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Netliukh A, Kobyletskyi O, Salo V, Prokopenko N, Sukhanov A. A complex approach to the treatment of arteriovenous IV-V degree malformations according to Spetzler‒Martin scale. Clinical case. UKRAINIAN INTERVENTIONAL NEURORADIOLOGY AND SURGERY 2023. [DOI: 10.26683/2786-4855-2022-3(41)-46-58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Four therapeutic approaches have been developed for the treatment of arteriovenous malformations (AVMs): microsurgery, radiosurgery, embolization, and conservative treatment. The lack of consensus regarding the choice of treatment method and the different specializations of the doctor who are onvolved to the patient with AVM often determine the wrong treatment strategy. We performed a prospective analysis of the results of AVM of the IV degree according to Spetzler‒Martin scale, 4–5 points on the Buffalo scale complex treatment, based on clinical and tomographic data after the use of partial endovascular embolization and radical microsurgical removal of the AVM node assisted by cell saving technology. According to cerebral angiography 4 months follow-up there is no visible AVM vessels, the malformation was completely resected.Treatment of large and giant AVMs (IV and V degrees according to the Spetzler‒Martin scale) requires tailored surgical treatment approache using endovascular, microsurgical and radiosurgical techniques, but in many cases without achieving a radical result. The use of cell saver technology is necessary to reduce the risks of intraoperative complications associated with blood loss during microsurgical intervention, and enables radical removal of the AVM and recovery of the patient. The role of cell saver technology is crucial in vascular microsurgical interventions, which are often accompanied by a significant volume of blood loss, ensuring rapid autologous hemotransfusion and restoration of circulating blood volume. Endovascular embolization is a necessary step to reduce the risks of intraoperative complications during microsurgical intervention, which, together with the use of cell saver technology, makes it possible to achieve radical AVM removal and patient recovery.
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Lak AM, Cerecedo-Lopez CD, Cha J, Aziz-Sultan MA, Frerichs KU, Gormley WB, Mekary RA, Du R, Patel NJ. Seizure Outcomes After Interventional Treatment in Cerebral Arteriovenous Malformation-Associated Epilepsy: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 160:e9-e22. [PMID: 35364673 DOI: 10.1016/j.wneu.2021.09.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/12/2021] [Accepted: 09/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Seizures are the second most common presenting symptom of cerebral arteriovenous malformations (AVMs). Evidence supporting different treatment modalities is continuously evolving and it remains unclear which modality offers better seizure outcomes. OBJECTIVE To compare various interventional treatment modalities (i.e., microsurgery, radiosurgery, endovascular embolization, or multimodality treatment), regarding outcomes in AVM-associated epilepsy. METHODS PubMed, Embase, and Web of Science were searched on December 31, 2020 for studies that evaluated outcomes in patients with AVM-associated epilepsy after undergoing different treatment modalities. Pooled analysis was performed using a random-effects model and stratified by different modalities. RESULTS Forty-nine studies including 2668 patients were included. Interventional management was associated with a 56.0% probability of seizure freedom and a 73.0% probability of seizure improvement. The probability of discontinuing antiepileptic drugs was estimated at 38.0%. The stratified analysis showed that microsurgery was associated with a higher probability of seizure freedom and seizure improvement than was radiosurgery, endovascular, or multimodality treatment. The probability of antiepileptic drug cessation was also higher after microsurgery compared with radiation therapy; however, only clinical but not statistical significance could be inferred because of the lack of comparative analyses. CONCLUSIONS Interventional management of AVM-related epilepsy was associated with seizure freedom and seizure improvement in 56% and 73% of cases. Microsurgery seemed to be associated with a higher incidence of seizure freedom and seizure improvement than did other modalities. Future well-designed comparative studies are needed to draw definitive conclusions regarding each modality.
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Affiliation(s)
- Asad M Lak
- Computational Neurosciences Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christian D Cerecedo-Lopez
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julia Cha
- Computational Neurosciences Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohammad Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kai U Frerichs
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - William B Gormley
- Computational Neurosciences Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rania A Mekary
- Computational Neurosciences Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Massachusetts, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nirav J Patel
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Uzunoglu I, Kızmazoglu C, Husemoglu RB, Gurkan G, Uzunoglu C, Atar M, Cakır V, Aydın HE, Sayın M, Yuceer N. Three-Dimensional Printing Assisted Preoperative Surgical Planning for Cerebral Arteriovenous Malformation. J Korean Neurosurg Soc 2021; 64:882-890. [PMID: 34689475 PMCID: PMC8590920 DOI: 10.3340/jkns.2021.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/19/2021] [Indexed: 11/27/2022] Open
Abstract
Objective The aim of this study to investigate the benefits of patient-based 3-dimensional (3D) cerebral arteriovenous malformation (AVM) models for preoperative surgical planning and education.
Methods Fifteen patients were operated on for AVMs between 2015 and 2019 with patient-based 3D models. Ten patients’ preoperative cranial angiogram screenings were evaluated preoperatively or perioperatively via patient-based 3D models. Two patients needed emergent surgical intervention; their models were solely designed based on their AVMs and used during the operation. However, the other patients who underwent elective surgery had the modeling starting from the skull base. These models were used both preoperatively and perioperatively. The benefits of patients arising from treatment with these models were evaluated via patient files and radiological data.
Results Fifteen patients (10 males and five females) between 16 and 66 years underwent surgery. The mean age of the patients was 40.0±14.72. The most frequent symptom patients observed were headaches. Four patients had intracranial bleeding; the symptom of admission was a loss of consciousness. Two patients (13.3%) belonged to Spetzler-Martin (SM) grade I, four (26.7%) belonged to SM grade II, eight (53.3%) belonged to SM grade III, and one (6.7%) belonged to SM grade IV. The mean operation duration was 3.44±0.47 hours. Three patients (20%) developed transient neurologic deficits postoperatively, whereas three other patients died (20%).
Conclusion Several technological innovations have emerged in recent years to reduce undesired outcomes and support the surgical team. For example, 3D models have been employed in various surgical procedures in the last decade. The routine usage of patient-based 3D models will not only support better surgical planning and practice, but it will also be useful in educating assistants and explaining the situation to the patient as well.
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Affiliation(s)
- Inan Uzunoglu
- Department of Neurosurgery, Katip Celebi Unıversity Ataturk Training and Research Hospital, Izmir, Turkey
| | - Ceren Kızmazoglu
- Department of Neurosurgery, Dokuz Eylül University School of Medicine, Izmir, Turkey
| | | | - Gokhan Gurkan
- Department of Neurosurgery, Katip Celebi Unıversity Ataturk Training and Research Hospital, Izmir, Turkey
| | - Cansu Uzunoglu
- Department of Neurological Intensive Care, Ege University School of Medicine, Izmir, Turkey
| | - Murat Atar
- Department of Neurosurgery, Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
| | - Volkan Cakır
- Department of Interventional Radiology, Tinaztepe University Galen Hospital, Izmir, Turkey
| | - Hasan Emre Aydın
- Department of Neurosurgery, Dumlupinar University Kutahya Evliya Celebi Training and Research Hospital, Kutahya, Turkey
| | - Murat Sayın
- Department of Neurosurgery, Katip Celebi Unıversity Ataturk Training and Research Hospital, Izmir, Turkey
| | - Nurullah Yuceer
- Department of Neurosurgery, Katip Celebi Unıversity Ataturk Training and Research Hospital, Izmir, Turkey
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Liu R, Zhan Y, Piao J, Yang Z, Wei Y, Liu P, Chen X, Jiang Y. Treatments of unruptured brain arteriovenous malformations: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e26352. [PMID: 34160402 PMCID: PMC8238300 DOI: 10.1097/md.0000000000026352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/10/2021] [Accepted: 05/28/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The best therapeutic option for unruptured brain arteriovenous malformations (bAVMs) patients is disputed. OBJECTIVE To assess the occurrence of obliteration and complications of patients with unruptured bAVMs after various treatments. METHODS A systematic literature search was performed in PubMed, EMBASE, Web of Science, and so on to identify studies fulfilling predefined inclusion criteria. Baseline, treatment, and outcomes data were extracted for statistical analysis. RESULTS We identified 28 eligible studies totaling 5852 patients. The obliteration rates were 98% in microsurgery group (95% confidence interval (CI): 96%-99%, I2 = 74.5%), 97% in surgery group (95%CI: 95%-99%, I2 = 18.3%), 87% in endovascular treatment group (95%CI: 80%-93%, I2 = 0.0%), and 68% in radiosurgery group (95%CI: 66%-69%, I2 = 92.0%). The stroke or death rates were 1% in microsurgery group (95%CI: 0%-2%, I2 = 0.0%), 0% in surgery group (95%CI: 0%-1%, I2 = 0.0%), 4% in endovascular treatment group (95%CI: 0%-8%, I2 = 85.8%), and 3% in radiosurgery group (95%CI: 3%-4%, I2 = 82.9%). In addition, the proportions of hemorrhage were 2% in microsurgery group (95%CI: 1%-4%, I2 = 0.0%), 23% in endovascular treatment group (95%CI: 7%-39%), and 12% in radiosurgery group (95%CI: 12%-13%, I2 = 99.2%). As to neurological deficit, the occurrence was 9% in microsurgery group (95%CI: 6%-11%, I2 = 94.1%), 20% in surgery group (95%CI: 13%-27%, I2 = 0.0%), 14% in endovascular treatment group (95%CI: 10%-18%, I2 = 64.0%), and 8% in radiosurgery group (95%CI: 7%-9%, I2 = 66.6%). CONCLUSIONS We found that microsurgery might provide lasting clinical benefits in some unruptured bAVMs patients for its high obliteration rates and low hemorrhage. These findings are helpful to provide a reference basis for neurosurgeons to choose the treatment of patients with unruptured bAVMs.
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Affiliation(s)
- Renjie Liu
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Yongle Zhan
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jianmin Piao
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Zhongxi Yang
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Yun Wei
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Pengcheng Liu
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Xuan Chen
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Yu Jiang
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Jean WC, Huynh T, Tai AX, Felbaum DR, Syed HR, Ngo HM. Outcome of Microsurgery for Arteriovenous Malformations in a Resource-Restricted Environment: Single-Surgeon Series from Vietnam. World Neurosurg 2019; 132:e66-e75. [PMID: 31518746 DOI: 10.1016/j.wneu.2019.08.256] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 08/30/2019] [Accepted: 08/31/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND The health care expenditure in Vietnam is equivalent to 1% of that in the United States. For most patients with brain arteriovenous malformations (AVM), surgery is the only available treatment modality. This study reports on the outcomes on AVM microsurgery in this resource-restricted environment. METHODS This is a prospectively collected, retrospectively analyzed case series of consecutive patients who underwent surgical resection of AVM by a single surgeon in Vietnam. All surgeries were performed in a 3-year period in Hanoi. The primary endpoints were obliteration of the AVM and surgical morbidity (modified Rankin Scale [mRS] > 1). RESULTS There were 86 patients and 62% presented with hemorrhage. Only 2 patients had preoperative embolization, and 47 patients (54%) had preoperative digital subtraction angiography. All patients underwent microsurgical resection of their AVM. Excluding the 4 patients who died, the AVM obliteration rate was 98%. The mean follow-up was 20.1 months. Before surgery, 36% of patients had at least some disability (mRS > 1). Postoperatively, this was reduced to 10% (McNemar P = 0.007). For the overall cohort, neurologic status was improved from initial encounter to final assessment (P = 0.001). Because of resource restrictions, some patients with hemorrhage experienced delays in treatment. There was no difference in outcome between patients who were admitted before or after 24 hours post ictus (P = 0.6). The days spent waiting for surgery did not correlate with final mRS in univariate regression (R2 = 0.01). CONCLUSIONS Notwithstanding the limitation in health care resources in Vietnam, surgery for AVMs was successful in eliminating the malformation, with obliteration rates and morbidity comparable with international standards.
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Affiliation(s)
- Walter C Jean
- Department of Neurosurgery, George Washington University, Washington, D.C., USA; Global Brainsurgery Initiative, Washington, D.C., USA.
| | - Trong Huynh
- Department of Neurosurgery, Viet Duc Hospital, Hanoi, Vietnam; Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Alexander X Tai
- Department of Neurosurgery, Georgetown University Hospital, Washington, D.C., USA
| | - Daniel R Felbaum
- Department of Neurosurgery, Georgetown University Hospital, Washington, D.C., USA; Global Brainsurgery Initiative, Washington, D.C., USA
| | - Hasan R Syed
- Global Brainsurgery Initiative, Washington, D.C., USA; Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Hung M Ngo
- Department of Neurosurgery, Viet Duc Hospital, Hanoi, Vietnam
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Diren F, Sencer S, Hakan T. Case Report of an Obstructive Hydrocephalus Caused by an Unruptured Mesencephalic Arteriovenous Malformation in a Boy and a Review of Literature. Open Neuroimag J 2018. [PMID: 29541280 PMCID: PMC5842379 DOI: 10.2174/1874440001812010010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective Arteriovenous malformation (AVM) is the most common form of intracranial vascular malformations in adults. Intracranial pediatric AVMs are rare. AVM located in the vicinity of the brain stem in children are even more rare. Case report This study reports a rare case of acute obstructive hydrocephalus following aqueductal stenosis caused by an unruptured grade IV perimesencephalic arteriovenous malformation. An 11-year-old boy admitted to the hospital with progressive headache, nausea and vomiting throughout a month. A Computerized Tomography (CT) showed an obstructive hydrocephaly. A Magnetic Resonance (MR) imaging revealed a mesencephalic AVM compressing the aqueduct. The patient deteriorated in hours and an emergency ventriculoperitoneal shunting was performed. He did well in the early postoperative period. AVM examined with Digital Subtraction Angiography (DSA) in detail for maintaining the definitive treatment by means of endovascular embolization, microsurgery and stereotactic radiosurgery; but the patient was lost to follow up. Conclusion A Pubmed search revealed 34 cases of hydrocephalus caused by an unruptured AVM in the literature, and only four cases were less than 18 years old with unruptured AVM locating in brain stem or posterior fossa. Although focal neurologic deficit, seizure and headache are the most common symptoms, acute neurologic deterioration due to hydrocephalus may be the presenting symptom in these cases. The decrease in intracranial pressure by changing the flow of cerebrospinal fluid (CSF) via an emergency ventriculoperitoneal (VP) shunting or Endoscopic Third Ventriculostomy (ETV) can be a lifesaving procedure that gives a chance for further treatment modalities.
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Affiliation(s)
- Furkan Diren
- International Kolon Hospital, Neurosurgery Clinic, İstanbul, Turkey
| | - Serra Sencer
- İstanbul University, İstanbul Medical School, Neuroradiology Department, İstanbul, Turkey
| | - Tayfun Hakan
- International Kolon Hospital, Neurosurgery Clinic, İstanbul, Turkey.,Okan University, Vocational School of Health Services, İstanbul, Turkey
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Cenzato M, Tartara F, D'Aliberti G, Bortolotti C, Cardinale F, Ligarotti G, Debernardi A, Fratianni A, Boccardi E, Stefini R, Zenga F, Boccaletti R, Lanterna A, Pavesi G, Ferroli P, Sturiale C, Ducati A, Cardia A, Piparo M, Valvassori L, Piano M. Unruptured Versus Ruptured AVMs: Outcome Analysis from a Multicentric Consecutive Series of 545 Surgically Treated Cases. World Neurosurg 2018; 110:e374-e382. [DOI: 10.1016/j.wneu.2017.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/30/2017] [Accepted: 11/02/2017] [Indexed: 10/18/2022]
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Yang H, Deng Z, Yang W, Liu K, Yao H, Tong X, Wu J, Zhao Y, Cao Y, Wang S. Predictive Factors of Postoperative Seizure for Pediatric Patients with Unruptured Arteriovenous Malformations. World Neurosurg 2017; 105:37-46. [DOI: 10.1016/j.wneu.2017.05.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 05/02/2017] [Accepted: 05/04/2017] [Indexed: 10/19/2022]
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