Endovascular management of arteriovenous malformations of the brain

Partial Endovascular Embolization of a Cerebral Arteriovenous Malformation in a Patient With Seizures Caused by a Steal Phenomenon: A Case Analysis

Cerebral arteriovenous malformations (cAVMs) are developmental pathologic lesions of the blood vessels of the brain in which multiple arteries shunt blood directly into the venous drainage network. They are lesions with an unclear etiology and, if left untreated, can bear significant risks of complications such as migraines, seizures, neurological deficits, and intracranial hemorrhages. The diagnosis is based on several imaging methods, with angiography being the primary method. Treatment modalities include microsurgery, radiosurgery, embolization with the intent of obliteration, and various multidisciplinary approaches. We aim to introduce the case of an adult female patient with symptomatic cAVM who underwent partial endovascular embolization of the lesion and evaluate her recovery and the overall reliability of her treatment modality. A 22-year-old female patient has presented to the Neurosurgery Clinic with clinical manifestations with photosensitive seizures, migraines, and a history of sleep disturbances persisting for a period of one year. An appointed MRI and angiography revealed the presence of a glomerular cAVM of the anterior parietal branch of the middle cerebral artery located within the intraparietal sulcus of the left cerebral hemisphere (Spetzler-Martin grade 2). The venous drainage of the malformation led to a loss of nutrients in the surrounding brain parenchyma (a steal phenomenon), causing the seizures. The patient successfully underwent transarterial endovascular embolization with Onyx, which proved to be partial on a postoperative angiography, and refused further embolization procedures. There were no postoperative complications to be mentioned. The patient reported no seizures or sleep disturbances at the 12-month follow-up, with sporadic weak headaches remaining. cAVMs remain a pathology with significant morbidity and mortality when undiagnosed. Symptomatic cAVMs leading to a steal phenomenon and seizures can be reliably managed via endovascular embolization alone when the malformation has an appropriate angioarchitecture, location, size, and a low Spetzler-Martin score. However, further inquiry is required into the use of partial embolization in cases where further multiple-stage embolization procedures are declined and/or complete occlusion of the lesion is unfeasible. This case report emphasizes that partial endovascular embolization can be successfully utilized as a treatment modality for the symptoms caused by a steal phenomenon of the venous drainage of a cAVM, such as seizure disorders and migraines, in the rare instance when multiple-stage embolization is declined by the patient and occlusion of the lesion remains subtotal.

Treatment of Brain Arteriovenous Malformations

Brain arteriovenous malformations (AVMs) are a rare entity of vascular anomalies, characteristic of anatomical shunting where arterial blood directly flows into the venous circulation. The main aim of the active treatment policy of brain AVMs is the prevention of haemorrhage. There are well-established treatment strategies that continually improve in their safety and efficacy, primarily due to the advances in imaging modalities, targeted and novel techniques, the development of alternative treatment approaches, and even better experience with the disease itself. There are interesting imaging novelties that may be prospectively applicable in the decision-making and planning of the most effective treatment approach for individual patients with intracranial AVM. Surgery is often considered the first-line treatment; however, each patient should be evaluated individually, and the risks of the active treatment policy should not overcome the benefits of the spontaneous natural history of the disease. All treatment modalities, i.e., surgery, radiosurgery, endovascular embolization, and observation, are justified but need to be meticulously selected for each individual patient in order to deliver the best treatment outcome. This chapter deals with historical and currently applied dogmas, followed by introductions of advances in each available treatment modality of AVM management.

Endovascular Treatment and Peri-interventional Management of Ruptured Cerebrovascular Lesions During Pregnancy : Case Series and Case-based Systematic Review

PURPOSE

Hemorrhagic stroke, particularly occurring from ruptured cerebrovascular malformations, is responsible for 5-12% of all maternal deaths during pregnancy and the puerperium. Whether endovascular treatment is feasible and safe for both the mother and the fetus, is still a matter of debate. The main objective of this case series and systematic review was to share our multi-institutional experience and to assess the feasibility and safety of endovascular treatment during pregnancy, as well as the corresponding maternal and fetal outcomes based on currently available evidence.

METHODS

We report a case series of 12 pregnant women presenting with hemorrhagic stroke from ruptured cerebrovascular arteriovenous malformations or aneurysms who underwent endovascular treatment prior to delivery. A systematic literature review of pregnant patients with endovascular treated cerebrovascular malformations, published between 1995 and 2022, was performed. Clinical patient information, detailed treatment strategies, maternal and fetal outcomes as well as information on the delivery were collected and assessed.

RESULTS

In most patients the course was uneventful and an excellent outcome without significant neurological deficits (mRS ≤ 1) was achieved. Furthermore, the maternal outcome was not worse compared to the general population who underwent endovascular treatment of ruptured vascular brain lesions. Also, in most cases a healthy fetus was born.

CONCLUSION

Endovascular treatment of ruptured cerebrovascular malformations during pregnancy is safe and feasible regarding both aspects, the maternal and fetal outcomes. Still, a stronger knowledge base is needed to correctly approach future cases of intracranial hemorrhage in the pregnant population.

An Approach for Cognitive Evaluation and Management of Grade 5 Arteriovenous Malformation-Associated Thalamic Dementia: A Case Report and Literature Review

The clinical approach to managing high-grade arteriovenous malformations (AVMs) has been challenging due to its various presentations, surgical risk of complications, and impact on patients' quality of life. We report a case of a 57-year-old female who experienced recurrent seizures and progressive cognitive decline secondary to a grade 5 cerebellar AVM. We reviewed the patient's presentation and clinical course. We also searched the literature for studies, reviews, and case reports involving the management of high-grade AVMs. We outline our recommendations on how to approach these cases after a review of the currently available treatment options.

Liquid Embolic Agents for Endovascular Embolization: A Review

Endovascular embolization (EE) has been used for the treatment of blood vessel abnormalities, including aneurysms, AVMs, tumors, etc. The aim of this process is to occlude the affected vessel using biocompatible embolic agents. Two types of embolic agents, solid and liquid, are used for endovascular embolization. Liquid embolic agents are usually injectable and delivered into the vascular malformation sites using a catheter guided by X-ray imaging (i.e., angiography). After injection, the liquid embolic agent transforms into a solid implant in situ based on a variety of mechanisms, including polymerization, precipitation, and cross-linking, through ionic or thermal process. Until now, several polymers have been designed successfully for the development of liquid embolic agents. Both natural and synthetic polymers have been used for this purpose. In this review, we discuss embolization procedures with liquid embolic agents in different clinical applications, as well as in pre-clinical research studies.

Microsurgery versus Microsurgery With Preoperative Embolization for Brain Arteriovenous Malformation Treatment: A Systematic Review and Meta-analysis

BACKGROUND

Preoperative embolization has traditionally been regarded as a safe and effective adjunct to microsurgical treatment of brain arteriovenous malformations (bAVM). However, there is currently no high-level evidence to ascertain this presumption.

OBJECTIVE

To compare the outcomes of microsurgery (MS) vs microsurgery with preoperative embolization (E + MS) in patients with bAVM through systematic review.

METHODS

We searched MEDLINE, PubMed, and Embase. The primary outcome was bAVM obliteration. Secondary outcomes were intraoperative bleeding (mL), complications, worsened modified Rankin Scale (mRS), and mortality. The pooled proportions of outcomes were calculated through the logit transformation method. The odds ratio (OR) of categorical data and mean difference of continuous data were estimated through the Mantel-Haenszel and the inverse variance methods, respectively.

RESULTS

Thirty-two studies met the eligibility criteria. One thousand eight hundred twenty-eight patients were treated by microsurgery alone, and 1088 were treated by microsurgery with preoperative embolization, respectively. The meta-analysis revealed no significant difference in AVM obliteration (94.1% vs 95.6%, OR = 1.15 [0.63-2.11], P = .65), mortality (1.7% vs 2%, OR = 0.88 [0.30-2.58], P = .82), procedural complications (18.2% vs 27.2%, OR = 0.47 [0.19-1.17], P = .10), worsened mRS (21.2% vs 18.5%, OR = 1.08 [0.33-3.54], P = .9), and intraoperative blood loss (mean difference = 182.89 [-87.76, 453.55], P = .19).

CONCLUSION

The meta-analysis showed no significant difference in AVM obliteration, mortality, complications, worse mRS, and intraoperative blood loss between MS and E + MS groups. For AVMs where MS alone has acceptable results, it is reasonable to bypass unnecessary preoperative embolization given higher postoperative complication risk.

Giant intracranial arteriovenous malformation as a possibility of epileptic seizures in a case of drowning

A male in his late 50s had been complaining of headaches and dizziness for 25 years. He also had episodes of losing consciousness, but had not sought treatment because of financial hardship. He was found in the ocean. Autopsy revealed foamy liquid leaking from his nose and mouth, and pleural effusions. The trachea and bronchi contained the same foamy liquid. The lungs were swollen and edematous, and leaked a large amount of foamy liquid. His cause of death was diagnosed as drowning. In the brain, the veins on the frontal lobe and the temporal pole, each on the right cerebral hemisphere, were dilated. A vascular lesion measuring 5 × 5 × 8 cm was found on the bottom of the right frontal lobe, and was located between the right middle cerebral artery and those veins. This vascular lesion extended to the brain parenchyma, and the basal ganglia of the right cerebrum was displaced outward and upward. The vascular lesions in the brain showed blood vessels of various sizes and shapes, and some of the vessel walls were thickened. The vascular lesion on the right frontal lobe was diagnosed as an arteriovenous malformation (AVM). According to the police investigation, the harbor where his body was found was a place he often came for fishing and walking. The possibility of suicide cannot be ruled out. Moreover, it was considered that his AVM might have rendered him unconscious, causing him to fall into the ocean.

Adaptive wireless millirobotic locomotion into distal vasculature

Microcatheters have enabled diverse minimally invasive endovascular operations and notable health benefits compared with open surgeries. However, with tortuous routes far from the arterial puncture site, the distal vascular regions remain challenging for safe catheter access. Therefore, we propose a wireless stent-shaped magnetic soft robot to be deployed, actively navigated, used for medical functions, and retrieved in the example M4 segment of the middle cerebral artery. We investigate shape-adaptively controlled locomotion in phantoms emulating the physiological conditions here, where the lumen diameter shrinks from 1.5 mm to 1 mm, the radius of curvature of the tortuous lumen gets as small as 3 mm, the lumen bifurcation angle goes up to 120^°, and the pulsatile flow speed reaches up to 26 cm/s. The robot can also withstand the flow when the magnetic actuation is turned off. These locomotion capabilities are confirmed in porcine arteries ex vivo. Furthermore, variants of the robot could release the tissue plasminogen activator on-demand locally for thrombolysis and function as flow diverters, initiating promising therapies towards acute ischemic stroke, aneurysm, arteriovenous malformation, dural arteriovenous fistulas, and brain tumors. These functions should facilitate the robot’s usage in new distal endovascular operations.

Accessibility into the distal vascular systems to treat various diseases remains challenging using medical catheters. Here, Wang et al. demonstrate that a stent-shaped wireless magnetic soft robot enables adaptive locomotion and medical functions into these distal vascular regions.

Preoperative embolisation of brain arteriovenous malformations: a systematic review and meta-analysis

Preoperative embolisation is a commonly performed adjunct to microsurgical excision of brain arteriovenous malformations (bAVMs), with aims such as lessening the technical difficulty of the microsurgical procedure, reducing operative time, decreasing blood loss, and improving patient functional outcomes. We aim to perform a systematic review of randomised trials and cohort studies evaluating preoperative embolisation of bAVMs published between 01 January 2000 and 31 March 2021 and appraise its role in clinical practice. A MEDLINE search was performed, and articles reporting on outcomes following preoperative embolisation, as an adjunct to microsurgery, were eligible for inclusion. PRISMA reporting and Cochrane Handbook guidelines were followed. The primary outcome measure was the risk of complications associated with preoperative embolisation. The study was registered with PROSPERO (CRD42021244231). Of the 1661 citations, 8 studies with 588 patients met predefined inclusion criteria. No studies specifically compared outcomes of surgical excision of bAVMs between those with and without preoperative embolisation. Spetzler Martin (SM) grading was available in 301 cases. 123 of 298 (41⋅28%) patients presented with haemorrhage. Complications related to embolisation occurred in 175/588 patients (29.4%, 95% CI 19.6–40.2). Permanent neurological deficits occurred in 36/541 (6%, 95% CI 3.9–8.5) and mortality in 6/588 (0.41%, 95% CI 0–1.4). This is the first systematic review evaluating preoperative embolisation of bAVMs. Existing studies assessing this intervention are of poor quality. Associated complication rates are significant. Based on published literature, there is currently insufficient evidence to recommend preoperative embolisation of AVMs. Further studies are required to ascertain if there are benefits of this procedure and if so, in which cases.

Comparison of embolization strategies for mixed plexiform and fistulous brain arteriovenous malformations: a computational model analysis of theoretical risks of nidus rupture

BACKGROUND

High-flow fistulas related to plexiform nidi are found in 40% of large brain arteriovenous malformations (AVMs). Endovascular occlusion of intranidal fistulas before plexiform components is empirically considered safe, but potential ensuing dangerous re-routing of flow through plexiform vessels may in theory raise their rupture risk. It remains unclear whether it is safer to embolize plexiform or fistulous vessels initially. We used a novel biomathematical AVM model to compare theoretical hemodynamic changes and rupture risks on sequential embolizations of both types of nidus vessels.

METHODS

We computationally modeled a theoretical AVM as an electrical circuit containing a nidus consisting of a massive stochastic network ensemble comprising 1000 vessels. We sampled and individually simulated 10 000 different nidus morphologies with a fistula angioarchitecturally isolated from its adjacent plexiform nidus. We used network analysis to calculate mean intravascular pressure (P_mean) and flow rate within each nidus vessel; and Monte Carlo analysis to assess overall risks of nidus rupture when simulating sequential occlusions of vessel types in all 10 000 nidi.

RESULTS

We consistently observed lower nidus rupture risks with initial fistula occlusion in different network morphologies. Intranidal fistula occlusion simultaneously reduced P_mean and flow rate within draining veins.

CONCLUSIONS

Initial occlusion of AVM fistulas theoretically reduces downstream draining vessel hypertension and lowers the risk of rupture of an adjoining plexiform nidus component. This mitigates the theoretical concern that fistula occlusion may cause dangerous redistribution of hemodynamic forces into plexiform nidus vessels, and supports a clinical strategy favoring AVM fistula occlusion before plexiform nidus embolization.

Cerebral abscess secondary to embolization of arteriovenous malformation: A case report and literature review

Background:

Infectious complications of the central nervous system secondary to endovascular procedures have rarely been reported. However, the number of complications has grown exponentially owing to the popularization of these procedures. The success rate of these procedures varies with the pathology, the patient, and surgical performance. Although brain abscesses have been extensively reported, their presence after endovascular procedures has not been described in detail in the literature. We present a case of brain abscess induced by embolization of an arteriovenous malformation (AVM), discuss the main indications, techniques, procedural complications, and review the associated literature.

Case Description:

A 13-year-old boy presented to us with a history of hemorrhagic stroke secondary to a cerebral AVM rupture. He underwent incomplete AVM resection (2014), with subsequent incomplete embolization (2017), and permanence of the endovenous catheter as a procedural complication. Physical examination revealed purulent exudate through the cervical surgical wound. We performed cervicotomy to remove the catheter but had no success in removing the intracranial material segment. The patient was subsequently diagnosed with a brain abscess (2018) and treated with antibiotics. Our team performed resection of the residual AVM, abscess, and the catheter-associated with the region.

Conclusion:

The patient showed significant clinical improvement after surgical resection of the malformation. No residual lesions were observed in the imaging examinations. Further, we reviewed the literature to find other cases of similar complications and their association with the endovascular procedure. We did not find complications in patients younger than the one presented in this case. Factors such as incomplete embolisation increase the risk of unfavourable outcomes.

Early period results of radiofrequency ablation and cyanoacrylate embolization for great saphenous vein insufficiency

OBJECTIVE

To evaluate the 6 months efficacy and safety of cyanoacrylate closure for the treatment of incompetent great saphenous veins (GSVs) in comparison with radiofrequency ablation (RFA).

METHODS

In this multicenter, retrospective, clinical trial, 398 symptomatic subjects with incompetent GSVs were assigned to either cyanoacrylate closure or RFA. The primary endpoint, complete closure of the target GSV, was determined using duplex ultrasound examination starting from one-, three-, and six-month visits.

RESULTS

All patients were followed for 6 months and there was no difference between the groups in terms of mean follow-up time. Hospital stay and return to work/activity were shorter in the cyanoacrylate ablation (CAA) group, and these differences between the groups were statistically significant. Ecchymosis was observed higher in the RFA group and was statistically significant.

CONCLUSIONS

In this study, in which we examined the CAA and RFA methods, we found that both methods were effective and reliable; however, we found that patients in the CAA group had a more comfortable postoperative period and returned to work earlier.

Safety of the APOLLO Onyx delivery microcatheter for embolization of brain arteriovenous malformations: results from a prospective post-market study

BACKGROUND

Catheter retention and difficulty in retrieval have been observed during embolization of brain arteriovenous malformations (bAVMs) with the Onyx liquid embolic system (Onyx). The Apollo Onyx delivery microcatheter (Apollo) is a single lumen catheter designed for controlled delivery of Onyx into the neurovasculature, with a detachable distal tip to aid catheter retrieval. This study evaluates the safety of the Apollo for delivery of Onyx during embolization of bAVMs.

METHODS

This was a prospective, non-randomized, single-arm, multicenter, post-market study of patients with a bAVM who underwent Onyx embolization with the Apollo between May 2015 and February 2018. The primary endpoint was any catheter-related adverse event (AE) at 30 days, such as unintentional tip detachment or malfunction with clinical sequelae, or retained catheter. Procedure-related AEs (untoward medical occurrence, disease, injury, or clinical signs) and serious AEs (life threatening illness or injury, permanent physiological impairment, hospitalization, or requiring intervention) were also recorded.

RESULTS

A total of 112 patients were enrolled (mean age 44.1±17.6 years, 56.3% men), and 201 Apollo devices were used in 142 embolization procedures. The mean Spetzler-Martin grade was 2.38. The primary endpoint was not observed (0/112, 0%). The catheter tip detached during 83 (58.5%) procedures, of which 2 (2.4%) were unintentional and did not result in clinical sequelae. At 30 days, procedure related AEs occurred in 26 (23.2%) patients, and procedure-related serious AEs in 12 (10.7%). At 12 months, there were 3 (2.7%) mortalities, including 2 (1.8%) neurological deaths, none of which were device-related.

CONCLUSION

This study demonstrates the safety of Apollo for Onyx embolization of bAVMs.

CLINICAL TRIAL REGISTRATION

CNCT02378883.

The First Successful Endovascular Management of Posterior Fossa Arteriovenous Malformations in Nepal: Case Series

Posterior fossa arteriovenous malformations represent 7-15% of all intracranial AVMs. They carry a higher risk of rupture than supratentorial AVMs and are associated with considerable rates of morbidity and mortality. Available treatment options include conservative management, microsurgical resection, radiosurgery, endovascular embolization, or combinations of these modalities. Recent advances in endovascular techniques have revolutionized their management with better clinical outcomes. We illustrate two cases of posterior fossa AVMs treated by endovascular techniques with good clinical outcomes. The first patient also had associated flow-related aneurysms. One of these aneurysms had already ruptured, so it was coiled first followed by AVM nidus embolization using the same microcatheter. The second patient had a diffuse type of posterior fossa AVM for which staged-embolization was planned and the first-stage partial embolization was successfully performed.

A comparison of dual-lumen balloon and simple microcatheters in the embolization of DAVFs and AVMs using onyx

Endovascular embolization of arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs) has become the mainstay in treatment for these pathologies. Traditional techniques required the formation of a proximal plug of Onyx around the microcatheter prior to embolization to avoid reflux. Recently, dual-lumen balloon catheters have been introduced as a potential solution to this issue. We sought to compare our institutional experience with dual-lumen balloons to traditional microcatheters in the endovascular embolization of AVMs and DAVFs. A retrospective analysis of consecutive patients treated with Scepter between 2016 and 2020 was obtained. A control cohort treated with Marathon between 2012 and 2020 was also obtained. Variables collected included patient demographics, procedure times, pedicles treated, operative complications, obliteration rate, and retreatment rate. A total of 44 trial (30 DAVFs and 14 AVMs) and 25 control (15 DAVFs and 10 AVMs) subjects were identified. Average Scepter procedure times were 66.0 and 68.0 min for DAVFs and AVMs, respectively. Average Scepter volume of Onyx injected was 2.2 and 1.4 mL for DAVFs and AVMs, respectively. Complete angiographic occlusion Scepter rate was 86.7% and 50.0% for DAVFs and AVMs, respectively. The Scepter retreatment rate was 13.3% and 50.0% for DAVFs and AVMs, respectively. Predictors of angiographic occlusion included the number of pedicles (OR 0.54, 95%CI 0.30-0.97, p = 0.04). Predictors of retreatment included DAVF (OR 0.16, 95%CI 0.04-0.66, p = 0.01) and Marathon (OR 3.34, 95%CI 1.00-11.56, p = 0.05). Our study shows that dual-lumen balloon catheters are a viable option in the embolization of DAVFs and AVMs.

Liquid embolic agent Fe3O4-EVOH for endovascular arteriovenous malformation embolisation: Preliminary evaluation in an in vivo swine rete mirabile model

AIM

Arteriovenous malformation (AVM) embolisation is in peril after the ARUBA trial. Advancements that are needed to reduce procedural risk are better control and visualisation during micro-catheter injection of liquid embolic material. The injectability, radiographic visualisation, mechanical stability and biocompatibility of the embolic agent Fe₃O₄-EVOH was evaluated in an in vivo swine AVM model.

METHODS

The swine AVM model is the rete mirabile (RM). Nine swine AVM models were embolised with the embolic agent Fe₃O₄-EVOH by using a 1.5 F micro-catheter. Procedure times, embolisation success (defined as complete embolisation of the nidus), volume of embolic agent and histopathology were assessed.

RESULTS

Six swine underwent embolisation of one side rete, and three underwent embolisation of both sides. We did not experience any technical complication during embolisation of each rete. The micro-catheter was easy to retrieve. Fluoroscopic visualisation of the Fe₃O₄-EVOH cast was adequate. The mean embolisation time for each RM was 7.5 minutes. The median volume of the embolic agent for each RM was 0.52 mL. At one, four and eight weeks following injection, microscopic and histological analysis demonstrated minimal inflammatory changes in the perivascular tissues and permanent occlusion of the embolised vasculature.

CONCLUSION

Fe₃O₄-EVOH embolic agent is an effective endovascular occlusion material, providing the initial in vivo characteristics of stability and biocompatibility.

Anesthetic Management of Awake Craniotomy for Resection of the Language and Motor Cortex Vascular Malformations

BACKGROUND

Although the safety and feasibility of awake craniotomy are well established for epilepsy and brain tumor surgery, its application for resection of vascular lesions, including arteriovenous malformations (AVMs) and cavernomas, is still limited. Apart from the usual challenges of awake craniotomy, vascular lesions pose several additional problems. Our goal is to determine the safety and practicality of awake craniotomy in patients with cerebral vascular malformations located near the eloquent areas, using a refined anesthetic protocol.

METHODS

A retrospective case series was performed on 7 patients who underwent awake craniotomy for resection of AVMs or cavernomas located in the eloquent language and motor areas. Our protocol consisted of achieving deep sedation, without a definitive airway, using a combination of propofol, dexmedetomidine, and remifentanil/fentanyl during scalp block placement and surgical exposure, then transitioning to a wakeful state during the resection.

RESULTS

Six patients had intracranial AVMs, and 1 patient had a cavernoma. Six patients had complete resection; however, 1 patient underwent repeat awake craniotomy for residual AVM nidus. The patients tolerated the resection under continuous awake neurologic and neurophysiologic testing without significant perioperative complications or the need to convert to general anesthesia with a definitive airway.

CONCLUSIONS

Awake craniotomy for excision of intracranial vascular malformations located near the eloquent areas, in carefully selected patients, can facilitate resection by allowing close neuromonitoring and direct functional assessment. A balanced combination of sedative and analgesic medications can provide both adequate sedation and rapid wakeup, facilitating the necessary patient interaction and tolerance of the procedure.

Three-year follow-up results of the prospective European Multicenter Cohort Study on Cyanoacrylate Embolization for treatment of refluxing great saphenous veins

OBJECTIVE

Cyanoacrylate closure of refluxing saphenous veins has demonstrated excellent safety and effectiveness results in feasibility and pivotal studies. This article provides the 36-month follow-up results of a prospective, multicenter, nonrandomized cohort study.

METHODS

A total of 70 patients were enrolled in a prospective, multicenter study conducted at seven centers in four European countries and underwent treatment of a solitary refluxing great saphenous vein with endovenous cyanoacrylate embolization without the use of tumescent anesthesia or postprocedure compression stockings. The primary effectiveness end point was freedom from recanalization (closure rate) of the great saphenous vein at 6 months. Safety was assessed by occurrence of adverse events after the procedure and during the 6-month follow-up period. Quality of life and clinical improvement parameters were measured before and after the procedure and through a 12-month follow-up period. Anatomic success and clinical improvement were assessed through 36 months after the procedure.

RESULTS

Of 70 treated patients, 64 (91%) were available for the 3-year follow-up. The closure rates by Kaplan-Meier life table methods at 6-, 12-, 24-, and 36-month time points were 91.4%, 90.0%, 88.5%, and 88.5%, respectively. Through 36 months, the improvement in change of the mean venous clinical severity score over time was statistically significant by dropping from 4.3 at baseline to 0.9 at the 36-month follow-up (P < .001).

CONCLUSIONS

The 3-year follow-up results of the prospective, multicenter eSCOPE study demonstrated the continued anatomic and clinical effectiveness of cyanoacrylate embolization over an extended follow-up period.

SPOT REGION OF INTEREST IMAGING: A NOVEL FUNCTIONALITY AIMED AT X-RAY DOSE REDUCTION IN NEUROINTERVENTIONAL PROCEDURES

AIM OF THE STUDY

The aim of this study was to describe a new functionality aimed at X-ray dose reduction, referred to as spot region of interest (Spot ROI) and to compare it with existing dose-saving functionalities, spot fluoroscopy (Spot F), and conventional collimation (CC).

MATERIAL AND METHODS

Dose area product, air kerma, and peak skin dose were measured for Spot ROI, Spot F, and CC in three different fields of view (FOVs) 20 × 20 cm, 15 × 15 cm, and 11 × 11 cm using an anthropomorphic head phantom RS-230T. The exposure sequence was 5 min of pulsed fluoroscopy (7.5 pulses per s) followed by 7× digital subtraction angiography (DSA) runs with 30 frames per DSA acquisition (3 fps × 10 s). The collimation in Spot F and CC was adjusted such that the size of the anatomical area exposed was as large as the Spot ROI area in each FOV.

RESULTS

The results for all FOVs were the following: for the fluoroscopy, all measured parameters for Spot ROI and Spot F were lower than corresponding values for CC. For DSA and DSA plus fluoroscopy, all measured parameters for Spot ROI were lower than corresponding parameters for Spot F and CC.

CONCLUSION

Spot ROI is a promising dose-saving technology that can be applied in fluoroscopy and acquisition. The biggest benefit of Spot ROI is its ability to keep the entire FOV information always visible.

A combined single-stage procedure to treat brain AVM

Complete resection of brain arteriovenous malformation (AVM) is a surgical challenge, mainly due to risk of intraoperative rupture. The objective of this feasibility study was to analyze complete resection rate at 3 months and clinical outcome at 6 months after treatment of brain AVM by combined single-stage embolization and surgical resection. A retrospective observational study from July 2015 to February 2019 was conducted at the Department of Neurosurgery of Strasbourg University Hospital, France. Decision to treat was taken on the basis of history of AVM rupture, symptomatic AVM, or morphologic risk factors for rupture. Complete resection rate was assessed on postoperative cerebral subtraction angiography at 3 months and clinical outcome at 6 months was evaluated on the modified Rankin Scale (mRS). In the 16 patients treated for symptomatic brain AVM, the rate of complete resection was 75%, resection with residual shunt 18.7%, and incomplete resection with residual nidus 6.3%. Good clinical outcome (mRS=0 or 1) was achieved in 81.3% of patients at 6 months. The transfusion rate was 7.1%. There were procedural complications in 12.5% of patients but no intraoperative ruptures. This combined single-stage procedure allows extensive preoperative embolization of the AVM, facilitating surgical microdissection by identifying the dissection plane and perforating arteries and allowing the operator to work in close contact with the nidus without fear of intraoperative rupture.

Pre-Surgical Endovascular Proximal Feeder Artery Devascularization Technique for the Treatment of Cranial Arteriovenous Malformations

Objective

Treatment of brain arteriovenous malformations (AVMs) aims to abolish any risk for intracranial hemorrhage with the preservation of the patient’s functional status. We present the technique of pre-surgical endovascular devascularization through proximal feeder artery occlusion for the treatment of cranial AVMs rather than nidus occlusion. Also, we highlight the advantages and the possible clinical indications.

Patients and Methods

Two patients with brain AVM and one patient with scalp AVM were treated by pre-surgical endovascular devascularization followed by surgical resection. Endovascular devascularization was performed by occlusion of the AVM feeders only with Liquid Embolic System Agent (Onyx^®) 18 without entering and filling the nidus. During surgery, feeding arteries colored with the black color of the Liquid Embolic System Agent were clearly identified and cut. Dissection of the AVM was performed, and resection of the nidus was achieved.

Results

Total resection of the AVM was achieved in all cases confirmed with follow-up angiographies, with no neurologic or systemic complications. Also, no major bleeding was detected. In addition, the surgical clips were avoided during surgery. Brain AVMs were safely resected in piecemeal fashion.

Conclusion

Pre-surgical endovascular proximal feeder artery devascularization technique shows to be a safe, simple and effective technique for the management of cranial arteriovenous malformations. This technique simplifies both the endovascular and surgical approaches to complicated cranial AVM cases.

Cerebral Abscess After Onyx Embolization of an Arteriovenous Malformation

BACKGROUND

Endovascular embolization is being increasingly used to treat cerebral arteriovenous malformations. Common complications associated with embolization include intracranial hemorrhage and ischemic stroke; intracranial infections seldomly occur and are even less frequently reported. Although abscess formation after embolization is exceedingly rare, it is a serious condition that warrants immediate attention.

CASE DESCRIPTION

This 53-year-old male with a ruptured left temporal-occipital arteriovenous malformation. He underwent uncomplicated 2-stage embolization with Onyx and was discharged. Five weeks after embolization, he returned to the hospital with worsening aphasia and contralateral hemiparesis, and a cerebral abscess was detected at the site of embolization. Bacterial cultures were positive for Escherichia coli, and he was treated successfully with surgical excision of the abscess and Onyx material, followed by long-term antibiotics.

CONCLUSIONS

Although rare, formation of an intracranial abscess after endovascular embolization is a potential complication in the treatment of arteriovenous malformations.

What is the best therapeutic approach to a pediatric patient with a deep-seated brain AVM?

Although brain arteriovenous malformations (bAVMs) account for a very small proportion of cerebral pathologies in the pediatric population, they are the cause of roughly 50% of spontaneous intracranial hemorrhages. Pediatric bAVMs tend to rupture more frequently and seem to have higher recurrence rates than bAVMs in adults. Thus, the management of pediatric bAVMs is particularly challenging. In general, the treatment options are conservative treatment, microsurgery, endovascular therapy (EVT), gamma knife radiosurgery (GKRS), proton-beam stereotactic radiosurgery (PSRS), or a combination of the above. In order to identify the best approach to deep-seated pediatric bAVMs, we performed a systematic review, according to the PRISMA guidelines. None of the options seem to offer a clear advantage over the others when used alone. Microsurgery provides the highest obliteration rate, but has higher incidence of neurological complications. EVT may play a role when used as adjuvant therapy, but as a stand-alone therapy, the efficacy is low and the long-term side effects of radiation from the multiple sessions required in deep-seated pediatric bAVMs are still unknown. GKRS has a low risk of complication, but the obliteration rates still leave much to be desired. Finally, PSRS offers promising results with a more accurate radiation that avoids the surrounding tissue, but data is limited due to its recent introduction. Overall, a multi-modal approach, or even an active surveillance, might be the most suitable when facing deep-seated bAVM, considering the difficulty of their management and the high risk of complications in the pediatric population.

Liquid Embolic Agents in Spectral X-Ray Photon-Counting Computed Tomography using Tantalum K-Edge Imaging

The aim was to evaluate the potential of Spectral Photon-Counting Computed Tomography (SPCCT) to differentiate between liquid embolic agents and iodinated contrast medium by using tantalum-characteristic K-edge imaging. Tubes with a concentration series of tantalum and inserts with different concentrations of iodine were scanned with a preclinical SPCCT system. Tantalum density maps (TDM) and iodine density maps (IDM) were generated from a SPCCT acquisition. Furthermore, region-of-interest (ROI) analysis was performed within the tubes in the conventional CT, the TDM and IDM. TDM and IDM enable clear differentiation between both substances. Quantitative measurements of different tantalum concentrations match well with those of actually diluted mixtures. SPCCT allows for differentiation between tantalum and iodine and may enable for an improved follow-up diagnosis in patients after vascular occlusion therapy.

A Retrospective Cohort Analysis of Hemorrhagic Arteriovenous Malformations Treated with Combined Endovascular Embolization and Gamma Knife Stereotactic Radiosurgery

BACKGROUND

The management of brain arteriovenous malformations (AVMs) remains a controversial topic. Given the relatively low incidence, high heterogeneity, and high morbidity and mortality of these lesions, consensus on treatment strategies is an issue of concern to organized neurosurgery. The present retrospective analysis examined and quantified the outcomes of patients with an initial presentation of intracranial hemorrhage from a Spetzler-Martin grade III or IV AVM, later ruled out as surgical candidates.

METHODS

A total of 16 patients (5 females; 11 males) had presented with symptomatic hemorrhage confirmed by non-contrast-enhanced computed tomography and were deemed to not be surgical candidates owing to AVM location and/or architecture. The patients underwent combined endovascular embolization and gamma knife stereotactic radiosurgery (SRS). The modified Rankin scale was used to measure the clinical outcomes, comparing the scores at presentation, gamma knife treatment, and the last known follow-up examination. A radiographic evaluation was used to determine the level of AVM nidus involution after the procedure.

RESULTS

The present study identified 16 patients with ruptured high-grade AVMs of high surgical risk. All the patients had undergone immediate embolization with delayed SRS for treatment of the hemorrhage and nidus of the AVM. A statistically significant proportion of patients showed marked improvement in the modified Rankin scale scores. No subsequent repeat hemorrhage or any associated complications after embolization occurred in any patient.

CONCLUSION

These findings warrant consideration of endovascular embolization with adjuvant SRS as a powerful treatment option for cases with high surgical morbidity due to AVM characteristics.

Initial experience with precipitating hydrophobic injectable liquid in cerebral arteriovenous malformations

BACKGROUND

Precipitating hydrophobic injectable liquid is a newly introduced liquid embolic agent for endovascular embolization with some technical advantages over other liquid embolic agents. We present our initial experience with precipitating hydrophobic injectable liquid in the endovascular treatment of cerebral arteriovenous malformations.

METHODS

From October 2015 to January 2018, 27 patients harboring cerebral arteriovenous malformations underwent endovascular embolization with precipitating hydrophobic injectable liquid 25. Clinical features, angiographic results, procedural details, complications, and follow-up details were retrospectively analyzed.

RESULTS

Twenty-seven patients with cerebral arteriovenous malformations were included. Total obliteration in one endovascular session was confirmed for 14/27 (52%) patients. Partial embolization was attained in 13 patients (48%) in whom staged treatment with following radiosurgery or surgery was planned. No mortality was recorded in this series. Complications during or after the embolization occurred in six of 27 (22.2%) patients.

CONCLUSION

In our initial experience, precipitating hydrophobic injectable liquid has acceptable clinical outcome comparable to other liquid embolic agents. Although this is the largest reported study in arteriovenous malformation treatment with precipitating hydrophobic injectable liquid, further studies are needed to validate its safety and efficacy.

Endovascular treatment of small cerebral arteriovenous malformations as a primary therapy

Purpose

The patient population that would benefit most from endovascular curative treatment of intracranial arteriovenous malformations is not clearly established. The aim of the study was to determine the effect of curative embolization of cerebral arteriovenous malformations with special regard to radiographic and clinical outcomes and procedure-related complications.

Material and methods

Between January 2009 and December 2014, 18 patients with intracranial arteriovenous malformations were embolized with Onyx with intent to cure. There were 4 women and 14 men with a mean age of 40 years (range 10-62 years). Inclusion criteria were: maximal diameter of the lesions ≤ 3 cm and arterial supply consisting of no more than 2 major arteries. There were 5 (27.8 %) patients with ruptured and 13 (72.2%) with unruptured lesions. Mean arteriovenous malformations size was 2.3 cm (range 1.5-2.9 cm).

Results

Thirty-three procedures were performed in 18 patients. Total obliteration was achieved in 5 patients (27.8%). The most common reason for initial incomplete angiographic occlusion were unfavorable angioarchitectural features of arteriovenous malformations with the rate of 44.4%. The mean follow-up of patients with complete occlusion was 35.2 months (range 18-60 months). Complication rate was 12.1%. One patient had permanent neurological deficit with resulting morbidity of 5.6%. There were no deaths.

Conclusions

Embolization of intracranial arteriovenous malformations plays a limited role as a sole therapeutic modality even in terms of small lesions with two or less arterial feeders, although larger prospective series are necessary to confirm your findings. Associated complications are not trivial and should be considered when choosing this form of treatment.

Giant intracranial arteriovenous malformation as the focus of epileptic seizures

A man in his late thirties was found in a supine position in the hallway of his house. He had been diagnosed with epilepsy at approximately 20 years old. Since stopping treatment, epileptic events occurred more frequently and his condition deteriorated in the past 2 years. Autopsy revealed that head injuries were found on the left side of his head. A fracture from the left parietal bone to the anterior cranial fossa was also detected. A subdural hemorrhage (hematoma) spanned a wide range. A subarachnoid hemorrhage was also identified in the left parietal region. His brain weighed 1603 g, was edematous, and showed right uncal herniation. In the right cerebral hemisphere, a thick, enlarged blood vessel ran from the sagittal sinus. An egg-sized tumorous lesion of blood vessels was found on the bottom of the frontal lobe. This vascular lesion had formed between the sagittal sinus and right anterior cerebral artery. Pathologically, veins and arteries were found together, and, thus, this case was diagnosed as an arteriovenous malformation (AVM). No other pathological and toxicological findings were observed. Subdural hematoma, the cause of death, occurred from the fall to the floor. An epileptic seizure may have been the cause of the fall. AVM on his brain was considered to be the focal lesion of epileptic seizures.

Quantitative evaluation of arteriovenous malformation hemodynamic changes after endovascular treatment using parametric color coding: A case series study

Background Brain arteriovenous malformations (AVMs) are complex vascular lesions. Endovascular treatment results are usually measured by calculating the volume reduction of the lesions. Nevertheless, vascular flow quantification seems a more physiologically accurate way of measuring endovascular results. We evaluated the use of parametric color coding (PCC) with digital subtraction angiography (DSA), in order to determine the feasibility of PCC to detect and measure the impact of AVM endovascular treatment-induced changes using real-time hemodynamic parameters. Methods and results Supratentorial brain AVM treatment was evaluated in 29 patients over the course of 38 sessions. Using regions of interest (ROIs) at the carotid siphon, arterial feeder, drainage vein and venous sinus, we found significant increase in time to peak (TTP) values at the arterial feeder, drainage vein and venous sinus. We compared TTP in four different embolization volume groups: I (0-25%), II (26-50%), III (51-75%) and IV (76-100%). We found significant differences between groups and a moderate correlation between embolization percentages, as well as an increase in TTP at the main vein ROI; but not in the arterial side or sinus. Conclusions Brain AVM endovascular treatment results can be quantified in vivo with PCC. PCC is capable of detecting hemodynamic changes after brain AVM endovascular treatment, that may reflect flow drop, and it is correlated with volume embolization.

Evaluation of a novel liquid embolic agent (precipitating hydrophobic injectable liquid (PHIL)) in an animal endovascular embolization model

BACKGROUND

The choice of the embolic agent and the embolization technique can have a significant impact on the success of endovascular embolization.

OBJECTIVE

To evaluate a novel iodinated copolymer-based liquid embolic agent (precipitating hydrophobic injectable liquid (PHIL)) in the porcine rete mirabile (RM), serving as an endovascular embolization model. Onyx, as an established liquid embolic agent, served as comparator.

MATERIALS AND METHODS

Sixteen embolization procedures were performed using PHIL (n=8) or Onyx (n=8) as liquid embolic agent. Waiting time between injections was set to 30 or 60 s (n=4 per study group). Survival time after intervention was 2 hours or 7 days. Embolization characteristics (eg, procedure times, number of injections and volume of embolic agent) and embolization extent (percentage of embolized RM in post-interventional x-ray) were assessed. Post-interventional CT and histopathological analyses were performed.

RESULTS

Embolization characteristics and embolization extent were not significantly different for PHIL and Onyx, including subgroups (eg, embolization extent 44% vs 69% (medians); p=0.101). For PHIL, extension of the waiting time from 30 to 60 s led to a significantly higher embolization extent (24% vs 72% (medians); p=0.035). Moderate disintegration and mild inflammation of the embolized blood vessels were present for both embolic agents.

CONCLUSION

PHIL is feasible for transarterial embolization in an acute and subacute endovascular embolization model. In this preliminary experimental in vivo study, embolization characteristics, embolization extent, and biocompatibility seem to be similar to those of Onyx.

Mid-term results in the treatment of varicose veins with N-butyl cyanoacrylate

Aim

To present mid-term results of patients with varicose veins treated with N-butyl cyanoacrylate (VariClose®), a nontumescent endovenous ablation technique.

Patients and method

Endovenous ablation was performed on 180 patients with saphenous vein incompetence between May and October 2014. One hundred sixty-eight subjects capable of being followed-up for 30 months were included. Patients’ pre- and postoperative data were recorded.

Results

Procedures were performed on the great saphenous vein in 159 patients and on the small saphenous vein in nine patients. Saphenous vein diameters ranged between 5.5 mm and 14 mm. Full ablation was achieved in all patients following the procedure. No complications were encountered. Patients were monitored for 30 months. Ablation rates were 100% at the 3rd month, 98.3% at the 6th month, 96.6% at 1 year, and 94.1% at 30 months. Mean venous clinical severity score was 10.2 before procedures, decreasing to 3.9 at 3 months, 4.2 at 6 months, 2.9 at 12 months, and 2.7 at 30 months ( p = 0.000).

Conclusion

Due to its high success rate, absence of complications, no tumescent anesthesia requirement and high patient satisfaction, endovenous ablation with N-butyl cyanoacrylate is a good method. However, long-term follow-up results are now needed.

Liquid Embolic Agents for Endovascular Embolization: Evaluation of an Established (Onyx) and a Novel (PHIL) Embolic Agent in an In Vitro AVM Model

BACKGROUND AND PURPOSE

Embolization plays a key role in the treatment of arteriovenous malformations. The aim of this study was to evaluate an established (Onyx) and a novel (precipitating hydrophobic injectable liquid [PHIL]) liquid embolic agent in an in vitro AVM model.

MATERIALS AND METHODS

An AVM model was integrated into a circuit system. The artificial nidus (subdivided into 28 honeycomb-like sections) was embolized with Onyx 18 (group Onyx; n = 8) or PHIL 25 (group PHIL; n = 8) with different pause times between the injections (30 and 60 seconds, n = 4 per study group) by using a 1.3F microcatheter. Procedure times, number of injections, embolization success (defined as the number of filled sections of the artificial nidus), volume of embolic agent, and frequency and extent of reflux and draining vein embolization were assessed.

RESULTS

Embolization success was comparable between Onyx and PHIL. Shorter pause times resulted in a significantly higher embolization success for PHIL (median embolization score, 28 versus 18; P = .011). Compared with Onyx, lower volumes of PHIL were required for the same extent of embolization (median volume per section of the artificial nidus, 15.5 versus 3.6 μL; P < .001).

CONCLUSIONS

While the embolization success was comparable for Onyx and PHIL, pause time had a considerable effect on the embolization success in an in vitro AVM model. Compared with Onyx, lower volumes of PHIL were required for the same extent of embolization.

Assessing the Role of Preoperative Embolization in the Surgical Management of Cerebral Arteriovenous Malformations

BACKGROUND

Preoperative embolization is established as an advantageous adjunct in multimodality treatment of cerebral arteriovenous malformations (AVMs). However, the benefit of preoperative embolization in AVMs with favorable surgical risk profile is debatable, because it has yet to be supported by evidence in comparative studies. In this study, we assessed outcome of surgically treated patients in a comparative setting.

METHODS

Our institutional AVM database of retrospectively and prospectively collected data between 1990 and 2015 was reviewed. Patients with complete clinical data who underwent surgical resection for AVMs were included. We performed a 1:1 ratio propensity score match for baseline variables that differed between patients with or without preoperative embolization. Differences in surgical risk and outcomes were evaluated between these 2 groups.

RESULTS

AVM size, eloquence, deep drainage, middle cerebral artery feeder, and ruptured presentation differed significantly between the 2 groups. Forty-eight patients without preoperative embolization were matched to 48 with embolization, with no significant differences in baseline variables or AVM characteristics between the 2 groups. We found no significant differences in AVM obliteration and postoperative modified Rankin Scale (mRS) score between embolized and nonembolized patients, respectively. Change in mRS score from preoperative score was also not significant, although more embolized patients had a decline in mRS score. Secondary outcome measures including duration of surgery (P = 0.172), intraoperative bleeding (P = 0.280), duration of hospitalization (P = 0.368), and postoperative symptoms were also similar between both groups.

CONCLUSIONS

Our data do not support substantial benefit of preoperative embolization for patients with a favorable surgical risk profile. Because of risks and costs with this intervention, the prudent use of preoperative embolization should be individually considered.

Basal subarachnoid hemorrhage by rupture of arteriovenous malformation at the cerebellopontine angle

A man in his late forties had lived as a recluse for more than ten years. He was found dead in his room. At autopsy, subarachnoid hemorrhage (SAH) was detected at the base of the brain, which weighed 1333 g. The cerebellar tonsil was swollen. The cerebral ventricle was enlarged and filled with blood. A hematoma was observed in the upper part of the left side of the cerebellar hemisphere. The location and size of SAH in this case indicated that the rupture of a cerebral aneurysm (CA) had occurred; however, CA was not detected. A mass of blood vessels buried in the hematoma was observed at the left cerebellopontine angle (CPA). The vascular lesion showed round-shaped blood vessels as well as flat-shaped vessels with the appearance of veins, but with elastic fibers indicative of arteries. The lesion was considered to be the nidus and was 5-8 mm in size. Feeding arteries appeared to be from the anterior inferior cerebellar artery (AICA). However, the draining vein and anastomotic parts of the artery and vein were not confirmed. Based on these histopathological features, this vascular lesion was diagnosed as arteriovenous malformation (AVM). A differential diagnosis between AVM at CPA and CA is needed in order to identify the source of non-traumatic SAH.

A Case Report of Onyx Pulmonary Arterial Embolism Contributing to Hypoxemia During Awake Craniotomy for Arteriovenous Malformation Resection

A healthy 26-year-old man with cerebral arteriovenous malformation underwent staged endovascular embolization with Onyx followed by awake craniotomy for resection. The perioperative course was complicated by tachycardia and severe intraoperative hypoxemia requiring significant oxygen supplementation. Postoperative chest computed tomography (CT) revealed hyperattenuating Onyx embolization material within the pulmonary vasculature, and an electrocardiogram indicated possible right heart strain, supporting clinically significant embolism. With awake arteriovenous malformation resection following adjunctive Onyx embolization becoming increasingly employed for lesions involving the eloquent cortex, anesthesiologists need to be aware of pulmonary migration of Onyx material as a potential contributor to significant perioperative hypoxemia.

Successful perinatal management of a ruptured brain arteriovenous malformation in a pregnant patient by endovascular embolization followed by elective cesarean section: a single-case experience

Background

Although brain arteriovenous malformations (AVM) usually remain asymptomatic during pregnancy, they can cause intracranial hemorrhage and lead to serious neurological deficits. Nowadays, it is accepted that treatment of a ruptured brain AVM during pregnancy should be based on neurologic, not obstetric, indications.Recently, endovascular treatment has been recognized as a treatment option associated in pregnant patients with brain AVMs.

Case presentation

A 34-year-old woman presented at 25 weeks of gestation with a history of severe headache followed by severe consciousness disturbance. Brain CT showed a subcortical hematoma in the right occipital lobe along with bilateral intraventricular hematomas. A cerebral angiogram was performed to confirm the diagnosis, which revealed right occipital AVM. At 27 weeks of gestation, endovascular embolization of the AVM was attempted under general anesthesia. The feeding artery and the nidus were simultaneously obliterated by injection of 50 % n-butyl-cyanoacrylate. As a result, the blood flow into the nidus was drastically decreased and the risk of re-bleeding was substantially reduced. At 38 weeks of gestation, elective cesarean section was performed to deliver the baby under combined spinal-epidural anesthesia (CSEA). An infant weighing 3665 g was delivered, with Apgar scores of 8 and 9 at 1 and 5 min, respectively.Postoperative analgesia was provided by a continuous infusion of ropivacaine via the epidural catheter. The infant was confirmed as not having any congenital anomalies.On POD 5, both of the patient and the infant were discharged home without any medical problems. The mother has shown no evidence of re-bleeding from the intracranial lesion since, and the infant is thriving well.

Conclusions

Endovascular treatment in pregnant women is associated with various unique concerns. However, it can be carried out safely and effectively and is useful not only for saving the mother's life but also for allowing the pregnancy to continue to term.

A new non-tumescent endovenous ablation method for varicose vein treatment: Early results of N-butyl cyanoacrylate (VariClose®)

Objective

This report aims to present the early results of a retrospective study of the use of N-butyl cyanoacrylate (VariClose®)-based non-tumescent endovenous ablation for the treatment of patients with varicose veins.

Method

One hundred and eighty patients with varicose veins due to incompetent saphenous veins were treated with the VariClose® endovenous ablation method between May 2014 and November 2014. The patient sample consisted of 86 men and 94 women, with a mean age of 47.7 ± 11.7 years. The patients had a great saphenous vein diameter greater than 5.5 mm and a small saphenous vein diameter greater than 4 mm in conjunction with reflux for more than 0.5 s. Patients with varicose veins were evaluated with venous duplex examination, Clinical, Etiological, Anatomical and Pathophysiological classification (CEAP), and their Venous Clinical Severity Scores were recorded.

Results

The median CEAP score of patients was three, and the saphenous vein diameters were between 5.5 and 14 mm (mean of 7.7 ± 2.1 mm). A percutaneous entry was made under local anesthesia to the great saphenous vein in 169 patients and to the small saphenous vein in 11 patients. Duplex examination immediately after the procedure showed closure of the treated vein in 100% of the treated segment. No complications were observed. The mean follow-up time was 5.5 months (ranging from three to seven months). Recanalization was not observed in any of the patients during follow-up. The average Venous Clinical Severity Scores was 10.2 before the procedure and decreased to 3.9 after three months (p < 0.001).

Conclusion

The application of N-butyl cyanoacrylate (VariClose®) is an effective method for treating varicose veins; it yielded a high endovenous closure rate, with no need for tumescent anesthesia. However, long-term results are currently unknown.

Endovascular stent graft exclusion of a thoracic arteriovenous malformation in a patient with Cobb syndrome

Cobb syndrome is a rare neurocutaneous disorder characterized by spinal vascular abnormalities in association with a vascular lesion of the skin at the same metamere. Patients present after the onset of symptoms such as paraplegia, back pain, and, less commonly, fatigue due to heart failure. Available treatment options to date have included neurosurgical resection and endovascular embolization. We present a patient with Cobb syndrome with a progressively symptomatic arteriovenous malformation involving the thoracic vertebrae and left hemithorax, with extensive blood supply from the T3 to T10 intercostal arteries, and demonstrate successful endovascular thoracic stent graft placement and coil embolization.

Angioarchitectural Risk Factors for Hemorrhage and Clinical Long-Term Outcome in Pediatric Patients with Cerebral Arteriovenous Malformations

BACKGROUND

Intracranial arteriovenous malformation (AVM) in children is a rare diagnosis. Little is known about factors determining AVM rupture and appropriate treatment strategies to prevent hemorrhage and associated disability. Available data suggest that children are subject to an increased risk for AVM rupture compared with adults.

METHODS

In 46 pediatric patients with AVM, demographic factors, clinical presentation, angioarchitectural features, and treatment regimens as well as clinical and radiologic outcomes were retrospectively analyzed. First-line treatment option was microsurgical resection of the disease, with or without preoperative embolization.

RESULTS

Twenty-four boys (52.2%) and 22 girls (47.8%) with a mean age on admission of 12.4 years (4-18 years) were included. Mean follow-up was 4 years (median, 1.5; range, 0.1-16.4). Thirty-one children presented with intracerebral hemorrhage (67.4%). Small AVMs (<3 cm) ruptured in 83.3% (n = 25) and were shown to be more prone to hemorrhage than larger ones (P < 0.01). Small AVM size (P < 0.01; odds ratio [OR], 0.12; 95% confidence interval [CI] 0.02-0.59) and exclusive deep venous drainage (P < 0.01; OR, 29.74; 95% CI, 2.45-4445.34) were independent risk factors for hemorrhage in the presented cohort. Good long-term outcome was associated with a high score on the Glasgow Coma Scale on admittance (P < 0.05; OR, 0.148; 95% CI, 0.03-0.73).

CONCLUSIONS

Two-thirds of children with AVM are admitted with intracerebral hemorrhage. Microsurgical resection was successful as confirmed by radiologic studies in 95%, and 79.5% of patients presented in a good clinical condition on follow-up (modified Rankin Scale 0 or 1). Microsurgical treatment is recommended if the lesion is accessible and angioarchitectural risk factors favor definitive treatment.

Transvenous Embolization in Pediatric Plexiform Arteriovenous Malformations

BACKGROUND:

Transvenous embolization is a developing concept for curative therapy of cerebral arteriovenous malformations (AVMs). The feasibility of this endovascular method has not been reported in children.

OBJECTIVE:

To report our experience treating pediatric AVMs with the transvenous approach (TVA).

METHODS:

A cohort of 7 pediatric patients (younger than 18 years of age) who underwent the TVA for cerebral AVMs between January 2012 and January 2014. The TVA was used alone or in conjunction with other arterial approaches in definitive embolization sessions. Patient demographics, AVM characteristics, clinical outcomes, and angiographic results were independently assessed. Pial arteriovenous fistulae and vein of Galen malformations were excluded. Control angiograms were obtained at 6 months, and curative treatment was determined by the anatomic obliteration of the nidus.

RESULTS:

All patients had anatomic exclusion of the AVM. The mean size was 2 ± 0.6 cm, and hemorrhage was the most common presentation (100%, n = 7). Most AVMs were deeply placed (71%, n = 5), and a proximal approach to the nidus was achieved in all cases. Transvenous embolization alone was performed in 3 patients (43%), whereas combined arterial and venous embolization was required in 4 patients (57%). The mean follow-up period was 20.2 ± 10.5 months. There were no hemorrhagic or thromboembolic events, and venous infarction was not documented. No recurrence was documented.

CONCLUSION:

This is the first report that demonstrates the feasibility of transvenous Onyx embolization of AVMs in the pediatric population. Such a technique may be considered in certain AVMs that meet anatomic criteria in which microsurgery and radiosurgery might not be indicated.

Arteriovenous malformation within an isocitrate dehydrogenase 1 mutated anaplastic oligodendroglioma

Background:

The co-occurrence of intracranial arteriovenous malformations (AVMs) and cerebral neoplasms is exceedingly rare but may harbor implications pertaining to the molecular medicine of brain cancer pathogenesis.

Case Description:

Here, we present a case of de novo AVM within an isocitrate dehydrogenase 1 mutated anaplastic oligodendroglioma (WHO Grade III) and review the potential contribution of this mutation to aberrant angiogenesis as an interesting case study in molecular medicine.

Conclusion:

The co-occurrence of an IDH1 mutated neoplasm and AVM supports the hypothesis that IDH1 mutations may contribute to aberrant angiogenesis and vascular malformation.