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Sebök M, Germans MR, Niftrik CHBV, Kulcsár Z, Regli L, Fierstra J. More pronounced hemodynamic alterations in patients with brain arteriovenous malformation–associated epilepsy. Neurosurg Focus 2022; 53:E4. [DOI: 10.3171/2022.4.focus22117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Epileptic seizures in patients with brain arteriovenous malformations (bAVMs) may be caused by hemodynamic alterations due to the complex angioarchitecture of bAVMs. In particular, an arterial steal phenomenon and venous outflow disruption may play an etiological role in seizure development but remain challenging to demonstrate quantitatively. Blood oxygenation level–dependent (BOLD) cerebrovascular reactivity (CVR) imaging is an emerging technique that can measure both arterial steal phenomenon (as a paradoxical BOLD signal decrease during a vasodilatory stimulus) and impaired perinidal BOLD-CVR (which has been found in the presence of venous congestion on conventional angiography in bAVM patients with epilepsy). By applying this innovative BOLD-CVR technique, the aim is to better study CVR patterns and their correlation with morphological features on conventional angiography in patients with bAVM with and without epilepsy.
METHODS
Twenty-two patients with unruptured and previously untreated bAVMs (8 with and 14 without epilepsy) were included in this case-control study. Quantitative CVR measurements were derived from BOLD functional MRI volumes using a novel standardized and precise hypercapnic stimulus (i.e., % BOLD/mm Hg CO2). In addition, 22 matched healthy controls underwent an identical BOLD-CVR study. Evaluation of venous congestion was performed on conventional angiography for all patients with bAVM.
RESULTS
Patients with bAVM-associated epilepsy showed impaired whole-brain BOLD-CVR compared to those in the nonepilepsy group, even after correction for AVM volume and AVM grade (epilepsy vs nonepilepsy group: 0.17 ± 0.07 vs 0.25 ± 0.07, p = 0.04). A BOLD-CVR–derived arterial steal phenomenon was observed in 2 patients with epilepsy (25%). Venous congestion was noted in 3 patients with epilepsy (38%) and in 1 patient without epilepsy (7%; p = 0.08).
CONCLUSIONS
These data suggest that whole-brain CVR impairment, and more pronounced hemodynamic alterations (i.e., arterial steal phenomenon and venous outflow restriction), may be more present in patients with bAVM-associated epilepsy. The association of impaired BOLD-CVR and bAVM-associated epilepsy will need further investigation in a larger patient cohort.
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Affiliation(s)
- Martina Sebök
- Department of Neurosurgery,
- Clinical Neuroscience Center, and
| | | | | | - Zsolt Kulcsár
- Clinical Neuroscience Center, and
- Department of Neuroradiology, University Hospital Zurich, University of Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery,
- Clinical Neuroscience Center, and
| | - Jorn Fierstra
- Department of Neurosurgery,
- Clinical Neuroscience Center, and
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2
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Ali MF. Transcranial Doppler ultrasonography (uses, limitations, and potentials): a review article. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-021-00114-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Abstract
Background
The additional information that transcranial Doppler can provide as part of a multimodal imaging protocol in many clinical settings has not been evaluated.
Main body
Transcranial Doppler is a bedside procedure used to assess cerebral blood flow velocity via cerebral circulation and pulsatility index (PI). Many diseases can lead to cerebral vessels vasospasm as in subarachnoid hemorrhage and trauma. Cerebral vessels vasospasm represented by abnormal elevation of cerebral blood flow velocity. Intracranial pressure can be monitored by pulsatility index which reflects blood flow resistance in cerebral vessels. Transcranial Doppler ultrasonography is also the unique modality for detection of micro emboli in high-risk patients. Also, it can be used for evaluation of circulatory arrest with subsequent confirmation of brain death
Conclusion
Transcranial Doppler ultrasonography is the only diagnostic modality that provides a reliable assessment of cerebral blood flow patterns in real time. The physiological information obtained from TCD is complementary to the anatomical details obtained from other neuroimaging modalities. TCD is relatively cheap, can be performed bedside, and allows monitoring in acute emergency settings.
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Perioperative Dynamics of Intracranial B-waves of Blood Flow Velocity in the Basal Cerebral Arteries in Patients with Brain Arteriovenous Malformation. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33839820 DOI: 10.1007/978-3-030-59436-7_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Intracranial B-waves (8-30 mHz) of blood flow velocity (BFV) in the cerebral arteries are observed in various pathologies of the brain. Changes in B-waves of BFV in pathological arteriovenous shunting and "steal" syndrome remain poorly understood. The aim of this study was to evaluate the dynamics of the B-wave amplitude of BFV (BWA) in patients with an arteriovenous malformation (AVM) in the brain. In 38 such patients, cerebral autoregulation (CA) was assessed using a cuff test and transfer function analysis of the mean blood pressure (BP) and BFV in the basal cerebral arteries within the range of Mayer waves (80-120 mHz). BWA was calculated with spectral analysis. Reliable CA impairment was denoted on the AVM side as compared with the contralateral side prior to intervention. BWA was greater on the AVM side (4.5 ± 2.7 cm/s) than on the contralateral side (2.2 ± 1.4 cm/s, p < 0.05). After embolization, there was a reliable improvement (p < 0.05) in CA and a decrease in BWA on the AVM side (2.7 ± 1.8 cm/s). Thus, a considerable increase in BWA on the AVM side that is not induced by BP fluctuations may indicate additional compensation for blood flow under conditions of reduced perfusion pressure. This assumption is supported by a reduction in BWA after AVM embolization.
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Zhang C, Chau N, Ho H. Patient-Specific Blood Flow Analysis for Cerebral Arteriovenous Malformation Based on Digital Subtraction Angiography Images. Front Bioeng Biotechnol 2020; 8:775. [PMID: 32793568 PMCID: PMC7390970 DOI: 10.3389/fbioe.2020.00775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 06/18/2020] [Indexed: 11/15/2022] Open
Abstract
Real-time digital subtraction angiography (DSA) is capable of revealing the cerebral vascular morphology and blood flow perfusion patterns of arterial venous malformations (AVMs). In this study, we analyze the DSA images of a subject-specific left posterior AVM case and customize a generic electric analog model for cerebral circulation accordingly. The generic model consists of electronic components representing 49 major cerebral arteries and veins, and yields their blood pressure and flow rate profiles. The model was adapted by incorporating the supplying and draining patterns of the AVM to simulate some typical AVM features such as the blood "steal" syndrome, where the flow rate in the left posterior artery increases by almost three times (∼300 ml/min vs 100 ml/min) compared with the healthy case. Meanwhile, the flow rate to the right posterior artery is reduced to ∼30 ml/min from 100 ml/min despite the presence of an autoregulation mechanism in the model. In addition, the blood pressure in the draining veins is increased from 9 to 22 mmHg, and the blood pressure in the feeding arteries is reduced from 85 to 30 mmHg due to the fistula effects of the AVM. In summary, a first DSA-based AVM model has been developed. More subject-specific AVM cases are required to apply the presented in silico model, and in vivo data are used to validate the simulation results.
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Affiliation(s)
- Changwei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Nixon Chau
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Harvey Ho
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
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Donzelli GF, Nelson J, McCoy D, McCulloch CE, Hetts SW, Amans MR, Dowd CF, Halbach VV, Higashida RT, Lawton MT, Kim H, Cooke DL. The effect of preoperative embolization and flow dynamics on resection of brain arteriovenous malformations. J Neurosurg 2020; 132:1836-1844. [PMID: 31100732 PMCID: PMC6858934 DOI: 10.3171/2019.2.jns182743] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 02/25/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Preoperative embolization of brain arteriovenous malformations (AVMs) is performed to facilitate resection, although its impact on surgical performance has not been clearly defined. The authors tested for associations between embolization and surgical performance metrics. METHODS The authors analyzed AVM cases resected by one neurosurgeon from 2006 to 2017. They tested whether cases with and without embolization differed from one another with respect to patient and AVM characteristics using t-tests for continuous variables and Fisher's exact tests for categorical variables. They used simple and multivariable regression models to test whether surgical outcomes (blood loss, resection time, surgical clip usage, and modified Rankin Scale [mRS] score) were associated with embolization. Additional regression analyses integrated the peak arterial afferent contrast normalized for the size of the region of interest (Cmax/ROI) into models as an additional predictor. RESULTS The authors included 319 patients, of whom 151 (47%) had preoperative embolization. Embolized AVMs tended to be larger (38% with diameter > 3 cm vs 19%, p = 0.001), less likely to have hemorrhaged (48% vs 63%, p = 0.013), or be diffuse (19% vs 29%, p = 0.045). Embolized AVMs were more likely to have both superficial and deep venous drainage and less likely to have exclusively deep drainage (32% vs 17% and 12% vs 23%, respectively; p = 0.002). In multivariable analysis, embolization was not a significant predictor of blood loss or mRS score changes, but did predict longer operating times (+29 minutes, 95% CI 2-56 minutes; p = 0.034) and increased clip usage (OR 2.61, 95% CI 1.45-4.71; p = 0.001). Cmax/ROI was not a significant predictor, although cases with large Cmax/ROI tended to have longer procedure times (+25 minutes per doubling of Cmax/ROI, 95% CI 0-50 minutes; p = 0.051). CONCLUSIONS In this series, preoperative embolization was associated with longer median resection times and had no association with intraoperative blood loss or mRS score changes.
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Affiliation(s)
- Grace F. Donzelli
- UCSF School of Medicine, UCSF Medical Center, San Francisco, California
| | - Jeffrey Nelson
- Departments of Anesthesia and Perioperative Care, UCSF Medical Center, San Francisco, California
| | - David McCoy
- Departments of Radiology and Biomedical Imaging, UCSF Medical Center, San Francisco, California
| | - Charles E. McCulloch
- Departments of Biostatistics and Epidemiology, UCSF Medical Center, San Francisco, California
| | - Steven W. Hetts
- Departments of Radiology and Biomedical Imaging, UCSF Medical Center, San Francisco, California
| | - Matthew R. Amans
- Departments of Radiology and Biomedical Imaging, UCSF Medical Center, San Francisco, California
| | - Christopher F. Dowd
- Departments of Radiology and Biomedical Imaging, UCSF Medical Center, San Francisco, California
| | - Van V. Halbach
- Departments of Radiology and Biomedical Imaging, UCSF Medical Center, San Francisco, California
| | - Randall T. Higashida
- Departments of Radiology and Biomedical Imaging, UCSF Medical Center, San Francisco, California
| | - Michael T. Lawton
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Helen Kim
- Departments of Anesthesia and Perioperative Care, UCSF Medical Center, San Francisco, California
| | - Daniel L. Cooke
- Departments of Radiology and Biomedical Imaging, UCSF Medical Center, San Francisco, California
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Burkhardt JK, Chen X, Winkler EA, Cooke DL, Kim H, Lawton MT. Delayed Venous Drainage in Ruptured Arteriovenous Malformations Based on Quantitative Color-Coded Digital Subtraction Angiography. World Neurosurg 2017; 104:619-627. [PMID: 28457930 DOI: 10.1016/j.wneu.2017.04.120] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 04/17/2017] [Accepted: 04/18/2017] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Clinically applicable hemodynamic risk factors to predict arteriovenous malformation (AVM) rupture are missing in the literature. The aim of this study was to use catheter angiography to identify hemodynamic parameters in ruptured and unruptured AVMs. METHODS Patients with frontal and temporal AVMs and Siemens syngo iFlow color-coding angiography were included in this study (n = 71). Clinical and radiologic data (age, sex, Spetzler-Martin [SM] and supplemented SM grade, and rupture status), and hemodynamic features (contrast mean transit time [MTT] of feeding arteries, draining veins, AVM nidus, and the cerebral circulation time [CCT]) were analyzed. Univariable analysis was performed to compare findings between ruptured and unruptured AVMs. RESULTS In total, 35 ruptured and 36 unruptured AVMs were analyzed. Clinical characteristics and AVM grades were comparable between ruptured and unruptured AVMs. Ipsilateral CCT (5.2 vs. 4.0 seconds; P = 0.035), MTT between Tmax of the ipsilateral internal carotid artery and Tmax of sinus entry of the draining vein (3.2 vs. 2.0 seconds; P < 0.001), and MTT between Tmax at the start of venous outflow and Tmax of sinus entry (1.6 vs. 0.7 seconds; P < 0.0001) were significantly longer in ruptured compared with unruptured AVMs. MTTs of nidus, between the internal carotid and feeding arteries, of the venous sinus passage as well as contralateral CCT and controlled ipsilateral CCT were comparable between both groups. CONCLUSIONS Ruptured AVMs have significantly prolonged venous drainage times compared with unruptured AVMs; this suggests restricted AVM drainage and increased blood pressure within the AVM nidus. Prospective studies are needed to determine the predictive power of these measurements.
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Affiliation(s)
- Jan-Karl Burkhardt
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Xiaolin Chen
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA; Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA; Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA.
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Relationship of pulsatility and resistance indices to cerebral arteriovenous malformation angioarchitectural features and hemorrhage. J Clin Neurosci 2016; 33:119-123. [PMID: 27595365 DOI: 10.1016/j.jocn.2016.02.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 02/14/2016] [Indexed: 11/22/2022]
Abstract
The role that hemodynamics plays in the pathophysiology of cerebral arteriovenous malformation (AVM) hemorrhage remains unclear. Here, we examine the relationship of pulsatility and resistance indices to AVM angioarchitectural features and hemorrhage. Records of patients with cerebral AVMs evaluated at our institution between 2007-2014 and with flows obtained before treatment using quantitative magnetic resonance angiography (QMRA) were retrospectively reviewed. Flow volume rate and flow velocity were measured in primary arterial feeders and compared to their contralateral counterparts. Pulsatility index (PI)=[(systolic flow velocity-diastolic flow velocity)/mean flow velocity] and resistance index (RI)=[(systolic flow velocity-diastolic flow velocity)/systolic flow velocity] were calculated for each feeder and compared to the normal contralateral vessel. Relationships between PI, RI and AVM clinical and angioarchitectural features were assessed using linear regression. Seventy-two patients with a total of 101 feeder arteries were included. PI and RI were significantly lower in AVM arterial feeders compared to normal vessels, thereby resulting in significantly higher flow volume rates and flow velocities in feeder vessels. There was no significant association of PI and RI with hemorrhagic presentation, exclusive deep venous drainage, venous stenosis, single draining vein, or deep location. In conclusion, PI and RI can be measured using QMRA and are lower in AVM arterial feeders compared to normal vessels. Although we found no significant correlation between PI, RI, and AVM angioarchitectural characteristics thought to be associated with increased hemorrhage risk, future studies with larger sample sizes may better elucidate this relationship.
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8
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Busch KJ, Kiat H, Stephen M, Simons M, Avolio A, Morgan MK. Cerebral hemodynamics and the role of transcranial Doppler applications in the assessment and management of cerebral arteriovenous malformations. J Clin Neurosci 2016; 30:24-30. [DOI: 10.1016/j.jocn.2016.01.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 01/04/2016] [Accepted: 01/26/2016] [Indexed: 11/29/2022]
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9
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Shakur SF, Liesse K, Amin-Hanjani S, Carlson AP, Aletich VA, Charbel FT, Alaraj A. Relationship of Cerebral Arteriovenous Malformation Hemodynamics to Clinical Presentation, Angioarchitectural Features, and Hemorrhage. Neurosurgery 2016; 63 Suppl 1:136-140. [DOI: 10.1227/neu.0000000000001285] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Sophia F. Shakur
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Kelly Liesse
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew P. Carlson
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Victor A. Aletich
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Fady T. Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
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10
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Khorvash F, Masaeli A, Shaygannejad V, Saadatnia M. Vasomotor reactivity comparison in multiple sclerosis patients with white matter lesions and nonmultiple sclerosis subjects with white matter lesions in brain magnetic resonance imaging. Adv Biomed Res 2016; 5:23. [PMID: 26962525 PMCID: PMC4770604 DOI: 10.4103/2277-9175.175916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 06/14/2015] [Indexed: 11/12/2022] Open
Abstract
Background: It has been recognized a close relationship between multiple sclerosis (MS) lesions and the cerebral vasculature. In this study, we observed cerebrovascular vasomotor reactivity difference between the MS patients and the non-MS migraine individuals. Materials and Methods: This prospective study was conducted on 40 patients with MS referring to Neurology Clinic of Isfahan Al-Zahra Hospital in 2012. The patients were compared with the same number of non-MS migraine individuals. Both groups had white matter lesions in brain magnetic resonance imaging. To evaluate the rate of cerebral artery vasomotor reactivity, transcranial Doppler device was used, and breath-holding index (BHI) was separately calculated for each middle cerebral artery. Main flow velocity (MFV) was determined by continuously recording of a period of 5 min of breathing the air in the room. The obtained data were analyzed using SPSS software version 18 and t-test, Chi-square and analysis of variance tests. Results: The mean values of MFV at rest was not significantly different between cases and control groups (46.21 ± 4.20 vs. 44.69 ± 4.34, P = 0.115) but difference between cases and control groups in MFV apnea was significant (59.11 ± 5.10 vs. 55.35 ± 6.03, P = 0.004). BHI in the control group was 0.79 ± 0.26 and in the case group was 0.93 ± 0.20 and these differences was found to be significant (P < 0.05). Conclusion: The mean of BHI and cerebral vasomotor reactivity in MS patients was more than the non-MS migraine individuals, although the mechanism of this process still remains unknown.
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Affiliation(s)
- Fariborz Khorvash
- Isfahan Neurosciences Research Center, Alzahra Hospital, Isfahan, Iran
| | - Ali Masaeli
- Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran
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11
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Transcranial Doppler Examination. Neuroophthalmology 2016. [DOI: 10.1007/978-3-319-28956-4_26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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12
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Intraoperative Monitoring of Brain Tissue Oxygenation During Arteriovenous Malformation Resection. J Neurosurg Anesthesiol 2014; 26:328-41. [DOI: 10.1097/ana.0000000000000033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Kaspera W, Ładziński P, Larysz P, Majchrzak H, Hebda A, Kopera M, Tomalski W, Ślaska A. Transcranial color-coded Doppler assessment of cerebral arteriovenous malformation hemodynamics in patients treated surgically or with staged embolization. Clin Neurol Neurosurg 2014; 116:46-53. [DOI: 10.1016/j.clineuro.2013.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 10/22/2013] [Accepted: 11/05/2013] [Indexed: 10/26/2022]
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15
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Alexander MD, Connolly ES, Meyers PM. Revisiting normal perfusion pressure breakthrough in light of hemorrhage-induced vasospasm. World J Radiol 2010; 2:230-2. [PMID: 21160635 PMCID: PMC2999324 DOI: 10.4329/wjr.v2.i6.230] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 06/02/2010] [Accepted: 06/28/2010] [Indexed: 02/06/2023] Open
Abstract
Cerebral arteriovenous malformations (AVMs) have abnormally enlarged arteries and veins prone to spontaneous hemorrhage. Immediately following surgical excision of a cerebral AVM, even normal brain tissue surrounding the lesion is subject to hemorrhage, a phenomenon termed normal perfusion pressure breakthrough (NPPB) syndrome. According to this theory, arteries supplying cerebral AVMs become dilated and lose their capacity to dilate or constrict to autoregulate pressure. Acutely after removal of a cerebral AVM, excessive blood pressure in these arterial feeders can cause normal brain tissue to bleed. However, this theory remains controversial. We present a patient with a cerebral AVM that demonstrated cerebrovascular reactivity and argues against an assumption underlying the theory of NPPB syndrome.
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Prakash N, Uhlemann F, Sheth SA, Bookheimer S, Martin N, Toga AW. Current trends in intraoperative optical imaging for functional brain mapping and delineation of lesions of language cortex. Neuroimage 2009; 47 Suppl 2:T116-26. [PMID: 18786643 PMCID: PMC2782948 DOI: 10.1016/j.neuroimage.2008.07.066] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Revised: 07/19/2008] [Accepted: 07/30/2008] [Indexed: 10/21/2022] Open
Abstract
Resection of a cerebral arteriovenous malformation (AVM), epileptic focus, or glioma, ideally has a prerequisite of microscopic delineation of the lesion borders in relation to the normal gray and white matter that mediate critical functions. Currently, Wada testing and functional magnetic resonance imaging (fMRI) are used for preoperative mapping of critical function, whereas electrical stimulation mapping (ESM) is used for intraoperative mapping. For lesion delineation, MRI and positron emission tomography (PET) are used preoperatively, whereas microscopy and histological sectioning are used intraoperatively. However, for lesions near eloquent cortex, these imaging techniques may lack sufficient resolution to define the relationship between the lesion and language function, and thus not accurately determine which patients will benefit from neurosurgical resection of the lesion without iatrogenic aphasia. Optical techniques such as intraoperative optical imaging of intrinsic signals (iOIS) show great promise for the precise functional mapping of cortices, as well as delineation of the borders of AVMs, epileptic foci, and gliomas. Here we first review the physiology of neuroimaging, and then progress towards the validation and justification of using intraoperative optical techniques, especially in relation to neurosurgical planning of resection AVMs, epileptic foci, and gliomas near or in eloquent cortex. We conclude with a short description of potential novel intraoperative optical techniques.
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Affiliation(s)
- Neal Prakash
- University of California, Los Angeles, Laboratory of Neuro Imaging, Los Angeles, CA 90095, USA.
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17
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Fu B, Zhao JZ, Yu LB. The application of ultrasound in the management of cerebral arteriovenous malformation. Neurosci Bull 2009; 24:387-94. [PMID: 19037325 DOI: 10.1007/s12264-008-1013-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Ultrasound is used in the diagnosis, treatment and follow-up of cerebral arteriovenous malformation (AVM). Several parameters including flow velocity, flow volume, resistance index, pulsatility index, vasomotor reactivity and their influencing factors are reviewed. The applications of ultrasound in the preoperative evaluation, intraoperative monitor and postoperative follow-up of AVM, are summarized. Although some limits exist, ultrasound can provide more reliable information about AVM, if lesions are classified according to their characteristics, compared in different conditions between preoperation and postoperation, feeding and non-feeding side, patients and healthy adults, and if ultrasound method is combined with other examinations and different developed ultrasound techniques. With the appearance and development of new ultrasound technique, its application will be wider in management of AVM.
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Affiliation(s)
- Bing Fu
- Department of neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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18
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Park SH, Hwang SK. Transcranial Doppler study of cerebral arteriovenous malformations after gamma knife radiosurgery. J Clin Neurosci 2009; 16:378-84. [PMID: 19138850 DOI: 10.1016/j.jocn.2008.04.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2007] [Revised: 04/24/2008] [Accepted: 04/29/2008] [Indexed: 10/21/2022]
Abstract
The aim of this study was to evaluate the clinical value of the Transcranial Doppler (TCD) in follow-up examinations after gamma knife radiosurgery (GKS) for arteriovenous malformations (AVM). We performed TCD after GKS in 18 patients who had cerebral AVMs to evaluate the hemodynamic effects of the procedure. Ten patients underwent TCD within 12 months after GKS, and eight between 12 and 24 months. The mean blood velocity (Vm) and pulsatility index (PI) were primarily analyzed in the feeding arteries (FAs) and non-FAs. Fifteen healthy volunteers served as control patients. The Vm values in the FAs after GKS ranged from 31 cm/s to 90 cm/s, with PI values ranging from 0.48 to 1.03. The Vm values in the comparable normal arteries ranged from 28 cm/s to 87 cm/s, and the PI values in these arteries ranged from 0.62 to 1.02. The Vm and PI values in every FA in all patients were normal compared to the values in the non-FAs (p=0.67 and 0.38, respectively). Our results suggest that AVM vessels with high Vm and low PI values return to normal as the nidus of the AVM is obliterated after GKS. Although there was a trend toward a reduction of the Vm values after obliteration, this trend was not significant, except when the < 12 month subgroup was compared to the 12-24 month subgroup. In our limited study, TDC proved to be a reliable, safe and non-invasive method to monitor the outcome of GKS for cerebral AVMs.
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Affiliation(s)
- Seong-Hyun Park
- Department of Neurosurgery, Kyungpook National University Hospital 50, Samduk-2-ga, Jung-gu, Daegu 700-721, South Korea.
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Lantz ER, Meyers PM. Neuropsychological effects of brain arteriovenous malformations. Neuropsychol Rev 2008; 18:167-77. [PMID: 18500557 DOI: 10.1007/s11065-008-9060-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2008] [Accepted: 03/24/2008] [Indexed: 11/24/2022]
Abstract
Brain arteriovenous malformations (AVM's) are developmental, chronic lesions that provide unique information about the human brain and can be a useful model for neuroscientists to study cerebral reorganization and hemodynamics. We review the neuroanatomy, epidemiology, natural history, imaging and treatment of brain AVMs, and provide a model with which to better understand neuropsychological functioning and brain reorganization. We suggest that future studies must exclude ruptured AVMs if they wish to further explain focal neurological/cognitive deficits associated with this neurovascular anomaly.
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Affiliation(s)
- Emily R Lantz
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA.
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20
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Bartels E. Evaluation of arteriovenous malformations (AVMs) with transcranial color-coded duplex sonography: does the location of an AVM influence its sonographic detection? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2005; 24:1511-7. [PMID: 16239654 DOI: 10.7863/jum.2005.24.11.1511] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
OBJECTIVE The clinical value of transcranial color-coded duplex sonography (TCCS) in the evaluation of arteriovenous malformations (AVMs) has not yet been fully investigated. In this study, 54 intracranial AVMs confirmed by angiography were prospectively examined over 6 years. The purpose of the study was to describe their typical sonographic features and to define sensitivity for diagnosis with regard to the location of an AVM. METHODS Transcranial color-coded duplex sonographic findings for 54 patients with intracranial AVMs are presented. The vessels of the circle of Willis were identified by location, course, and direction of flow on color flow images. RESULTS In accordance with digital subtraction angiography, the intracranial AVMs could be visualized in 42 cases (sensitivity, 77.8%). The pathologic vessels were coded in different shades of blue and red, corresponding to varying blood flow directions in the AVM. The major feeding vessels could be easily identified. Hemodynamic parameters showing increased systolic and diastolic flow velocities and a decreased pulsatility index were better attainable with TCCS than with conventional transcranial Doppler sonography. Arteriovenus malformations located near the cortex, that is, in the parietal, frontal, occipital, and cerebellar regions of the brain, could not be visualized. In contrast, AVMs located in the basal regions were very easy to image (sensitivity, 88.9%). Additionally, TCCS proved useful for follow-up examinations postoperatively or after embolization. CONCLUSIONS Transcranial color-coded duplex sonography is a valuable noninvasive method for the diagnosis and long-term follow-up of intracranial AVMs. Arteriovenous malformations located in the axial imaging plane can be more easily detected. Nevertheless, TCCS should not be used as a screening method.
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Affiliation(s)
- Eva Bartels
- Department of Clinical Neurophysiology, Georg-August-University Göttingen, Robert-Koch-Strasse 40, D-37075 Göttingen, Germany.
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21
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Semenyutin VB, Aliev VA, Nikitin PI, Kozlov AV. The intracranial B-waves' amplitude as prognostication criterion of neurological complications in neuroendovascular interventions. ACTA NEUROCHIRURGICA. SUPPLEMENT 2005; 94:53-8. [PMID: 16060241 DOI: 10.1007/3-211-27911-3_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
The purpose of this study was to evaluate dynamics of B-waves' amplitudes (BWA) of blood flow velocity (BFV) in patients with cerebrovascular diseases during endovascular operations. We examined 12 patients with neurovascular pathology during neuroendovascular interventions. Patients were divided into two groups: 1st group (6 cases)--without intraoperative neurological complications, 2nd group (6 cases)--with complications. Bilateral monitoring of BFV in middle cerebral arteries was carried out applying Multi Dop X. To estimate BWA Fourier analysis was used. In the 1st group preoperative BWA on the affected side was 3.9 +/- 0.6 cm/s. Intraoperative (during an access to pathologic formation and its embolisation) BWA increased up to 7.7 +/- 1.1 cm/s (p < 0.05). Postoperative BWA decreased to 4.2 +/- 0.8 cm/s. In the 2nd group the preoperative BWA on the affected side was 9.6 +/- 1.1 cm/s (p < 0.05), thus higher than in the 1st group. Intraoperatively we observed further increase of BWA up to 12.1 +/- 2.6 cm/s, accompanied by occurrence or increase of neurological symptoms. Postoperative BWA decreased to 10.4 +/- 2.9 cm/s, whereas we didn't observe regression of neurological symptoms.
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Affiliation(s)
- V B Semenyutin
- Russian Polenov Neurosurgical Institute, Saint-Petersburg, Russia.
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22
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Zazulia AR, Markham J, Powers WJ. Cerebral Blood Flow and Metabolism in Human Cerebrovascular Disease. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50047-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Taylor CL, Selman WR, Ratcheson RA. Steal affecting the central nervous system. Neurosurgery 2002; 50:679-88; discussion 688-9. [PMID: 11904017 DOI: 10.1097/00006123-200204000-00002] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2001] [Accepted: 11/15/2001] [Indexed: 11/26/2022] Open
Abstract
Steal is a pathophysiological process in which increased blood flow through a low-resistance vascular bed is sufficient to divert flow away from a region of the central nervous system. Three disease states in which steal may cause neurological deficits due to central nervous system ischemia are reviewed. Subclavian steal occurs when stenosis of the subclavian artery proximal to the vertebral origin causes retrograde flow in the left vertebral artery. Patients with anatomic subclavian steal usually do not develop neurological symptoms but may rarely present with posterior circulation ischemia. Arteriovenous malformations alter cerebral blood flow patterns and regional perfusion pressure. It has been hypothesized that cerebral arteriovenous malformations may cause neurological deficits due to steal and that these deficits may be cured with arteriovenous malformation treatment. Intra-arterial pressure measurements and transcranial velocity studies show regional hemodynamic alterations. However, these changes have not been correlated with presenting symptoms. Evidence from single-photon emission computed tomography does suggest a relationship between regional hypoperfusion and neurological deficits. Coarctation of the aorta may divert flow from the spinal cord circulation through intercostal arteries distal to the stenosis. This is a possible but unproven mechanism of myelopathology. Steal syndromes may be amenable to treatment by open surgical or endovascular approaches. Experimental studies of the pathophysiology of steal are strengthened by precise definitions of the measured parameters and innovative applications of technology.
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Affiliation(s)
- Christopher L Taylor
- Department of Neurological Surgery, University of Texas Southwestern Medical School, Dallas, Texas 75390-8855, USA.
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Schreiber SJ, Franke U, Doepp F, Staccioli E, Uludag K, Valdueza JM. Dopplersonographic measurement of global cerebral circulation time using echo contrast-enhanced ultrasound in normal individuals and patients with arteriovenous malformations. ULTRASOUND IN MEDICINE & BIOLOGY 2002; 28:453-458. [PMID: 12049958 DOI: 10.1016/s0301-5629(02)00477-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Echo-contrast "bolus tracking" by ultrasound (US) is an exciting new tool to study cerebral haemodynamics. In the present study, a global cerebral circulation time (CCT) was measured by extracranial Doppler as the time difference of contrast bolus arrival between the internal carotid artery and internal jugular vein. A total of 64 healthy volunteers and 9 patients with an angiographically diagnosed arteriovenous malformation (AVM) were studied. CCT in volunteers and patients was calculated as the time interval between the points of 10% rise (CCT(1)) and 90% rise (CCT(3)) of the total intensity increase and between the turning points (CCT(2)) of the resulting time-intensity curves. In the volunteer group, CCT(1) was 5.4 +/- 1.8 s, CCT(2) was 7 +/- 1.3 s and CCT(3) 7.5 +/- 1.8 s. CCT results in the AVM group were 2.8 +/- 2.5 s, 3.0 +/- 1.3 s and 4.5 +/- 2.1 s, respectively, and differed significantly from the controls. For the first time, we could confirm a significant shortening of CCT in patients with cerebral AVM by US. The presented test might become a new, additional tool for AVM evaluation and follow-up of treatment in these patients.
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Abstract
Transcranial color coded sonography has proved valuable in the diagnostic work-up of cerebrovascular disorders in adults. More recently, evidences have converged that transcranial sonography is also useful in the diagnosis of brain parenchymal disorders. Here, a new field of application is the visualization of signal intensity shift in specific brain areas in some neurodegenerative disorders (Parkinson's disease, idiopathic dystonia, and depression). Findings obtained by transcranial ultrasound complement information from other neuroimaging data in these disorders and have led to the generation of new pathophysiological concepts. In this review we summarize the application fields of transcranial sonography with special emphasis on recent findings in neurodegenerative disorders and their implications for future research. As new application and processing techniques are being developed transcranial color coded sonography will gain increasing impact on both diagnosis and research of neurological disorders.
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Affiliation(s)
- Daniela Berg
- Department of Neurology, Bayerische Julius-Maximilians-Universität Würzburg, Germany
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26
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Morgan M, Winder M. Haemodynamics of arteriovenous malformations of the brain and consequences of resection: a review. J Clin Neurosci 2001; 8:216-24. [PMID: 11386794 DOI: 10.1054/jocn.2000.0795] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The physiological manifestations of arteriovenous fistulae in humans have been studied since the 18th century. However, confusion regarding concepts of cerebral 'steal', 'normal perfusion breakthrough', and 'congestive hyperaemia' continue. Although the advent of more accurate monitoring of pressures and flows within the brain has provided useful information to help understand some of these proposed pathological hypotheses, disagreement still exists. The purpose of this review is to examine the current physiological data in attempt to explain the clinicopathological manifestations of arteriovenous malformations of the brain and the consequences of their removal.
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Affiliation(s)
- M Morgan
- North and West Cerebrovascular Unit, Department of Surgery, The University of Sydney, Australia
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Van Roost D, Schramm J. What factors are related to impairment of cerebrovascular reserve before and after arteriovenous malformation resection? A cerebral blood flow study using xenon-enhanced computed tomography. Neurosurgery 2001; 48:709-16; discussion 716-7. [PMID: 11322430 DOI: 10.1097/00006123-200104000-00001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To examine the incidence and possible determinants of impaired vascular reserve in arteriovenous malformation (AVM)-affected brain, before and after surgery. METHODS In a prospective study of 30 patients, the regional cerebrovascular reserve capacity (rCRC) and the vasodilated regional cerebral blood flow (rCBF) were assessed during an acetazolamide challenge, using xenon-enhanced computed tomography, before and after complete AVM resection. Single brain slices at the level of the basal ganglia were examined, and scanning through the AVMs was avoided. Five regions of interest in the AVM-bearing hemisphere were compared with their counterparts in the unaffected hemisphere. Vasodilated rCBF reductions of at least 20% in one or more regions of interest and rCRC values of less than 10 ml/100 g/min were considered to be significant. RESULTS Ipsilateral vasodilated rCBF was significantly reduced in 17 patients before surgery and 15 patients after surgery. Ipsilateral rCRC was impaired in 14 patients before surgery and 12 patients after surgery. Large AVM size, venous congestion, and AVM-related vascular territories were correlated with impaired vascular reserve in AVM-nonadjacent brain tissue before surgery. Similar correlations were observed after surgery, except that not AVM size but a large number of AVM-supplying vascular territories was correlated. Moreover, the smallest AVMs and those supplied by a single vascular territory, as well as hemorrhage and nonhemorrhagic neurological deficits as presenting symptoms, were correlated with reduced ipsilateral vasodilated rCBF before surgery. Among patients with AVMs and nonhemorrhagic epilepsy, a trend of impaired cerebrovascular reserve was observed. In the only case of postresectional "breakthrough," the preoperative rCRC was not impaired but abnormally high. CONCLUSION Among the determinants of impaired cerebrovascular reserve, AVM size is already a constituent of current grading scales and decision-making paradigms, whereas factors such as venous congestion have been less closely considered or less obvious but may deserve increased attention in the future. Nonhemorrhagic epilepsy in patients with AVMs may constitute the clinical equivalent of chronic cerebral ischemia in a murine model. Postresectional breakthrough may be partly attributable to individual predisposition to excessive vasoreactivity in the whole brain.
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Affiliation(s)
- D Van Roost
- Department of Neurosurgery, University of Bonn, Germany.
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Van Roost D, Schramm J. What Factors Are Related to Impairment of Cerebrovascular Reserve before and after Arteriovenous Malformation Resection? A Cerebral Blood Flow Study Using Xenon-enhanced Computed Tomography. Neurosurgery 2001. [DOI: 10.1227/00006123-200104000-00001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Babikian VL, Feldmann E, Wechsler LR, Newell DW, Gomez CR, Bogdahn U, Caplan LR, Spencer MP, Tegeler C, Ringelstein EB, Alexandrov AV. Transcranial Doppler ultrasonography: year 2000 update. J Neuroimaging 2000; 10:101-15. [PMID: 10800264 DOI: 10.1111/jon2000102101] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
In this update, the main clinical applications of transcranial Doppler ultrasonography are reassessed. A specific format for technology assessment, personal experience, and an extensive review of the literature form the basis of the evaluation. The document is approved by the American Society of Neuroimaging and the Neurosonology Research Group of the World Federation of Neurology.
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Affiliation(s)
- V L Babikian
- Department of Neurology of Boston University, MA, USA
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31
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Taormina MA, Nichols FT. Use of Transcranial Doppler Sonography to Evaluate Patients With Cerebrovascular Disease. Neurosurg Clin N Am 1996. [DOI: 10.1016/s1042-3680(18)30348-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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32
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Correlation of the Angioarchitectural Features of Cerebral Arteriovenous Malformations with Clinical Presentation of Hemorrhage. Neurosurgery 1995. [DOI: 10.1097/00006123-199511000-00002] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Turjman F, Massoud TF, Viñuela F, Sayre JW, Guglielmi G, Duckwiler G. Correlation of the angioarchitectural features of cerebral arteriovenous malformations with clinical presentation of hemorrhage. Neurosurgery 1995; 37:856-60; discussion 860-2. [PMID: 8559332 DOI: 10.1227/00006123-199511000-00002] [Citation(s) in RCA: 181] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Superselective angiography is the most accurate technique in the analysis of brain arteriovenous malformation (AVM) angioarchitecture. Therefore, we reviewed the selective and superselective angiograms of 100 consecutive patients with intracerebral AVMs. Our purpose was to determine which parameters of angioarchitecture were significantly correlated with a clinical presentation of hemorrhage. The vascular characteristics evaluated on the angiograms were the size of the AVM, the location of the AVM, the type of nidus, the type of feeders, the characteristics of venous drainage, and the number and location of aneurysms. The parameters found to correlate with hemorrhage were deep venous drainage (P = 0.01), feeding by perforators (P = 0.01), intranidal aneurysm(s) (P = 0.004), multiple aneurysms (P = 0.001), feeding by the vertebrobasilar system (P = 0.002), and location in the basal ganglia (P = 0.04). Six parameters of AVM angioarchitecture were correlated with a clinical presentation of hemorrhage. Among these parameters, three (feeding by perforators, number of aneurysms, and presence of intranidal aneurysms) were well displayed by superselective angiogram.
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Affiliation(s)
- F Turjman
- Endovascular Therapy Service, University of California Los Angeles Medical Center, USA
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