomography Angiography. The first patient was treated with extra ventricular drainage initially, while the second case was not. Transfemoral cerebral angiography revealed small arteriovenous malformations in both patients, and both had successful endovascular embolization afterwards. The first case was shunt-free, while the second case had her drainage switched to ventriculoperitoneal shunt right after the embolization procedure. Both patients recovered fully without complications and sequelae, and were discharged afterwards. DISCUSSION Both patients did not undergo surgical resection of the arteriovenous malformations; the first case only underwent endovascular embolization, while the second case underwent embolization and ventriculoperitoneal shunting. The cases described here help highlight the irreplaceable role of Transfemoral Cerebral Angiography as a gold standard for cases for arteriovenous malformations compared to other modalities, such as Computed Tomography Angiography (CTA). Smaller arteriovenous malformations in paediatrics are reported to achieve complete radiological resolution, and cerebrospinal fluid diversion in hydrocephalic cases are not always performed. Several factors to be considered include initial consciousness and severity of neurological deficit, which were taken into account in the management of our patients. CONCLUSION Embolization procedures may be beneficial in some pediatric arteriovenous malformations, preferably in smaller ones that undetectable by angiography. Several factors such as the consciousness and neurological deficit upon initial presentation may help in the decision making of these cases.
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Affiliation(s)
- Muhammad Arifin Parenrengi
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr Soetomo Academic General Hospital, Indonesia.
| | - Wihasto Suryaningtyas
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr Soetomo Academic General Hospital, Indonesia.
| | - Joandre Fauza
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Dr Soetomo Academic General Hospital, Indonesia.
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Hunugundmath SM, Basu S, Zade B, Maiya V, Sharma R, Bhanage A, Vatyam S. The Outcomes of Radiosurgery for Arteriovenous Malformations—Experience of a Tertiary Cancer Center from India. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0041-1724464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Objectives This article assesses the treatment outcomes in the patients diagnosed with arteriovenous malformations (AVMs) treated with stereotactic radiosurgery.
Materials and Methods We retrospectively analyzed 30 patients diagnosed with AVM treated between 2010 and 2018.The median age at presentation was 30 years (range: 14–60 years). The median planning target volume (PTV) was 6.8 mL (range: 0.9–54 mL). The median dose prescribed was 18 Gy (range: 16–24 Gy). Modified radiosurgery-based AVM grading score was calculated for all the patients.
Results The median follow-up of the entire cohort was 60 months (range: 24–96 months). The obliteration rates for patients followed up for 3 and 5 years were 75 and 86.1%, respectively. Age (< 35 years; p = 0.007) and PTV (< 7 mL; p = 0.04), had better obliteration rates. Three patients had hemorrhage, from the AVM after irradiation. None of them were fatal.
Conclusion Stereotactic radiosurgery is a preferred noninvasive treatment modality with acceptable morbidity.
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Affiliation(s)
| | - Sumit Basu
- Ruby Hall Clinic, Pune, Maharashtra, India
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Bunevicius A, Joyner DA, Muttikkal TE, Ahn J, Sheehan J. Magnetic Resonance Perfusion Changes of Arteriovenous Malformations Treated with Stereotactic Radiosurgery. World Neurosurg 2020; 146:e1003-e1011. [PMID: 33227527 DOI: 10.1016/j.wneu.2020.11.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The latency period from stereotactic radiosurgery (SRS) to obliteration of arteriovenous malformations (AVM) requires continuous imaging surveillance. Magnetic resonance (MR) perfusion is promising for noninvasive monitoring of AVMs after SRS. We studied longitudinal MR perfusion changes of brain AVMs treated with SRS. METHODS Consecutive patients treated for brain AVMs using SRS who had MR perfusion imaging studies performed before and at least once after SRS were studied. We estimated ipsilateral/contralateral brain hemisphere ratios of MR perfusion indexes, including regional cerebral blood flow (rCBF) and relative cerebral blood volume (rCBV), in the AVM nidus, perinidal region, and remote anterior and posterior brain regions. RESULTS Eleven patients (6 women; median age, 21 years) underwent SRS (median prescription dose, 18 Gy; range, 12-20 Gy) for brain AVMs (median Spetzler-Martin grade 2 and median volume 4.6 mL). Before the SRS, rCBV and rCBF ratios were significantly higher in the AVM nidus compared with other investigated brain regions (P < 0.001). Median time from SRS to the first and last post-SRS MR perfusion studies was 8 and 35 months, respectively. There was a statically significant decrease of rCBV (P = 0.043) and rCBF (P = 0.036) ratios in the AVM nidus, but not other brain regions, during post-SRS follow-up. CONCLUSIONS There is a gradual decrease of rCBV and rCBF in the AVM nidus after SRS. MR perfusion imaging is promising for monitoring of hemodynamic changes of AVMs after SRS. Larger studies investigating clinical value of MR perfusion imaging for AVMs after SRS are warranted.
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Affiliation(s)
- Adomas Bunevicius
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - David A Joyner
- Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | | | - Jungeun Ahn
- School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.
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Di Bartolomeo A, Scafa AK, Giugliano M, Dugoni DE, Ruggeri AG, Delfini R. Ruptured Brain Arteriovenous Malformations: Surgical Timing and Outcomes-A Retrospective Study of 25 Cases. J Neurosci Rural Pract 2020; 12:4-11. [PMID: 33551615 PMCID: PMC7857959 DOI: 10.1055/s-0040-1716792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background One important problem in treatment of ruptured brain arteriovenous malformations (bAVMs) is surgical timing. The aim of the study was to understand which parameters affect surgical timing and outcomes the most. Materials and Methods Between January 2010 and December 2018, 25 patients underwent surgery for a ruptured bAVM at our institute. Intracerebral hemorrhage (ICH) score was used to evaluate hemorrhage severity, while Spetzler-Martin scale for AVM architecture. We divided patients in two groups: "early surgery" and "delayed surgery." The modified Rankin Scale (mRS) evaluated the outcomes. Results Eleven patients were in the "early surgery" group: age 38 ± 18 years, Glasgow Coma Scale (GCS) 7.64 ± 2.86, ICH score 2.82 ± 0.71, hematoma volume 45.55 ± 23.21 mL. Infratentorial origin of hemorrhage was found in 27.3% cases; AVM grades were I to II in 82%, III in 9%, and IV in 9% cases. Outcome at 3 months was favorable in 36.4% cases and in 54.5% after 1 year. Fourteen patients were in the "delayed surgery" group: age 41 ± 16 years, GCS 13.21 ± 2.39, ICH score 1.14 ± 0.81, hematoma volume 29.89 ± 21.33 mL. Infratentorial origin of hemorrhage was found in 14.2% cases; AVM grades were I to II in 50% and III in 50%. Outcome at 3 months was favorable in 78.6% cases and in 92.8% after 1 year. Conclusions The early outcome is influenced more by the ICH score, while the delayed outcome by Spetzler-Martin grading. These results suggest that it is better to perform surgery after a rest period, away from the hemorrhage when possible. Moreover, this study suggests how in young patient with a high ICH score and a low AVM grade, early surgery seems to be a valid and feasible therapeutic strategy.
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Affiliation(s)
- Alessandro Di Bartolomeo
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Anthony Kevin Scafa
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Marco Giugliano
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Demo Eugenio Dugoni
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Andrea Gennaro Ruggeri
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
| | - Roberto Delfini
- Department of Neurological Sciences, Neurosurgery, "La Sapienza" University of Rome, Rome, Italy
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LoPresti MA, Ravindra VM, Pyarali M, Goethe E, Gadgil N, Wagner K, Kan P, Lam S. Pediatric intracranial arteriovenous malformations: a single-center experience. J Neurosurg Pediatr 2020. [DOI: 10.3171/2019.9.peds19235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEIntracranial arteriovenous malformations (AVMs) are a common cause of intracranial hemorrhage in children. Exploring outcomes of treatment and factors that predict recurrence may help guide the management of pediatric AVMs. In this study, the authors review a single-center experience with pediatric AVMs, aiming to identify factors contributing to recurrence and areas for improvement in treatment.METHODSA single-center retrospective review of patients ages 0–18 years with AVMs in the period from 2005 to 2018 was conducted. Demographic, clinical, and radiographic data were collected and examined to compare the clinical and functional outcomes of patients managed with and those managed without open microsurgical resection.RESULTSOne hundred five patients were diagnosed and treated during the study period. Fifty (47.6%) had been treated surgically and 35 (33.3%) nonsurgically, and 20 (19%) had been treated primarily at an outside institution and thus were excluded from further analysis. Of the 50 treated surgically, 92% had complete obliteration on postoperative imaging, with the remaining patients having residual AVM and undergoing re-resection or SRS, ultimately resulting in a 96% radiographic cure rate. The surgically treated patients were followed up for an average of 3.34 years. Eighty-two percent had a modified Rankin Scale (mRS) score of 0–2. There was a recurrence rate of 12%, with the time to recurrence averaging 327.86 days (range 85–596 days). Of the 35 patients managed without open surgery, 77% underwent serial imaging surveillance, 20% underwent endovascular embolization, and 3% underwent stereotactic radiosurgery. Radiographic cure was seen in 6% of those treated nonsurgically, and all had undergone endovascular treatment alone. The nonsurgically treated patients were followed up for an average of 2.14 years. Eighty percent had an mRS score of 0–2.CONCLUSIONSThe data revealed that patients with lower-grade AVMs treated surgically and those with higher-grade AVMs managed without surgery have good functional and clinical outcomes. A high rate of recurrence was noted, and the possible contributing factors were explored. The authors encourage further study into mechanisms to reduce AVM recurrence in pediatric patients and look forward to advances in the medical management of lesions that are considered unresectable.
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Affiliation(s)
- Melissa A. LoPresti
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Vijay M. Ravindra
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Monika Pyarali
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Eric Goethe
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Nisha Gadgil
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Kathyrn Wagner
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Sandi Lam
- Division of Neurosurgery, Texas Children’s Hospital, Houston; and
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Tzikoulis V, Gkantaifi A, Alongi F, Tsoukalas N, Saraireh HH, Charalampakis N, Tzikoulis G, Andreou E, Tsapakidis K, Kardamakis D, Tsanadis K, Kyrgias G, Tolia M. Benign Intracranial Lesions - Radiotherapy: An Overview of Treatment Options, Indications and Therapeutic Results. Rev Recent Clin Trials 2019; 15:93-121. [PMID: 31713498 DOI: 10.2174/1574887114666191111100635] [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: 07/20/2019] [Revised: 10/14/2019] [Accepted: 10/26/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Radiation Therapy (RT) is an established treatment option for benign intracranial lesions. The aim of this study is to display an update on the role of RT concerning the most frequent benign brain lesions and tumors. METHODS Published articles about RT and meningiomas, Vestibular Schwannomas (VSs), Pituitary Adenomas (PAs), Arteriovenous Malformations (AVMs) and craniopharyngiomas were reviewed and extracted data were used. RESULTS In meningiomas RT is applied as an adjuvant therapy, in case of patientrefusing surgery or in unresectable tumors. The available techniques are External Beam RT (EBRT) and stereotactic ones such as Stereotactic Radiosurgery (SRS), Fractionated Stereotactic RT (FSRT), Intensity Modulated RT (IMRT) and proton-beam therapy. The same indications are considered in PAs, in which SRS and FSRT achieve excellent tumor control rate (92-100%), acceptable hormone remission rates (>50%) and decreased Adverse Radiation Effects (AREs). Upon tumor growth or neurological deterioration, RT emerges as alone or adjuvant treatment against VSs, with SRS, FSRT, EBRT or protonbeam therapy presenting excellent tumor control growth (>90%), facial nerve (84-100%), trigeminal nerve (74-99%) and hearing (>50%) preservation. SRS poses an effective treatment modality of certain AVMs, demonstrating a 3-year obliteration rate of 80%. Lastly, a combination of microsurgery and RT presents equal local control and 5-year survival rate (>90%) but improved toxicity profile compared to total resection in case of craniopharyngiomas. CONCLUSION RT comprises an effective treatment modality of benign brain and intracranial lesions. By minimizing its AREs with optimal use, RT projects as a potent tool against such diseases.
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Affiliation(s)
- Vasileios Tzikoulis
- School of Health Sciences, Faculty of Medicine, Biopolis, University of Thessaly, Larisa, 41500, Greece
| | - Areti Gkantaifi
- Radiotherapy Department, Interbalkan Medical Center, Thessaloniki, Greece
| | - Filippo Alongi
- Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Nikolaos Tsoukalas
- Oncology Department, Veterans Hospital (NIMTS), 10-12 Monis Petraki Str., 115 21, Athens, Greece
| | - Haytham Hamed Saraireh
- Radiation Oncology Department, Jordanian Royal Medical Services, King Hussein Medical Center, King Abdullah II St 230, Amman, Jordan
| | | | - Georgios Tzikoulis
- Department of Biochemistry and Biotechnology, University of Thessaly, Biopolis, 41500, Larisa, Greece
| | - Emmanouil Andreou
- School of Health Sciences, Faculty of Medicine, Biopolis, University of Thessaly, Larisa, 41500, Greece
| | - Konstantinos Tsapakidis
- Department of Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larisa, Greece
| | - Dimitrios Kardamakis
- Department of Radiation Oncology, Medical School, University of Patras, 265 04, Patra, Greece
| | - Konstantinos Tsanadis
- Department of Radiotherapy/Radiation Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larisa, Biopolis, 41500 Larisa, Greece
| | - George Kyrgias
- Department of Radiotherapy/Radiation Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larisa, Biopolis, 41500 Larisa, Greece
| | - Maria Tolia
- Department of Radiotherapy/Radiation Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larisa, Biopolis, 41500 Larisa, Greece
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Hasegawa T, Kato T, Naito T, Tanei T, Torii J, Ishii K, Tsukamoto E. Long-Term Outcomes for Pediatric Patients with Brain Arteriovenous Malformations Treated with Gamma Knife Radiosurgery, Part 1: Analysis of Nidus Obliteration Rates and Related Factors. World Neurosurg 2019; 126:e1518-e1525. [PMID: 30922904 DOI: 10.1016/j.wneu.2019.03.176] [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: 12/22/2018] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Little is known about long-term outcomes for pediatric brain arteriovenous malformations (AVMs) treated with Gamma Knife radiosurgery (GKRS). This study investigated annual hemorrhage rates and nidus obliteration rates, and the factors affecting them, in pediatric AVMs treated with GKRS. METHODS We examined 189 pediatric AVM patients (age ≤15 years) who underwent GKRS and had at least 12 months of follow-up. The Spetzler-Martin (S-M) grade was I in 29 patients (15%), II in 57 (30%), III in 82 (43%), IV in 16 (9%), and V in 5 (3%). The median treatment volume was 2.2 cm3, and the median marginal dose was 20 Gy. RESULTS The mean follow-up period was 136 months. During a cumulative latency period to nidus obliteration of 813 years, 23 hemorrhages occurred, resulting in an annual post-GKRS hemorrhage rate of 2.8%. The cumulative hemorrhage rates after GKRS were 3.3%, 8.5%, and 11.9% at 3, 5, and 10 years, respectively. Higher S-M grade was significantly associated with intracranial hemorrhages during the latency period (P < 0.001). The actuarial nidus obliteration rates with repeated GKRS were 64% and 81% at 5 and 10 years, respectively. Absence of pre-GKRS embolization (P = 0.023) and higher marginal dose (P = 0.029) were significant factors predicting nidus obliteration. CONCLUSIONS GKRS is a reasonable treatment option in pediatric AVMs to prevent future hemorrhages. Because higher S-M grade AVMs are more likely to hemorrhage during the latency period, a combined therapy with endovascular embolization should be considered to prevent AVM rupture.
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Affiliation(s)
- Toshinori Hasegawa
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan.
| | - Takenori Kato
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Takehiro Naito
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Takafumi Tanei
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Jun Torii
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Kazuki Ishii
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Eisuke Tsukamoto
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
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13
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Juszkat R, Żabicki B, Stanistawska K, Szepelak K, Kądziołka B, Sosnowski P, Kocięcki J. Eyelid arteriovenous malformation treated with pre-surgical embolization: A case report. Interv Neuroradiol 2018; 24:327-330. [PMID: 29359613 DOI: 10.1177/1591019917753711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Arteriovenous malformations are potentially serious vascular anomalies that are rarely encountered in the eyelid and require a multidisciplinary approach. Objectives We would like to describe the technical and clinical aspects related to the treatment of palpebral arteriovenous malformation with selective embolization, followed by surgical resection. Methods A 40-year-old patient presented with an isolated high-flow palpebral arteriovenous malformation. Transarterial embolization, using a liquid embolic agent (PHIL™), was performed in this patient. Results Angiographic and clinical follow-up revealed good results with clinical regression of the mass. Conclusion Although endovascular treatment of palpebral arteriovenous malformations is technically challenging, good functional and cosmetic result was achieved. Arteriovenous malformation embolization using PHIL™ seems to be very effective and makes subsequent surgical procedure safe and feasible. Level IV Evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
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Affiliation(s)
- Robert Juszkat
- 1 Department of General and Interventional Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Bartosz Żabicki
- 1 Department of General and Interventional Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Katarzyna Stanistawska
- 1 Department of General and Interventional Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Karolina Szepelak
- 1 Department of General and Interventional Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Bartosz Kądziołka
- 2 Department of Neurosurgery, John Paul II Western Hospital, Grodzisk Mazowiecki, Poland
| | - Piotr Sosnowski
- 1 Department of General and Interventional Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jarosław Kocięcki
- 3 Department of Ophthalmology, Poznan University of Medical Sciences, Poznan, Poland
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Sackey FNA, Pinsker NR, Baako BN. Highlights on Cerebral Arteriovenous Malformation Treatment Using Combined Embolization and Stereotactic Radiosurgery: Why Outcomes are Controversial? Cureus 2017; 9:e1266. [PMID: 28652950 PMCID: PMC5481174 DOI: 10.7759/cureus.1266] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 05/22/2017] [Indexed: 11/05/2022] Open
Abstract
Cerebral arteriovenous malformations (AVMs) are abnormal tangling between brain arteries and veins causing an arteriovenous shunt called nidus with an intervening network of vessels from the region of formation and spans through the brain. AVM effect is debilitating to the affected individual due to associated persistent intracerebral hemorrhage, resulting in significant occurrences of seizures and neurological damage. Recent innovative treatments involve a combination of embolization (Embo) procedures followed by stereotactic radiosurgery (SRS), designed to optimize less-invasive practice for the obliteration of the AVMs. Three groups of investigators reported different outcomes based on obliteration rates and adverse events, making the effectiveness of options for therapy, controversial. We have taken the case-oriented-approach to highlight on varying outcomes from various studies and provide insights as to why findings from different operation settings could be so conflicting. We chose 18 articles for systematic analysis based on initial electronic database selection of 40 key papers already identified for inclusion, followed by independent blinding assessment by two co-authors. Our evaluation was based first on our specific inclusion criteria, examining method quality, obliteration rates, serious adverse events (SAEs) and mortality rates. Second, we made a comparison between SRS or embo alone treatments versus combined embo/SRS procedures, relative to AVM sizes, following Spetzler-Martin (SM) method. Third, we considered publications which had concrete statistics with well-defined P-values and clarified outcomes for accurate evaluation. We found that patients with small to medium-sized AVM were susceptible to either embo alone or SRS alone treatments, yielding obliteration rates from 71%-100%. Except for one report, giant sizes AVMs were not amenable to these single treatments, subjecting patients to embo/SRS procedures, which yielded mixed results: One group reported 52%-65% obliteration rates, compared to 23%-28% embo alone treatment. A second group contradicted this apparent beneficial outcome, obtaining obliteration rates of 53% with combined treatment compared to 71% with SRS alone, four-year postoperative. A third group reported there was no difference between single and combined treatments and obtained complete obliteration of 70%-82%, ranging from three-five-years postoperative follow-up. In all the cases analyzed, obliteration rates improved with time. SAEs, such as persistent hemorrhage and permanent neurologic deficits (P-NDs), as well as mortality, were minimal during intraoperative and postoperative follow-ups. The problem of conflicting outcomes in combined treatments of AVM by EMBO/SRS exists. Previous investigators, however, have overlooked to address this issue satisfactorily. Our analysis found that the reported inconsistencies in AVM treatment outcomes are attributable to key factors making therapy unpredictable, which includes: the size of the AVM, nidus localization and accessibility of either Embo or radiation dose applied, certain Embo materials lowering obliteration rates by masking radioactive effect on the nidus during SRS and follow-up timing for obtaining obliteration rates determine the extent of obliteration. We have indicated critical factors which require consideration when planning strategies for treatment of AVM patients and have made suggestions of how to overcome such hurdles.
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Affiliation(s)
- Faustina N A Sackey
- Loeb Health Research Institute at Ottawa Hospital, University of Ottawa, Ontario, Canada
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Koçer N, Hanımoğlu H, Batur Ş, Kandemirli SG, Kızılkılıç O, Sanus Z, Öz B, Işlak C, Kaynar MY. Preliminary experience with precipitating hydrophobic injectable liquid in brain arteriovenous malformations. Diagn Interv Radiol 2017; 22:184-9. [PMID: 26782157 DOI: 10.5152/dir.2015.15283] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Advancement in microcatheter design and emergence of new embolic agents offer better results in endovascular treatment of brain arteriovenous malformations (AVMs). Precipitating hydrophobic injectable liquid (PHIL) (Microvention) is a newly introduced dimethyl sulfoxide-based embolic agent for endovascular use. Herein, we present three patients who underwent endovascular treatment of brain AVMs with PHIL, followed by surgical resection. Endovascular features and same-day surgical handling of the new embolic agent PHIL are presented along with histopathologic changes in the acute stage in brain AVMs are presented, and its major differences from Onyx. In our series, PHIL had moderate inflammatory reaction in the acute stage without any associated angionecrosis that is different than Onyx which cause mild inflammatory reaction with angionecrosis. Smallest vessel containing PHIL was 2.9 μm compared to 5 μm with Onyx, which suggests better penetration.
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Affiliation(s)
- Naci Koçer
- Division of Neuroradiology, the Department of Radiology, İstanbul University Cerrahpaşa School of Medicine, İstanbul, Turkey.
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Intervention for A randomized trial of unruptured brain arteriovenous malformations (ARUBA) - Eligible patients: An evidence-based review. Clin Neurol Neurosurg 2016; 150:133-138. [PMID: 27656780 DOI: 10.1016/j.clineuro.2016.09.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 11/21/2022]
Abstract
While intervention for ruptured arteriovenous malformations (AVMs) of the brain is typically warranted, the management of unruptured AVMs remains controversial. Despite numerous retrospective studies, only one randomized controlled trial has been conducted, comparing the role of medical management alone to medical management plus surgical and/or radiosurgical intervention in patients with unruptured AVMs: A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA). To great controversy, ARUBA concluded that medical management alone was superior to intervention for unruptured AVMs, which was subsequently challenged by various single-institution and multi-center studies analyzing outcomes of ARUBA-eligible patients. This review summarizes studies returned from a PubMed database search querying, 'ARUBA,' 'ARUBA-eligible,' 'surgery unruptured AVM,' and "radiosurgery unruptured AVM". The rates of the primary endpoint of symptomatic stroke or death were low among the analyzed studies (0-12.2%, mean 8.0%) and similar to the medically managed arm of ARUBA (10.1%). Likewise, the percentage of patients with impaired functional outcomes (modified Rankin score ≥2) in the reviewed studies was low (5.9%-13.1%; mean: 9.9%) and comparable to the 14.0% observed in the medically management arm of ARUBA. The key findings of ARUBA and subsequent work in its aftermath are overviewed and analyzed for the role of surgery and/or radiosurgery in patients with unruptured AVMs.
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17
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Herial NA, Khan AA, Sherr GT, Qureshi MH, Suri MFK, Qureshi AI. Detachable-Tip Microcatheters for Liquid Embolization of Brain Arteriovenous Malformations and Fistulas: A United States Single-Center Experience. Neurosurgery 2016; 11 Suppl 3:404-11; discussion 411. [PMID: 26083156 DOI: 10.1227/neu.0000000000000839] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The US Food and Drug Administration recently approved a detachable-tip microcatheter, the Apollo microcatheter (eV3, Inc, Irvine, California), to prevent catheter entrapment during embolization of brain arteriovenous malformations (AVMs) using liquid embolic systems. OBJECTIVE To report technical aspects and clinical results of cerebral embolizations with the Apollo microcatheter in 7 embolizations in 3 adult patients. METHODS A 62-year-old man presented with an AVM in the parieto-occipital region measuring 3.6 × 1.6 cm with major cortical feeders from the right middle cerebral artery (MCA) and minor contribution from the distal right anterior cerebral artery. Two pedicles originating from the MCA were embolized. A 48-year-old woman presented with a left frontal AVM measuring 3.3 × 1.8 cm with arterial feeders from the left MCA, left middle meningeal artery, and contralateral anterior cerebral artery. Three pedicles originating from the left MCA were embolized. A 76-year-old man presented with an arteriovenous fistula with multiple fistulous connections and feeders from both vertebral and occipital arteries and the left posterior cerebral artery draining into the left transverse, torcula, and left sigmoid sinus. Two major occipital artery feeders were embolized. RESULTS Seven Apollo microcatheters were used with the Onyx 18 liquid embolic system. The length of the detachable tip was 15 mm in 2 and 30 mm in 5 embolizations. The mean microcatheter in-position time within the pedicle was 20 minutes. Detachment of tip occurred in 3 instances. No limitations in accessing target arterial feeders and safe tip disengagement were noted despite prolonged injection times. CONCLUSION Our initial experience supports the feasibility, safety, and effectiveness of detachable-tip microcatheters in treating brain AVMs and arteriovenous fistulas.
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Affiliation(s)
- Nabeel A Herial
- *Zeenat Qureshi Stroke Institute and ‡Department of Neurosurgery, CentraCare Health, St. Cloud, Minnesota
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18
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Boone C, Caplan JM, Garzon-Muvdi T, Yang W, Ye X, Groves ML, Tamargo RJ, Ahn ES, Huang J. Hemorrhage Risk in Pediatric Patients with Multiple Intracranial Arteriovenous Malformations. Pediatr Neurosurg 2016; 51:175-82. [PMID: 27057753 DOI: 10.1159/000444286] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 01/21/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS This study aims to characterize the clinical features, treatment strategies, and annual hemorrhage incidence rate of pediatric patients with multiple arteriovenous malformations (MAVM). METHODS The PubMed and EMBASE databases and the arteriovenous malformations (AVM) database at the Johns Hopkins Hospital were searched for reports of pediatric patients (under 21 years of age) with MAVM. Data related to demographics, clinical features, management, and treatment outcomes were analyzed using descriptive statistics. Twenty-four pediatric patients met the inclusion criteria. RESULTS The annual hemorrhage incidence rate was 2.1%. The most common presenting features were neurological deficit (38%) and hemorrhage (21%). Treatment with embolization has become the most frequently used modality. In patients undergoing staged treatment of MAVM, hemorrhage of an untreated nidus (n = 1), visualization of a new nidus (n = 2), or disappearance of a draining vein (n = 1) occurred. CONCLUSION The annual hemorrhage incidence rate for pediatric patients with MAVM approaches the upper range of previously reported hemorrhage rates for solitary AVM. A staged approach to treating MAVM requires close follow-up as changes to the remaining nidi may occur during the latency period. Limitations of this study include its small sample size and reporting bias.
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Affiliation(s)
- Christine Boone
- Department of Neuroscience, Johns Hopkins School of Medicine, Baltimore, Md., USA
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19
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Boone CE, Caplan JM, Yang W, Ye X, Colby GP, Coon AL, Tamargo RJ, Huang J. Hemorrhage risk and clinical features of multiple intracranial arteriovenous malformations. J Clin Neurosci 2015; 23:51-57. [PMID: 26461910 DOI: 10.1016/j.jocn.2015.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Accepted: 07/19/2015] [Indexed: 11/29/2022]
Abstract
The aim of this report is to examine clinical characteristics, treatment strategies, and annual hemorrhage incidence rate for patients with multiple arteriovenous malformations (MAVM). The PubMed and EMBASE databases and the arteriovenous malformations (AVM) database at The Johns Hopkins Hospital were searched to identify patients with MAVM. Data related to demographics, clinical features, management, and treatment outcomes were analyzed with descriptive statistics. Thirty-eight patients met the inclusion criteria. The annual hemorrhage incidence rate was 6.7%. Surgical intervention remained the most common single-modality treatment from 1949-2011. Between 1990 and 2011, multiple-modality treatment strategies (36% of cases) were employed more frequently. The most common presenting features were neurological deficit (74%) and hemorrhage (63%). In patients undergoing staged treatment of MAVM, hemorrhage of an untreated nidus (n=5), visualization of a new nidus (n=9), and disappearance of an untreated nidus (n=2) were observed. Limitations of this study include small sample size and reporting bias. The annual hemorrhage incidence rate for MAVM patients was approximately two- to three-fold greater than the reported annual hemorrhage rates for solitary AVM. Combining different treatment modalities has become the most common management strategy. The potential instability of remaining nidi with staged or incomplete treatment necessitates close follow-up in these cases.
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Affiliation(s)
- Christine E Boone
- Department of Neuroscience, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins School of Medicine, 1800 Orleans Street, Zayed 6115F, Baltimore, MD 21287, USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins School of Medicine, 1800 Orleans Street, Zayed 6115F, Baltimore, MD 21287, USA
| | - Xiaobu Ye
- Department of Neurosurgery, Johns Hopkins School of Medicine, 1800 Orleans Street, Zayed 6115F, Baltimore, MD 21287, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, Johns Hopkins School of Medicine, 1800 Orleans Street, Zayed 6115F, Baltimore, MD 21287, USA
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins School of Medicine, 1800 Orleans Street, Zayed 6115F, Baltimore, MD 21287, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins School of Medicine, 1800 Orleans Street, Zayed 6115F, Baltimore, MD 21287, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins School of Medicine, 1800 Orleans Street, Zayed 6115F, Baltimore, MD 21287, USA.
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20
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Zhao Z, Johnson MS, Chen B, Grace M, Ukath J, Lee VS, McRobb LS, Sedger LM, Stoodley MA. Live-cell imaging to detect phosphatidylserine externalization in brain endothelial cells exposed to ionizing radiation: implications for the treatment of brain arteriovenous malformations. J Neurosurg 2015; 124:1780-7. [PMID: 26430846 DOI: 10.3171/2015.4.jns142129] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Stereotactic radiosurgery (SRS) is an established intervention for brain arteriovenous malformations (AVMs). The processes of AVM vessel occlusion after SRS are poorly understood. To improve SRS efficacy, it is important to understand the cellular response of blood vessels to radiation. The molecular changes on the surface of AVM endothelial cells after irradiation may also be used for vascular targeting. This study investigates radiation-induced externalization of phosphatidylserine (PS) on endothelial cells using live-cell imaging. METHODS An immortalized cell line generated from mouse brain endothelium, bEnd.3 cells, was cultured and irradiated at different radiation doses using a linear accelerator. PS externalization in the cells was subsequently visualized using polarity-sensitive indicator of viability and apoptosis (pSIVA)-IANBD, a polarity-sensitive probe. Live-cell imaging was used to monitor PS externalization in real time. The effects of radiation on the cell cycle of bEnd.3 cells were also examined by flow cytometry. RESULTS Ionizing radiation effects are dose dependent. Reduction in the cell proliferation rate was observed after exposure to 5 Gy radiation, whereas higher radiation doses (15 Gy and 25 Gy) totally inhibited proliferation. In comparison with cells treated with sham radiation, the irradiated cells showed distinct pseudopodial elongation with little or no spreading of the cell body. The percentages of pSIVA-positive cells were significantly higher (p = 0.04) 24 hours after treatment in the cultures that received 25- and 15-Gy doses of radiation. This effect was sustained until the end of the experiment (3 days). Radiation at 5 Gy did not induce significant PS externalization compared with the sham-radiation controls at any time points (p > 0.15). Flow cytometric analysis data indicate that irradiation induced growth arrest of bEnd.3 cells, with cells accumulating in the G2 phase of the cell cycle. CONCLUSIONS Ionizing radiation causes remarkable cellular changes in endothelial cells. Significant PS externalization is induced by radiation at doses of 15 Gy or higher, concomitant with a block in the cell cycle. Radiation-induced markers/targets may have high discriminating power to be harnessed in vascular targeting for AVM treatment.
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Affiliation(s)
- Zhenjun Zhao
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University
| | | | - Biyi Chen
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University
| | - Michael Grace
- Genesis Cancer Care, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Jaysree Ukath
- Genesis Cancer Care, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Vivienne S Lee
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University
| | - Lucinda S McRobb
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University
| | - Lisa M Sedger
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University
| | - Marcus A Stoodley
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University
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Walcott BP, Hattangadi-Gluth JA, Stapleton CJ, Ogilvy CS, Chapman PH, Loeffler JS. Proton beam stereotactic radiosurgery for pediatric cerebral arteriovenous malformations. Neurosurgery 2014; 74:367-73; discussion 374. [PMID: 24448188 DOI: 10.1227/neu.0000000000000294] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND For cerebral arteriovenous malformations (AVMs) determined to be high risk for surgery or endovascular embolization, stereotactic radiosurgery (SRS) is considered the mainstay of treatment. OBJECTIVE To determine the outcomes of pediatric patients with AVMs treated with proton SRS. METHODS We reviewed the records of 44 consecutively treated pediatric patients (younger than 18 years of age) who underwent proton SRS at our institution from 1998 to 2010. The median target volume was 4.5 ± 5.9 mL (range, 0.3-29.0 mL) and the median maximal diameter was 3.6 ± 1.5 cm (range, 1-6 cm). Radiation was administered with a median prescription dose of 15.50 ± 1.87 CGE to the 90% isodose. RESULTS At a median follow-up of 52 ± 25 months, 2 patients (4.5%) had no response, 24 patients (59.1%) had a partial response, and 18 patients (40.9%) experienced obliteration of their AVM. The median time to obliteration was 49 ± 26 months, including 17 patients who underwent repeat proton radiosurgery. Four patients (9%) experienced hemorrhage after treatment at a median time of 45 ± 15 months. Univariate analysis identified modified AVM scale score (P = .045), single fraction treatment (0.04), larger prescription dose (0.01), larger maximum dose (<0.001), and larger minimum dose (0.01) to be associated with AVM obliteration. CONCLUSION High-risk AVMs can be safely treated with proton radiosurgery in the pediatric population. Because protons deposit energy more selectively than photons, there is the potential benefit of protons to lower the probability of damage to healthy tissue in the developing brain.
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Affiliation(s)
- Brian P Walcott
- Departments of *Neurosurgery and ‡Radiation Oncology, §Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; ¶Department of Radiation Oncology, University of California San Diego, San Diego, California; ‖Department of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Caruso JP, Moosa S, Fezeu F, Ramesh A, Sheehan JP. A cost comparative study of Gamma Knife radiosurgery versus open surgery for intracranial pathology. J Clin Neurosci 2014; 22:184-8. [PMID: 25444994 DOI: 10.1016/j.jocn.2014.08.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 08/30/2014] [Indexed: 10/24/2022]
Abstract
Resection is the traditional treatment for common intracranial pathologies including brain metastases, arteriovenous malformations (AVM), and acoustic neuromas. However, more recently Gamma Knife radiosurgery (GKRS; Elekta AB, Stockholm, Sweden) has emerged as an effective, alternative treatment modality. There are limited data investigating the cost effectiveness of these two treatment modalities. In this study, we compare the costs of GKRS and open surgical excision. This was a retrospective study including all patients at a single-institution across a 3 year period with at least 12 months of post-resection follow-up for brain metastases, acoustic neuromas, or AVM. The costs of care were then totaled and compared to known average costs for GKRS at the same institution. The average 12 month costs of treating patients with brain metastases, acoustic neuromas, and AVM using open surgery were USD$55,938, $67,538, and $78,332, respectively. The average 12 month costs of treating brain metastases, acoustic neuromas, and AVM with GKRS were USD$23,069, $37,840, and $46,293, respectively. This shows that GKRS was on average 58.8%, 44.0%, and 40.9% of the cost of open surgery for brain metastases, acoustic neuromas, and AVM, respectively. GKRS is a cost effective, first-line, alternative to open surgery for treatment of brain metastatic lesions, acoustic neuromas, and AVM in selected patients. This result conforms to previous studies, which also demonstrate that radiosurgery is the more cost-effective treatment for brain metastases and acoustic neuromas when patients are well suited for either approach. Further prospective studies are needed to show that this result is valid at other institutions.
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Affiliation(s)
- James P Caruso
- Department of Neurological Surgery, University of Virginia Health System, P.O. Box 800212, Charlottesville, VA 22908, USA
| | - Shayan Moosa
- Department of Neurological Surgery, University of Virginia Health System, P.O. Box 800212, Charlottesville, VA 22908, USA
| | - Francis Fezeu
- Department of Neurological Surgery, University of Virginia Health System, P.O. Box 800212, Charlottesville, VA 22908, USA
| | - Arjun Ramesh
- Department of Neurological Surgery, University of Virginia Health System, P.O. Box 800212, Charlottesville, VA 22908, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, P.O. Box 800212, Charlottesville, VA 22908, USA; Department of Radiation Oncology, University of Virginia Health System, Charlottesville, VA, USA.
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23
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Zhao B, Cao Y, Zhao Y, Wu J, Wang S. Functional MRI-guided microsurgery of intracranial arteriovenous malformations: study protocol for a randomised controlled trial. BMJ Open 2014; 4:e006618. [PMID: 25341453 PMCID: PMC4208052 DOI: 10.1136/bmjopen-2014-006618] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Intracranial arteriovenous malformations (AVMs) are associated with high morbidity and mortality. Modern microsurgery has improved the results of surgical treatment of AVMs; however, the treatment of AVMs, particularly eloquently located AVMs, still carries a high risk. Functional MRI (fMRI) has been reported to be used for the preoperative evaluation of AVMs in small case series. The purpose is to identify the utility and efficacy of fMRI-guided microsurgery of AVMs in a large randomised controlled trial. METHODS AND ANALYSIS The study is a prospective, randomised controlled clinical trial. This study will enrol a total of 600 eligible patients. These eligible patients will be randomised to the standard microsurgery group and the fMRI-guided microsurgery group in a 1:1 ratio. Patient baseline characteristics and AVM architecture and characteristics will be described. In the fMRI-guided group, fMRI mapping of an eloquent cortex in all AVMs will be identified. Surgical complications and outcomes at pretreatment, post-treatment, at discharge and at 1-month, 3-month and 6-month follow-up intervals will be analysed using the modified Rankin Scale (mRS). This trial will determine whether fMRI-guided microsurgery could improve outcomes in patients with AVMs and also identify the safety and efficacy of fMRI-guided microsurgery. ETHICS AND DISSEMINATION The study protocol and written informed consent were reviewed and approved by the Institutional Review Board of Beijing Tiantan Hospital Affiliated to Capital Medical University (ky2012-016-02). Study findings will be disseminated in the printed media. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT01758211.
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Affiliation(s)
- Bing Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; Center of stroke, Beijing institute for brain disorders; Beijing Key Laboratory of Translational Medicine for Cerebraovascular Disease; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; Center of stroke, Beijing institute for brain disorders; Beijing Key Laboratory of Translational Medicine for Cerebraovascular Disease; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; Center of stroke, Beijing institute for brain disorders; Beijing Key Laboratory of Translational Medicine for Cerebraovascular Disease; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; Center of stroke, Beijing institute for brain disorders; Beijing Key Laboratory of Translational Medicine for Cerebraovascular Disease; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University; Center of stroke, Beijing institute for brain disorders; Beijing Key Laboratory of Translational Medicine for Cerebraovascular Disease; China National Clinical Research Center for Neurological Diseases, Beijing, China
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24
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Wang JY, Yang W, Ye X, Rigamonti D, Coon AL, Tamargo RJ, Huang J. Impact on Seizure Control of Surgical Resection or Radiosurgery for Cerebral Arteriovenous Malformations. Neurosurgery 2013; 73:648-55; discussion 655-6. [DOI: 10.1227/neu.0000000000000071] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Seizures are a common presenting symptom of arteriovenous malformations (AVMs). However, the impact of treatment modality on seizure control remains unclear.
OBJECTIVE:
To compare seizure control after surgical resection or radiosurgery for AVMs.
METHODS:
We analyzed retrospectively collected information for 378 patients with cerebral AVMs treated at our institution from 1990 to 2010. The application of strict inclusion criteria resulted in a study population of 164 patients.
RESULTS:
In our cohort, 31 patients (20.7%) had Spetzler-Martin grade I AVMs, 51 (34.0%) grade II, 47 (31.3%) grade III, 20 (13.3%) grade IV, and 1 (0.7%) grade V. Of the 49 patients (30%) presenting with seizures, 60.4% experienced seizure persistence after treatment. For these patients, radiosurgery was associated with seizure recurrence (odds ratio: 4.32, 95% confidence interval: 1.24-15.02, P = .021). AVM obliteration was predictive of seizure freedom at last follow-up (P = .002). In contrast, for patients presenting without seizures, 18.4% experienced de novo seizures after treatment, for which surgical resection was identified as an independent risk factor (hazard ratio: 8.65, 95% confidence interval: 3.05-24.5, P < .001).
CONCLUSION:
Although our data suggest that achieving seizure freedom should not be the primary goal of AVM treatment, surgical resection may result in improved seizure control compared with radiosurgery for patients who present with seizures. Conversely, in patients without presenting seizures, surgical resection increases the risk of new-onset seizures compared with radiosurgery, but primarily within the early posttreatment period. Surgical resection and radiosurgery result in divergent seizure control rates depending on seizure presentation.
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Affiliation(s)
- Joanna Y. Wang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xiaobu Ye
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniele Rigamonti
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander L. Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J. Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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25
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Strauss I, Frolov V, Buchbut D, Gonen L, Maimon S. Critical appraisal of endovascular treatment of brain arteriovenous malformation using Onyx in a series of 92 consecutive patients. Acta Neurochir (Wien) 2013; 155:611-7. [PMID: 23430232 DOI: 10.1007/s00701-013-1633-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 01/24/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND The introduction of Onyx has led us to adopt a new treatment approach for brain arteriovenous malformation (AVM), using endovascular embolization with Onyx as the first line treatment with a curative intent. The aim of the present report is to evaluate our results using this strategy, with special emphasis on angiographic characteristics affecting treatment risks and success rates. METHODS From October 2006 to December 2009, 92 consecutive patients harboring brain AVM were treated with Onyx during 177 procedures. RESULTS Endovascular treatments were completed in 68 out of 92 patients. Median number of procedures was two. Complete obliteration using embolization exclusively was achieved in 25 patients, resulting in a 37 % cure rate in patients who concluded treatments (25/68), and 27 % in the cohort. In Spetzler-Martin grades 1 & 2 AVMs, complete obliteration was achieved in 48 % of the cases. Complete obliteration rates were significantly higher in lesions with superficial big feeding arteries. There were 15 bleeding complications during 177 embolization sessions (8.4 % per procedure); seven cases resolved in less than 3 months. Permanent disability rate was 6.5 %; mortality rate was 2.2 %. Bleeding was related to the use of the microcatheter/guidewire in six cases and to the use of the embolization material in nine, the amount of Onyx injected was significantly higher in those nine cases. CONCLUSIONS Embolization of brain AVM using Onyx and detachable tip microcatheters results in a relatively high rate of complete obliteration. Angioarchitecture of the lesion can predict treatment success. Higher amounts of Onyx injected per session increase the bleeding risk.
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Kim JD, Crockett C, Diaz O, Lee AG, Miller NR. Down but not out. Surv Ophthalmol 2013; 58:644-51. [PMID: 23453400 DOI: 10.1016/j.survophthal.2012.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 09/28/2012] [Accepted: 10/02/2012] [Indexed: 12/01/2022]
Abstract
A 20-year-old Hispanic man with Down syndrome presented with progressively worsening headache, fluctuating decreased vision, and bilateral optic disk edema. Magnetic resonance imaging of the head showed an empty sella, and magnetic resonance venography showed thrombosis of left transverse and sigmoid sinuses. Catheter angiography angiogram showed a dural arteriovenous fistula in the wall of left transverse and sigmoid sinuses. The patient underwent Onyx endovascular embolization of the fistula, resulting in its angiographic obliteration, followed by resolution of his clinical signs and symptoms.
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Affiliation(s)
- James D Kim
- Department of Ophthalmology, The University of Texas Medical Branch, Galveston, Texas
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27
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Fareed MM, Amro AA, Bayoumi Y, Orz YI, Tunio M, Maklad A, Riaz K. LINAC Stereotactic Radiosurgery for brain arteriovenous malformation: a single institutional experience from Saudi Arabia. ACTA ACUST UNITED AC 2013. [DOI: 10.7243/2052-6946-1-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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28
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Abstract
Intracranial arteriovenous malformations (AVMs) are a common cause of stroke in younger patients, and often present as intracerebral hemorrhages (ICH), associated with 10 % to 30 % mortality. Patients who present with a hemorrhage from an AVM should be initially stabilized according to acute management guidelines for ICH. The characteristics of a lesion including its size, location in eloquent tissue, and high-risk features will influence risk of rupture, prognosis, as well as help guide management decisions. Given that rupture is associated with an increased risk of 6 % re-rupture in the year following the initial hemorrhage, versus 1 % to 3 % predicted annual risk in non-ruptured lesions only, definitive treatment is encouraged after ICH stabilization. A rest period of 2 to 6 weeks after hemorrhage is recommended before definitive treatment to avoid disrupting friable parenchyma and the hematoma. Treatment may consist of endovascular embolization, surgical resection, radiosurgery, or a combination of these three interventions based on the lesion.
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29
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Davies JM, Yanamadala V, Lawton MT. Comparative effectiveness of treatments for cerebral arteriovenous malformations: trends in nationwide outcomes from 2000 to 2009. Neurosurg Focus 2012; 33:E11. [DOI: 10.3171/2012.5.focus12107] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The development of multimodality approaches for the treatment of cerebral arteriovenous malformations (AVMs), including microsurgery, endovascular therapy, and radiosurgery, has shifted modern treatment paradigms in the last 10 years. This study examines these changes in detail from a nationwide perspective.
Methods
The authors examined data from 2001 to 2009 in the Nationwide Inpatient Sample (NIS) database, and they assessed the safety, quality, and cost-effectiveness, including the total number of discharges, discharge proportion, length of stay, and hospital charges. The authors also examined patient demographics (including age, sex, income level, and insurance), hemorrhage status at presentation, and trends in open surgical and endovascular treatment.
Results
A total of 33,997 inpatient admissions for patients with a primary diagnosis of intracranial AVM were identified, with a mean of 4191 patients admitted annually. The mean hospital charges increased 2-fold over the study period without significant differences in outcomes. There were substantial differences between surgical, endovascular, radiosurgical, and multimodality treatments. The proportion of AVMs treated microsurgically remained stable over this period, while the proportion treated endovascularly dramatically increased in size, and the data demonstrate important patient-level distinctions among groups. Outcomes and complication profiles were significantly different between treatment modalities and were impacted by age and hemorrhage status.
Conclusions
Charges associated with treatment of cerebral AVMs to the payer and society have increased dramatically over the first decade of the 21st century without clear improvements in quality parameters. However, analysis of the 3 primary treatment modalities has demonstrated differences and warrants further investigation to understand which patient population would benefit maximally from each. Unfortunately, with only imprecise measurements of quality in health care delivery, it remains imperative to develop national databases in which parameters, such as survival, functional outcomes, quality of life, and complication rates, can be assessed to examine the value of care delivered in a more meaningful way. Demonstrating an ever-increasing value of delivered health care will be imperative in our evolving health care system.
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Affiliation(s)
- Jason M. Davies
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
| | | | - Michael T. Lawton
- 1Department of Neurological Surgery, University of California, San Francisco, California; and
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