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Pinto DS, Clode H, Madrazo BL, Paes FM, Alessandrino F. Imaging review of spontaneous renal hemorrhage. Emerg Radiol 2024; 31:515-528. [PMID: 38703272 DOI: 10.1007/s10140-024-02233-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/18/2024] [Indexed: 05/06/2024]
Abstract
Spontaneous renal hemorrhage (SRH) is a diagnostic challenge and a significant cause of morbidity, and sometimes mortality. Early identification is essential to institute lifesaving and reno-protective interventions. In this review, we classify spontaneous renal hemorrhage by location, presentation and etiology. We also discuss the diagnostic approach to renal hemorrhage and optimum imaging modalities to arrive at the diagnosis. Finally, we review strategies to avoid missing a diagnosis of SRH and discuss the pitfalls of imaging in the presence of renal hemorrhage.
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Affiliation(s)
- Denver S Pinto
- Jackson Memorial Hospital, University of Miami, Miami, USA.
| | - Hannah Clode
- Jackson Memorial Hospital, University of Miami, Miami, USA
- Department of Radiology, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | | | - Fabio M Paes
- Miller School of Medicine, Jackson Memorial Hospital - Ryder Trauma Center, University of Miami, Miami, FL, USA
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Zhang Y, Chen Y, Li R, Ma L, Han H, Li Z, Zhang H, Yuan K, Zhao Y, Jin W, Chen P, Zhou W, Ye X, Li Y, Wang S, Chen X, Zhao Y. Overloaded transnidal pressure gradient as the hemodynamic mechanism leading to arteriovenous malformation rupture: a quantitative analysis using intravascular pressure monitoring and color-coded digital subtraction angiography. J Neurointerv Surg 2024:jnis-2023-021348. [PMID: 38471763 DOI: 10.1136/jnis-2023-021348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/18/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND The hemodynamics of brain arteriovenous malformations (AVMs) may have implications for hemorrhage. This study aimed to explore the hemodynamics of ruptured AVMs by direct microcatheter intravascular pressure monitoring (MIPM) and indirect quantitative digital subtraction angiography (QDSA). METHODS We recruited patients with AVMs at a tertiary neurosurgery center from October 2020 to March 2023. In terms of MIPM, we preoperatively super-selected a predominant feeding artery and main draining vein through angiography to measure intravascular pressure before embolization. In processing of QDSA, we adopted previously standardized procedure for quantitative hemodynamics analysis of pre-embolization digital subtraction angiography (DSA), encompassing main feeding artery, nidus, and the main draining vein. Subsequently, we investigated the correlation between AVM rupture and intravascular pressure from MIPM, as well as hemodynamic parameters derived from QDSA. Additionally, we explored the interrelationships between hemodynamic indicators in both dimensions. RESULTS After strict screening of patients, our study included 10 AVMs (six ruptured and four unruptured). We found that higher transnidal pressure gradient (TPG) (53.00±6.36 vs 39.25±8.96 mmHg, p=0.042), higher feeding artery pressure (FAP) (72.83±5.46 vs 65.00±6.48 mmHg, p=0.031) and higher stasis index of nidus (3.54±0.73 vs 2.43±0.70, p=0.043) were significantly correlated with AVM rupture. In analysis of interrelationships between hemodynamic indicators in both dimensions, a strongly positive correlation (r=0.681, p=0.030) existed between TPG and stasis index of nidus. CONCLUSIONS TPG and FAP from MIPM platform and nidus stasis index from QDSA platform were correlated with AVM rupture, and both were positively correlated, suggesting that higher pressure load within nidus may be the central mechanism leading to AVM rupture.
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Affiliation(s)
- Yukun Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Weitao Jin
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Pingting Chen
- College of Energy and Power Engineering, Nanjing University of Aeronautics and Astronautics, Nanjing, Jiangsu, China
| | - Wanting Zhou
- Department of Artificial Intelligence, Beijing University of Posts and Telecommunications, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
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Huang PW, Peng SJ, Pan DHC, Yang HC, Tsai JT, Shiau CY, Su IC, Chen CJ, Wu HM, Lin CJ, Chung WY, Guo WY, Lo WL, Lai SW, Lee CC. Vascular compactness of unruptured brain arteriovenous malformation predicts risk of hemorrhage after stereotactic radiosurgery. Sci Rep 2024; 14:4011. [PMID: 38369533 PMCID: PMC10874940 DOI: 10.1038/s41598-024-54369-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/12/2024] [Indexed: 02/20/2024] Open
Abstract
The aim of the study was to investigate whether morphology (i.e. compact/diffuse) of brain arteriovenous malformations (bAVMs) correlates with the incidence of hemorrhagic events in patients receiving Stereotactic Radiosurgery (SRS) for unruptured bAVMs. This retrospective study included 262 adult patients with unruptured bAVMs who underwent upfront SRS. Hemorrhagic events were defined as evidence of blood on CT or MRI. The morphology of bAVMs was evaluated using automated segmentation which calculated the proportion of vessel, brain tissue, and cerebrospinal fluid in bAVMs on T2-weighted MRI. Compactness index, defined as the ratio of vessel to brain tissue, categorized bAVMs into compact and diffuse types based on the optimal cutoff. Cox proportional hazard model was used to identify the independent factors for post-SRS hemorrhage. The median clinical follow-ups was 62.1 months. Post-SRS hemorrhage occurred in 13 (5.0%) patients and one of them had two bleeds, resulting in an annual bleeding rate of 0.8%. Multivariable analysis revealed bAVM morphology (compact versus diffuse), bAVM volume, and prescribed margin dose were significant predictors. The post-SRS hemorrhage rate increased with larger bAVM volume only among the diffuse nidi (1.7 versus 14.9 versus 30.6 hemorrhage per 1000 person-years in bAVM volume < 20 cm3 versus 20-40 cm3 versus > 40 cm3; p = 0.022). The significantly higher post-SRS hemorrhage rate of Spetzler-Martin grade IV-V compared with grade I-III bAVMs (20.0 versus 3.3 hemorrhages per 1000 person-years; p = 0.001) mainly originated from the diffuse bAVMs rather than the compact subgroup (30.9 versus 4.8 hemorrhages per 1000 person-years; p = 0.035). Compact and smaller bAVMs, with higher prescribed margin dose harbor lower risks of post-SRS hemorrhage. The post-SRS hemorrhage rate exceeded 2.2% annually within the diffuse and large (> 40 cm3) bAVMs and the diffuse Spetzler-Martin IV-V bAVMs. These findings may help guide patient selection of SRS for the unruptured bAVMs.
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Affiliation(s)
- Po-Wei Huang
- Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Syu-Jyun Peng
- Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jo-Ting Tsai
- Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - I-Chang Su
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Texas Health Science Center, Houston, TX, USA
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Lun Lo
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Shao-Wen Lai
- Product and Engineering, Zippin, San Carlos, CA, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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McGuire LS, Rizko M, Brunozzi D, Charbel FT, Alaraj A. Vessel wall imaging and quantitative flow assessment in arteriovenous malformations: A feasibility study. Interv Neuroradiol 2022:15910199221143189. [PMID: 36471507 DOI: 10.1177/15910199221143189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION Cerebral arteriovenous malformations (AVMs) carry a rupture rate of 2-3% per year. Several architectural factors may influence rupture rate, and a recently theorized model of AVMs describes the influence of vessel wall inflammation. A novel imaging modality, vessel wall imaging (VWI), has been developed to view inflammatory processes in vessel wall foci but has not yet been examined in AVMs, which is the aim of this study. METHODS This retrospective review studies prospectively collected data on patients with ruptured and unruptured AVMs between 2019 and 2021. Inclusion criteria included adult patients (≥18 years) with radiographically diagnosed AVM who underwent VWI. Charts were reviewed for medical history, clinical presentation, hospital course, discharge condition, and follow-up. Angioarchitectural features, blood flow, and VWI were compared in patients with and without hemorrhagic patients. RESULTS Nine patients underwent VWI, mean age 37.7 ± 9.9 years. Four presented with hemorrhage (44.4%). Seven (77.7%) received glue embolization and 6 (66.7%) underwent surgical resection. All patients (4/4) with a history of hypertension presented with hemorrhage (p = 0.0027). Size and Spetzler-Martin grade were not associated with hemorrhage (p = 0.47, p = 0.59). Net AVM flow was higher in patients presenting with hemorrhage, although nonsignificant (p = 0.19). With VWI, 3 (75%) hemorrhagic AVMs showed visible nidus and draining veins, and all three demonstrated positive post-contrast wall enhancement in at least one of their draining veins; conversely, of fivenonhemorrhagic AVMs, only 2 (40%) demonstrated post-contrast wall enhancement in any draining vein (p = 0.090). CONCLUSION This pilot study successfully demonstrated capture of venous walls in AVMs using VWI. In this study, draining vein enhancement occurred more often in hemorrhagic AVM and in those with higher venous volumetric flow.
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Affiliation(s)
- Laura Stone McGuire
- Department of Neurosurgery, 14681The University of Illinois at Chicago, Chicago, IL, USA
| | - Mark Rizko
- Department of Neurosurgery, 14681The University of Illinois at Chicago, Chicago, IL, USA
| | - Denise Brunozzi
- Department of Neurosurgery, 14681The University of Illinois at Chicago, Chicago, IL, USA
| | - Fady T Charbel
- Department of Neurosurgery, 14681The University of Illinois at Chicago, Chicago, IL, USA
| | - Ali Alaraj
- Department of Neurosurgery, 14681The University of Illinois at Chicago, Chicago, IL, USA
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Volders D, Cora EA, Chaalala C, Cartier M, Tanaka M, Farzin B, Berthelet F, Raymond J. Fatal hemorrhagic complication after coil embolization of a petrosal arteriovenous shunt. Interv Neuroradiol 2022; 28:629-633. [PMID: 34775852 PMCID: PMC9706274 DOI: 10.1177/15910199211057705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 10/17/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Cerebello-pontine AVMs (CPAVMs) and petrous apex dural arteriovenous fistulae (DAVFs) are rare and sometimes difficult to distinguish. We report a fatal hemorrhagic complication after coil embolization of the petrosal vein draining a trigeminal AVM misdiagnosed as a DAVF. CASE PRESENTATION A 73-year-old woman with a petrous apex arteriovenous shunt with dual dural and pial arterial supply presented with posterior fossa hemorrhage. The draining petrosal vein was catheterized and coiled via the superior petrosal sinus. Two episodes of contrast extravasation occurred during coiling, but the lesion was completely occluded at the end of the procedure. The patient developed a fatal posterior fossa hemorrhage in the recovery room. Microscopic pathology revealed numerous dilated vessels within the trigeminal nerve. CONCLUSION CPAVMs and DAVFs with pial drainage should be distinguished pre-operatively. Occlusion of a pial vein (as opposed to a sinus) in the treatment of an arteriovenous shunt carries hemorrhagic risk if a liquid embolic agent is not used to completely occlude all pathological vessels.
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Affiliation(s)
- David Volders
- Department of Radiology, Centre Hospitalier de l’Université de Montréal
(CHUM), Montreal, Quebec, Canada
- Department of Radiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Elena Adela Cora
- Department of Radiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Chiraz Chaalala
- Department of Neurosurgery, Centre Hospitalier de l’Université de Montréal
(CHUM), Montreal, Quebec, Canada
| | - Maxime Cartier
- Department of Radiology, Centre Hospitalier de l’Université de Montréal
(CHUM), Montreal, Quebec, Canada
| | - Michihiro Tanaka
- Department of Neurointervention, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Behzad Farzin
- Department of Radiology, Centre Hospitalier de l’Université de Montréal
(CHUM), Montreal, Quebec, Canada
| | - France Berthelet
- Department of Anatomy and Pathology, Centre Hospitalier de l’Université de Montréal
(CHUM), Montreal, Canada
| | - Jean Raymond
- Department of Radiology, Centre Hospitalier de l’Université de Montréal
(CHUM), Montreal, Quebec, Canada
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Transvenous Embolization Technique for Brain Arteriovenous Malformations. Neurosurg Clin N Am 2022; 33:185-191. [DOI: 10.1016/j.nec.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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7
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Menon DD, Patil D, K M B, Acharya UV, Pandey P. High flow arteriovenous malformation with transverse-sigmoid sinus stenosis and congestive venopathy mimicking DAVF. Br J Neurosurg 2022:1-4. [PMID: 34994263 DOI: 10.1080/02688697.2021.2024500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 09/30/2021] [Accepted: 12/27/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND Arteriovenous malformations commonly present with hemorrhage, seizures, headache and other symptomatology. However, AVMs presenting as venous hypertension, owing to downstream stenosis/occlusion of venous sinuses, are very rare. This presentation is much more common in patients with dural AVFs. CASE DESCRIPTION We present a young lady with left frontal arteriovenous malformation with bilateral transverse-sigmoid sinus stenosis, presenting with features of venous hypertension, which was treated with surgical excision of AVM. This case demonstrates a rare example of AVM with co-existing venous sinus stenosis distal to the nidus. CONCLUSIONS High flow AVMs may co-exist with venous sinus stenosis or occlusion and lead to congestive venopathy. Treatment of AVM with surgical resection can be performed safely to relieve the hyper-dynamic venous congestion.
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Affiliation(s)
- Dinesh D Menon
- Department of Neurosurgery, Manipal Hospitals, Bengaluru, India
| | - Dnyandeep Patil
- Department of Neurosurgery, Manipal Hospitals, Bengaluru, India
| | - Bopanna K M
- Department of Neurosurgery, Manipal Hospitals, Bengaluru, India
| | - Ullas V Acharya
- Department of Interventional Neuroradiology, Manipal Hospitals, Bengaluru, India
| | - Paritosh Pandey
- Department of Neurosurgery, Manipal Hospitals, Bengaluru, India
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Kochi R, Endo H, Uchida H, Kawaguchi T, Omodaka S, Matsumoto Y, Tominaga T. Efficacy of arterial spin labeling for detection of the ruptured micro-arteriovenous malformation: illustrative cases. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 3:CASE21597. [PMID: 36131567 PMCID: PMC9379700 DOI: 10.3171/case21597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/18/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND Diagnosis of a microarteriovenous malformation (micro-AVM) is difficult, especially in the acute stage of rupture because of the small size of the nidus and the existence of hematoma. We report two cases of ruptured micro-AVMs detected by arterial spin labeling (ASL). OBSERVATIONS In one case, a 45-year-old male was transported with a complaint of right hemiparesis. Computed tomography (CT) revealed a right parietal lobar hemorrhage. Standard magnetic resonance imaging (MRI) showed no abnormal findings as the cause of the hemorrhage. ASL 23 days after the onset demonstrated high signals on the medial wall of the hematoma. Digital subtraction angiography (DSA) showed a micro-AVM in accordance with the site of high signals on ASL. In another case, a 38-year-old female was transported with a complaint of left hemianopsia. CT on admission revealed a right parietal lobar hemorrhage. Standard MRI showed no abnormal findings as the cause of the hemorrhage. ASL 15 days after the onset demonstrated high signals on the internal wall of the hematoma. DSA showed micro-AVM in accordance with the site of high signaling on ASL. Both cases were successfully treated with open surgery. LESSONS ASL can manifest micro-AVMs as high signals within the hematoma. ASL is a useful less-invasive screening tool for the detection of ruptured micro-AVMs.
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Affiliation(s)
| | - Hidenori Endo
- Departments of Neurosurgery and
- Neuroendovascular Therapy, Kohnan Hospital, Sendai, Miyagi, Japan
| | | | | | - Shunsuke Omodaka
- Division of Advanced Cerebrovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan; and
| | - Yasushi Matsumoto
- Division of Advanced Cerebrovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan; and
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Nicholson P, Krings T. Interventional Therapy of Brain and Spinal Arteriovenous Malformations. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00069-7] [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]
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Jain MS, Telischak NA, Heit JJ, Do HM, Massoud TF. Comparison of embolization strategies for mixed plexiform and fistulous brain arteriovenous malformations: a computational model analysis of theoretical risks of nidus rupture. J Neurointerv Surg 2021; 14:1213-1219. [PMID: 34893533 DOI: 10.1136/neurintsurg-2021-018067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 11/29/2021] [Indexed: 11/03/2022]
Abstract
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 (Pmean) 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 Pmean 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.
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Affiliation(s)
- Mika S Jain
- Departments of Physics and Computer Science, Stanford University School of Humanities and Sciences, Stanford, California, USA
| | - Nicholas A Telischak
- Division of Neuroimaging and Neurointervention, Department of Radiology, and Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Jeremy J Heit
- Division of Neuroimaging and Neurointervention, Department of Radiology, and Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Huy M Do
- Division of Neuroimaging and Neurointervention, Department of Radiology, and Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Tarik F Massoud
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
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Keränen S, Suutarinen S, Mallick R, Laakkonen JP, Guo D, Pawlikowska L, Jahromi BR, Rauramaa T, Ylä-Herttuala S, Marchuk D, Krings T, Koivisto T, Lawton M, Radovanovic I, Kim H, Faughnan ME, Frösen J. Cyclo-oxygenase 2, a putative mediator of vessel remodeling, is expressed in the brain AVM vessels and associates with inflammation. Acta Neurochir (Wien) 2021; 163:2503-2514. [PMID: 34185176 PMCID: PMC8357659 DOI: 10.1007/s00701-021-04895-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/26/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Brain arteriovenous malformations (bAVM) may rupture causing disability or death. BAVM vessels are characterized by abnormally high flow that in general triggers expansive vessel remodeling mediated by cyclo-oxygenase-2 (COX2), the target of non-steroidal anti-inflammatory drugs. We investigated whether COX2 is expressed in bAVMs and whether it associates with inflammation and haemorrhage in these lesions. METHODS Tissue was obtained from surgery of 139 bAVMs and 21 normal Circle of Willis samples. The samples were studied with immunohistochemistry and real-time quantitative polymerase chain reaction (RT-PCR). Clinical data was collected from patient records. RESULTS COX2 expression was found in 78% (109/139) of the bAVMs and localized to the vessels' lumen or medial layer in 70% (95/135) of the bAVMs. Receptors for prostaglandin E2, a COX2-derived mediator of vascular remodeling, were found in the endothelial and smooth muscle cells and perivascular inflammatory cells of bAVMs. COX2 was expressed by infiltrating inflammatory cells and correlated with the extent of inflammation (r = .231, p = .007, Spearman rank correlation). COX2 expression did not associate with haemorrhage. CONCLUSION COX2 is induced in bAVMs, and possibly participates in the regulation of vessel wall remodelling and ongoing inflammation. Role of COX2 signalling in the pathobiology and clinical course of bAVMs merits further studies.
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Affiliation(s)
- Sara Keränen
- Hemorrhagic Brain Pathology Research Group, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Joensuu, Kuopio, Finland
| | - Santeri Suutarinen
- Hemorrhagic Brain Pathology Research Group, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Joensuu, Kuopio, Finland
| | - Rahul Mallick
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Joensuu, Kuopio, Finland
| | - Johanna P Laakkonen
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Joensuu, Kuopio, Finland
| | - Diana Guo
- Center for Cerebrovascular Research, Dept of Anesthesiology and Perioperative Care, UCSF, San Francisco, CA, USA
| | - Ludmila Pawlikowska
- Center for Cerebrovascular Research, Dept of Anesthesiology and Perioperative Care, UCSF, San Francisco, CA, USA
| | - Behnam Rezai Jahromi
- Hemorrhagic Brain Pathology Research Group, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Joensuu, Kuopio, Finland
| | - Tuomas Rauramaa
- Hemorrhagic Brain Pathology Research Group, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Department of Pathology, Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland
| | - Seppo Ylä-Herttuala
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Joensuu, Kuopio, Finland
| | - Doug Marchuk
- Division of Human Genetics, Duke University School of Medicine, Durham, NC, USA
| | - Timo Krings
- Department of Neuroradiology, University Hospital Network Toronto, Toronto, Canada
| | - Timo Koivisto
- Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Michael Lawton
- Department of Neurosurgery, Barrow Brain and Spine Institute, Phoenix, AZ, USA
| | - Ivan Radovanovic
- Department of Neurosurgery, University Hospital Network Toronto, Toronto, Canada
| | - Helen Kim
- Center for Cerebrovascular Research, Dept of Anesthesiology and Perioperative Care, UCSF, San Francisco, CA, USA
| | - Marie E Faughnan
- Toronto HHT Centre, St. Michael's Hospital and Li Ka Shing Knowledge Institute, Toronto, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Juhana Frösen
- Hemorrhagic Brain Pathology Research Group, NeuroCenter, Kuopio University Hospital, Kuopio, Finland.
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Joensuu, Kuopio, Finland.
- Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland.
- Department of Neurosurgery, Tampere University Hospital and University of Tampere, Elämänaukio 2, PoBox 33521, Tampere, Finland.
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12
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Youn SW, Lee J. From 2D to 4D Phase-Contrast MRI in the Neurovascular System: Will It Be a Quantum Jump or a Fancy Decoration? J Magn Reson Imaging 2020; 55:347-372. [PMID: 33236488 DOI: 10.1002/jmri.27430] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/16/2022] Open
Abstract
Considering the crosstalk between the flow and vessel wall, hemodynamic assessment of the neurovascular system may offer a well-integrated solution for both diagnosis and management by adding prognostic significance to the standard CT/MR angiography. 4D flow MRI or time-resolved 3D velocity-encoded phase-contrast MRI has long been promising for the hemodynamic evaluation of the great vessels, but challenged in clinical studies for assessing intracranial vessels with small diameter due to long scan times and low spatiotemporal resolution. Current accelerated MRI techniques, including parallel imaging with compressed sensing and radial k-space undersampling acquisitions, have decreased scan times dramatically while preserving spatial resolution. 4D flow MRI visualized and measured 3D complex flow of neurovascular diseases such as aneurysm, arteriovenous shunts, and atherosclerotic stenosis using parameters including flow volume, velocity vector, pressure gradients, and wall shear stress. In addition to the noninvasiveness of the phase contrast technique and retrospective flow measurement through the wanted windows of the analysis plane, 4D flow MRI has shown several advantages over Doppler ultrasound or computational fluid dynamics. The evaluation of the flow status and vessel wall can be performed simultaneously in the same imaging modality. This article is an overview of the recent advances in neurovascular 4D flow MRI techniques and their potential clinical applications in neurovascular disease. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY STAGE: 3.
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Affiliation(s)
- Sung Won Youn
- Department of Radiology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jongmin Lee
- Department of Radiology and Biomedical Engineering, Kyungpook National University School of Medicine, Daegu, Korea
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13
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See AP, Mohammaden MH, Rizko M, Stapleton CJ, Amin-Hanjani S, Charbel FT, Aletich V, Alaraj A. Morbidity and mortality associated with sequential flow reduction embolization technique of cerebral arteriovenous malformations using n-butyl cyanoacrylate. J Neurointerv Surg 2020; 13:237-241. [PMID: 32801122 DOI: 10.1136/neurintsurg-2020-016223] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/18/2020] [Accepted: 07/29/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Endovascular embolization of cerebral arteriovenous malformations (AVM) with liquid n-butyl cyanoacrylate (n-BCA) serves multiple purposes including AVM occlusion and flow reduction in preparation for other treatment modalities. The objective was to study the clinical, structural, and angiographic factors affecting complications associated with AVM treatment by sequential n-BCA embolizations for nidal occlusion versus quantitative flow reduction in preparation for surgical resection or radiosurgery. METHODS We performed a retrospective review of all patients who underwent endovascular embolization of cerebral AVM at our institution between 1998 and 2019, during which time the technique of traditional embolization evolved to a strategy of targeted sequential flow reduction guided by serial flow imaging based on quantitative magnetic resonance angiography, in conjunction with a shift away from nidal penetration. RESULTS Among 251 patients, 47.8% of patients presented with ruptured AVM. On average, each patient underwent 2.4 embolizations, for a total of 613 sessions. Major morbidity related to embolization occurred in 18 (7.2%) patients, but this occurred disproportionately in the traditional embolization strategy (n=16, 8%) in contrast with the flow-targeting strategy (n=2, 3.8%). Four patients (1.6%) died in the overall group, and these all occurred with the traditional embolization strategy (2% of 199 patients); no deaths occurred in the flow-targeting strategy (n=52). CONCLUSION Embolization with n-BCA targeted to sequential flow reduction and feeder occlusion with limited nidal penetration prior to definitive surgical or radiosurgical treatment can be safely performed with low overall morbidity and mortality.
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Affiliation(s)
- Alfred P See
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60607, USA
| | - Mahmoud H Mohammaden
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60607, USA
| | - Mark Rizko
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60607, USA
| | | | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60607, USA
| | - Fady T Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60607, USA
| | - Victor Aletich
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60607, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60607, USA
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14
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Fu W, Huo R, Yan Z, Xu H, Li H, Jiao Y, Wang L, Weng J, Wang J, Wang S, Cao Y, Zhao J. Mesenchymal Behavior of the Endothelium Promoted by SMAD6 Downregulation Is Associated With Brain Arteriovenous Malformation Microhemorrhage. Stroke 2020; 51:2197-2207. [PMID: 32486965 DOI: 10.1161/strokeaha.120.030046] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE In unruptured brain arteriovenous malformations (bAVMs), microhemorrhage portends a higher risk of future rupture and may represent a transitional state along the continuum of destabilization. Exploration of the molecular and cellular mechanisms of microhemorrhage will provide a possible target for medical treatment to prevent bAVM bleeding. METHODS We performed RNA sequencing analysis on 34 unruptured bAVM surgical samples. Functional pathway analysis was performed to identify potential signals associated with the microhemorrhagic phenotype. Candidate gene was then investigated in bAVM specimens by immunohistochemical staining. Several functional assays were used to investigate the effects of candidate genes on the phenotypic properties of cultured human umbilical vein endothelial cells. Then, Masson trichrome staining and immunofluorescence staining were used to evaluate the phenotypic and molecular changes in bAVM tissue. RESULTS Via RNA sequencing, we identified differential gene expression between 18 microhemorrhagic bAVMs and 16 nonmicrohemorrhagic bAVMs. TGFβ (transforming growth factor-beta)/BMP (bone morphogenetic protein) signaling was associated with the bAVM microhemorrhage group when SMAD6 (SMAD family member 6) was downregulated. Immunohistochemical staining showed that the vascular endothelium of microhemorrhagic bAVMs exhibited decreased SMAD6 expression. Functional assays revealed that SMAD6 downregulation promoted the formation of endothelial cell tubes with deficient cell-cell junctions and facilitated the acquisition of mesenchymal behavior by endothelial cells. Masson trichrome and immunofluorescence staining demonstrated that mesenchymal phenotype of endothelial cells is promoted in microhemorrhagic bAVMs. CONCLUSIONS TGFβ/BMP signaling mediated by SMAD6 in vascular endothelial cells is associated with microhemorrhagic bAVMs, and mesenchymal behavior of endothelial cells induced by SMAD6 downregulation is related with bAVM microhemorrhage.
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Affiliation(s)
- Weilun Fu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Ran Huo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Zihan Yan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Hongyuan Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Hao Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Linjian Wang
- Savaid Medical School, University of the Chinese Academy of Sciences, Beijing (L.W., J.Z.)
| | - Jiancong Weng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Jie Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.)
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,Beijing Neurosurgical Institute, Capital Medical University, China (Y.C.)
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,China National Clinical Research Center for Neurological Diseases, Beijing (W.F., R.H., Z.Y, H.X., H.L., Y.J., J. Weng, J. Wang, S.W., Y.C., J.Z.).,Savaid Medical School, University of the Chinese Academy of Sciences, Beijing (L.W., J.Z.)
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15
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Ramachandran S, Mukherjee D, Delf J, Bown MJ, Kandiyil N. A comparison of arterial spin labelling with catheter angiography in evaluating arteriovenous malformations: a systematic review. Br J Radiol 2020; 93:20190830. [PMID: 32208976 PMCID: PMC10993222 DOI: 10.1259/bjr.20190830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/10/2020] [Accepted: 03/12/2020] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To compare the performance of arterial spin labelling (ASL) in evaluating arteriovenous malformations (AVMs) against the current gold standard of catheter angiography. METHODS We systematically reviewed the published literature using EMBASE and Medline. We included studies that compared ASL to catheter angiography in the assessment of AVMs in three outcome domains: detection, angioarchitectural and haemodynamic features. RESULTS From 314 unique citations, 19 studies representing 289 patients with intracranial AVMs met our inclusion criteria. We did not pool data due to marked heterogeneity in study outcome measures. Seven studies showed high diagnostic performance of ASL in identifying arterial feeders, with sensitivity ranging from 84.6 to 100% and specificity ranging from 93.3 to 100%. Six studies showed strong ability in detecting arteriovenous shunting, with sensitivity ranging from 91.7 to 100% and specificity ranging from 90 to 100%. Seven studies demonstrated that ASL could identify nidal location and size as well as catheter angiography, while five studies showed relatively poorer performance in delineating venous drainage. Two studies showed 100% sensitivity of ASL in the identification of residual or obliterated AVMs following stereotactic radiosurgery. CONCLUSIONS Despite limitations in the current evidence base and technical challenges, this review suggests that ASL has a promising role in the work-up and post-treatment follow-up of AVMs. Larger scale prospective studies assessing the diagnostic performance of ASL are warranted. ADVANCES IN KNOWLEDGE ASL demonstrates overall validity in the evaluation of intracranial AVMs.
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Affiliation(s)
- Sanjeev Ramachandran
- University Hospitals of Leicester NHS Trust,
Leicester, United Kingdom
- University of Leicester,
Leicester, United Kingdom
| | - Deyashini Mukherjee
- University Hospitals of Leicester NHS Trust,
Leicester, United Kingdom
- University of Leicester,
Leicester, United Kingdom
| | - Jonathan Delf
- University Hospitals of Leicester NHS Trust,
Leicester, United Kingdom
| | - Matthew James Bown
- University Hospitals of Leicester NHS Trust,
Leicester, United Kingdom
- University of Leicester,
Leicester, United Kingdom
| | - Neghal Kandiyil
- University Hospitals of Leicester NHS Trust,
Leicester, United Kingdom
- University of Leicester,
Leicester, United Kingdom
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16
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Targeted endovascular treatment for ruptured brain arteriovenous malformations. Neurosurg Rev 2019; 43:1509-1518. [DOI: 10.1007/s10143-019-01205-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 10/08/2019] [Accepted: 10/29/2019] [Indexed: 11/26/2022]
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17
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Jain MS, Do HM, Massoud TF. Computational Network Modeling of Intranidal Hemodynamic Compartmentalization in a Theoretical Three-Dimensional Brain Arteriovenous Malformation. Front Physiol 2019; 10:1250. [PMID: 31607956 PMCID: PMC6769414 DOI: 10.3389/fphys.2019.01250] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 09/12/2019] [Indexed: 11/15/2022] Open
Abstract
There are currently no in vivo techniques to accurately study dynamic equilibrium of blood flow within separate regions (compartments) of a large brain arteriovenous malformation (AVM) nidus. A greater understanding of this AVM compartmentalization, even if theoretical, would be useful for optimal planning of endovascular and multimodal AVM therapies. We aimed to develop a biomathematical AVM model for theoretical investigations of intranidal regions of increased mean intravascular pressure (Pmean) and flow representing hemodynamic compartments, upon simulated AVM superselective angiography (SSA). We constructed an AVM model as a theoretical electrical circuit containing four arterial feeders (AF1–AF4) and a three-dimensional nidus of 97 interconnected plexiform and fistulous components. We simulated SSA by increases in Pmean in each AF (with and without occlusion of all other AFs), and then used network analysis to establish resulting increases in Pmean and flow within each nidus vessel. We analyzed shifts in hemodynamic compartments consequent to increasing AF injection pressures. SSA simulated by increases of 10 mm Hg in AF1, AF2, AF3, or AF4 resulted in dissipation of Pmean over 38, 66, 76, or 20% of the nidus, respectively, rising slightly with simultaneous occlusion of other AFs. We qualitatively analyzed shifting intranidal compartments consequent to varying injection pressures by mapping the hemodynamic changes onto the nidus network. Differences in extent of nidus filling upon SSA injections provide theoretical evidence that hemodynamic and angioarchitectural features help establish AVM nidus compartmentalization. This model based on a theoretical AVM will serve as a useful computational tool for further investigations of AVM embolotherapy strategies.
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Affiliation(s)
- Mika S Jain
- Department of Physics, School of Humanities and Sciences, Stanford University, Stanford, CA, United States.,Department of Computer Science, School of Engineering, Stanford University, Stanford, CA, United States
| | - Huy M Do
- Division of Neuroimaging and Neurointervention, Department of Radiology, School of Medicine, Stanford University, Stanford, CA, United States.,Department of Neurosurgery, School of Medicine, Stanford University, Stanford, CA, United States
| | - Tarik F Massoud
- Division of Neuroimaging and Neurointervention, Department of Radiology, School of Medicine, Stanford University, Stanford, CA, United States
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18
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Jain MS, Do HM, Wintermark M, Massoud TF. Large-scale ensemble simulations of biomathematical brain arteriovenous malformation models using graphics processing unit computation. Comput Biol Med 2019; 113:103416. [PMID: 31494430 DOI: 10.1016/j.compbiomed.2019.103416] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/24/2019] [Accepted: 08/24/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Theoretical modeling allows investigations of cerebral arteriovenous malformation (AVM) hemodynamics, but current models are too simple and not clinically representative. We developed a more realistic AVM model based on graphics processing unit (GPU) computing, to replicate highly variable and complex nidus angioarchitectures with vessel counts in the thousands-orders of magnitude greater than current models. METHODS We constructed a theoretical electrical circuit AVM model with a nidus described by a stochastic block model (SBM) of 57 nodes and an average of 1000 plexiform and fistulous vessels. We sampled and individually simulated 10,000 distinct nidus morphologies from this SBM, constituting an ensemble simulation. We assigned appropriate biophysical values to all model vessels, and known values of mean intravascular pressure (Pmean) to extranidal vessels. We then used network analysis to calculate Pmean and volumetric flow rate within each nidus vessel, and mapped these values onto a graphic representation of the nidus network. We derived an expression for nidus rupture risk and conducted a model parameter sensitivity analysis. RESULTS Simulations revealed a total intranidal volumetric blood flow ranging from 268 mL/min to 535 mL/min, with an average of 463 mL/min. The maximum percentage rupture risk among all vessels in the nidus ranged from 0% to 60%, with an average of 29%. CONCLUSION This easy to implement biomathematical AVM model, allowed by parallel data processing using advanced GPU computing, will serve as a useful tool for theoretical investigations of AVM therapies and their hemodynamic sequelae.
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Affiliation(s)
- Mika S Jain
- Department of Physics, Stanford University School of Humanities and Sciences, Stanford, CA, USA; Department of Computer Science, Stanford University School of Engineering, Stanford, CA, USA
| | - Huy M Do
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford, CA, USA; Department of Neurosurgery, Stanford, CA, USA
| | - Max Wintermark
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford, CA, USA; Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Tarik F Massoud
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford, CA, USA.
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19
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Alexander MD, Hippe DS, Cooke DL, Hallam DK, Hetts SW, Kim H, Lawton MT, Sekhar LN, Kim LJ, Ghodke BV. Targeted Embolization of Aneurysms Associated With Brain Arteriovenous Malformations at High Risk for Surgical Resection: A Case-Control Study. Neurosurgery 2019; 82:343-349. [PMID: 28419337 DOI: 10.1093/neuros/nyx167] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 03/10/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND High-risk components of brain arteriovenous malformations (BAVMs) can be targeted to reduce the risk of lesion rupture. OBJECTIVE To evaluate targeted embolization of aneurysms against other means of treatment with a case-control analysis; we previously investigated this approach associated with BAVMs. METHODS Retrospective analysis of patients with BAVMs was performed, identifying patients treated with intention to occlude only an aneurysm associated with a BAVM. For each targeted aneurysm embolization (TAE) patient identified, 4 control patients were randomly selected, controlling for rupture status, age, and Spetzler-Martin plus Lawton-Young supplemental score. Analysis was performed to compare rates of adverse events (hemorrhage, new seizure, and death) between the 2 groups. RESULTS Thirty-two patients met inclusion criteria, and 128 control patients were identified, out of 1103 patients treated during the study period. Thirty-four adverse events occurred (15 ruptures, 15 new seizures, and 11 deaths) during the follow-up period (mean 1157 d for the TAE cohort and 1036 d for the non-TAE cohort). Statistically lower associations were noted for the TAE group for any adverse event (hazard ratio 0.28, P = .037) and the composite outcome of hemorrhage or new seizure (hazard ratio 0.20, P = .029). CONCLUSION For BAVMs at high risk for surgical resection, TAE can be performed safely and effectively. Patients treated with TAE had better outcomes than matched patients undergoing other combinations of treatment. TAE can be considered for BAVMs with high operative risk prior to radiosurgery or when no other treatment options are available.
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Affiliation(s)
- Matthew D Alexander
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Daniel S Hippe
- Uni-versity Washington, Department of Radiology, Seattle, Washington
| | - Daniel L Cooke
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Danial K Hallam
- Uni-versity Washington, Department of Radiology, Seattle, Washington
| | - Steven W Hetts
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Helen Kim
- Univer-sity of California San Francisco, Depart-ment of Anesthesia and Perioperative Care, San Francisco, California
| | - Michael T Lawton
- University of California San Francisco, Department of Neurological Surgery, San Francisco, California
| | - Laligam N Sekhar
- University Washington, De-partment of Neurological Surgery, Seattle, Washington
| | - Louis J Kim
- University Washington, De-partment of Neurological Surgery, Seattle, Washington
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20
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Brunozzi D, Theiss P, Amin-Hanjani S, Charbel FT, Mohammaden M, Andrews A, Linninger A, Alaraj A. Ratio of Arteriovenous Malformation Draining Vein to Adjacent Venous Sinus Diameter Is Associated with Increased Risk of Venous Stenosis. World Neurosurg 2019; 130:e1111-e1115. [PMID: 31323417 DOI: 10.1016/j.wneu.2019.07.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 07/09/2019] [Accepted: 07/10/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The development of venous outflow stenosis in cerebral arteriovenous malformation (AVM) is poorly understood. The location of stenosis within the AVM draining vein in relation to the adjacent venous sinus and the hypothesis that the ratio of draining vein to adjacent sinus diameter might predict the development of venous stenosis were explored. METHODS Patients with supratentorial AVMs (1997-2018) were reviewed (N = 290). AVM draining vein and adjacent venous sinus diameters, degree of draining vein stenosis, and distance from the maximal stenotic point to the junction of the adjacent draining sinus were recorded. Correlation between percentage of AVM draining vein stenosis and the ratio of AVM draining vein to venous sinus diameters was analyzed. RESULTS A total of 360 draining veins in 243 AVMs with complete angiographic data were measured. Venous stenosis (in 131 draining veins) was observed within 20 mm of the junction to the adjacent draining sinus in 85% of our sample. The ratio of draining vein to adjacent sinus diameter correlated positively with the percentage of venous stenosis (P < 0.01, r = 0.21). The ratio between 0.51-1.0 and >1.0 showed significant tighter stenosis compared with the ratio ≤0.5 (25.9% and 28.9% vs. 10.0%, respectively; P < 0.01). CONCLUSIONS AVM venous outflow stenosis is observed close to the adjacent venous sinus junction. The degree of venous stenosis is greater when the ratio of AVM draining vein/adjacent venous sinus diameter is >0.5. This may be related to more turbulent flow at the junction of the draining vein and venous sinus, especially in larger draining veins, which causes venous stenosis to develop over time.
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Affiliation(s)
- Denise Brunozzi
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Peter Theiss
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Fady T Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mahmoud Mohammaden
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Amanda Andrews
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Andreas Linninger
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA; Department of Bioengineering, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA; Department of Bioengineering, University of Illinois at Chicago, Chicago, Illinois, USA.
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21
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Chen X, Lu X, Yan F, Xu W, Gao L, Zheng J, Yu J. Spontaneous thrombosis in main draining veins of unruptured cerebral arteriovenous malformations: A case report. Medicine (Baltimore) 2019; 98:e15588. [PMID: 31145278 PMCID: PMC6709146 DOI: 10.1097/md.0000000000015588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE Spontaneous obliteration of unruptured arteriovenous malformations (AVMs) is rare. It occurs in <1.5% of cerebral AVMs and only 7 cases have been reported so far. This phenomenon, together with the formation and outcome of cerebral AVMs, remains barely understood. In this work, we presented a case that spontaneous venous thrombosis in main draining veins of an unruptured AVM were confirmed, and reviewed the relevant literature in order to discuss the possible mechanisms. PATIENT CONCERNS Clinical data and treatment of a 33-year-old man with a preliminary diagnosis as right parietal mass with secondary epilepsy. DIAGNOSES The diagnosis of the mass was a right parietal arteriovenous malformation (AVM) that was 3.5 cm in size and supplied mainly by multiple feeders of right middle cerebral artery (MCA). INTERVENTIONS An operation was performed with meticulous hemostasis of the extracranial soft tissue and the AVM was resected completely. OUTCOMES The patient's neurological deficits improved postoperatively and he was subsequently discharged 1 week after surgery. LESSONS Thrombosis of the draining veins may be due to venous stagnation. Spontaneous venous thrombosis in an unruptured AVM is rare. Spontaneous obliteration of an AVM can occur by 2 mechanisms: occlusion of the feeding arteries or of the draining veins. Surgical or interventional treatment of an unruptured AVM with thrombosed draining veins is highly controversial now. However, we favor an aggressive treatment strategy.
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Bhogal P, Lansley J, Wong K, Udani SD, Uff C, Wadley J, Kumar A, Matouk CC, Makalanda HL. Vessel wall enhancement of a ruptured intra-nidal aneurysm in a brain arteriovenous malformation. Interv Neuroradiol 2019; 25:310-314. [PMID: 30764685 DOI: 10.1177/1591019918824796] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Ruptured arteriovenous malformations are a frequently encountered pathology with significant associated morbidity and mortality. Identifying and securing the rupture point is mandatory; however, this can often be difficult. Black blood vessel wall magnetic resonance imaging is a promising technique for identifying ruptured saccular aneurysms and has been used in cases of multiple aneurysms. Here we describe a case of using this imaging technique to identify the rupture point in a ruptured arteriovenous malformation with histopathological correlation.
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Affiliation(s)
- Pervinder Bhogal
- 1 Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | - Joseph Lansley
- 1 Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | - Ken Wong
- 1 Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | - Sundip D Udani
- 1 Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
| | - Chris Uff
- 2 Department of Neurosurgery, The Royal London Hospital, London, UK
| | - John Wadley
- 2 Department of Neurosurgery, The Royal London Hospital, London, UK
| | - Atul Kumar
- 3 Department of Neuropathology, Institute of Neurology, London, UK
| | - Charles C Matouk
- 4 Departments of Neurosurgery and of Radiology and Biomedical Imaging, Yale University, New Haven, USA
| | - Hegoda Ld Makalanda
- 1 Department of Interventional Neuroradiology, The Royal London Hospital, London, UK
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Venous Stenosis and Hemorrhage After Radiosurgery for Cerebral Arteriovenous Malformations. World Neurosurg 2018; 122:e1615-e1625. [PMID: 30500592 DOI: 10.1016/j.wneu.2018.11.193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND The risk of hemorrhage remains after radiosurgery for patients with arteriovenous malformations (AVMs), especially during the latency period. The effect of venous outflow stenosis on postradiosurgery AVM hemorrhage has been understudied. The present study sought to clarify the effect of venous stenosis on postradiation hemorrhage. METHODS We retrospectively reviewed the records of patients with AVM seen at our institution from 1990 to 2015. Patients who had undergone radiosurgery were included, and those without sufficient data were excluded. We performed multivariable Cox regression to evaluate the predictors of postradiosurgery hemorrhage, with specific emphasis on venous stenosis. Patients were censored from the first radiosurgery to hemorrhage or the last follow-up visit. The baseline and angiographic characteristics were compared between those with venous stenosis and those without to address potential confounders. RESULTS The present study included 240 patients, of whom 29 (12.1%) had venous stenosis. The venous stenosis cohort included more patients with venous varices (P = 0.009) and fewer with deep venous drainage (P = 0.048) compared with those without venous stenosis. Most patients had grade III or higher AVMs (63.2%), with an obliteration rate of 32.9%. In an all-inclusive multivariable Cox regression, hemorrhage risk was associated with venous stenosis (hazard ratio [HR], 3.70; P = 0.034), age (HR, 1.05; P = 0.002), AVM volume (HR, 1.04; P = 0.004), and hemorrhage before treatment (HR, 4.11; P = 0.014). Male gender was protective (HR, 0.31; P = 0.036) against hemorrhage. CONCLUSIONS We identified statistically significant risk factors for postradiosurgery AVM hemorrhage, which included advanced age, female gender, the presence of venous stenosis, a larger AVM volume, and previous hemorrhage. We recommend cautious selection of patients for radiosurgery with close follow-up after treatment, especially for patients with these risk factors.
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Chen CJ, Norat P, Ding D, Mendes GAC, Tvrdik P, Park MS, Kalani MY. Transvenous embolization of brain arteriovenous malformations: a review of techniques, indications, and outcomes. Neurosurg Focus 2018; 45:E13. [DOI: 10.3171/2018.3.focus18113] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endovascular embolization of brain arteriovenous malformations (AVMs) is conventionally performed from a transarterial approach. Transarterial AVM embolization can be a standalone treatment or, more commonly, used as a neoadjuvant therapy prior to microsurgery or stereotactic radiosurgery. In contrast to the transarterial approach, curative embolization of AVMs may be more readily achieved from a transvenous approach. Transvenous embolization is considered a salvage therapy in contemporary AVM management. Proposed indications for this approach include a small (diameter < 3 cm) and compact AVM nidus, deep AVM location, hemorrhagic presentation, single draining vein, lack of an accessible arterial pedicle, exclusive arterial supply by perforators, and en passage feeding arteries. Available studies of transvenous AVM embolization in the literature have reported high complete obliteration rates, with reasonably low complication rates. However, evaluating the efficacy and safety of this approach is challenging due to the limited number of published cases. In this review the authors describe the technical considerations, indications, and outcomes of transvenous AVM embolization.
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Affiliation(s)
- Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Pedro Norat
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- 2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - George A. C. Mendes
- 3Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, France
| | - Petr Tvrdik
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Min S. Park
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - M. Yashar Kalani
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Orlov K, Panarin V, Krivoshapkin A, Kislitsin D, Berestov V, Shayakhmetov T, Gorbatykh A. Assessment of periprocedural hemodynamic changes in arteriovenous malformation vessels by endovascular dual-sensor guidewire. Interv Neuroradiol 2018; 21:101-7. [PMID: 25934783 DOI: 10.15274/inr-2014-10096] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Endovascular embolization is an important modality in the treatment of brain AVMs. Nowadays staged embolization is the method of choice for the prevention of perioperative hemorrhagic complications. Current theory suggests that simultaneous occlusion of more than 60% of AVM volume induces significant redistribution local blood flow. That, in turn, may lead to hemorrhage due to AVM rupture. Aside from angiographic findings, there is still no method that predicts the degree of safe partial embolization. Intraluminal measurement of flow velocity and pressure in the vicinity of the AVM nidus might allow detecting the changes in local hemodynamics. That can provide a valuable data and shed the light on the origin of vascular catastrophes. Ten patients underwent 12 embolization sessions with intraluminal flow velocity and pressure monitoring. The measurements were performed by dual-sensor guidewire. The "Combomap" (Volcano) system with Combowire microguidewires was chosen for measurements, as there is a documented experience of safe use of said guidewires in the cerebral vasculature. The findings observed during the study matched empirical data as well as the current physiological hypothesis of AVM hemorrhage. In conjunction with DSA runs, intraluminal flow velocity and pressure monitoring has the potential to become a valuable tool in AVM treatment.
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Affiliation(s)
- Kirill Orlov
- Department of Neurosurgery, Novosibirsk Research Institution of Circulation Pathology, Novosibirsk, Russia
| | - Vyacheslav Panarin
- Department of Neurosurgery, Novosibirsk Research Institution of Circulation Pathology, Novosibirsk, Russia
| | - Alexey Krivoshapkin
- Department of Neurosurgery, Novosibirsk Research Institution of Circulation Pathology, Novosibirsk, Russia
| | - Dmitry Kislitsin
- Department of Neurosurgery, Novosibirsk Research Institution of Circulation Pathology, Novosibirsk, Russia
| | - Vadim Berestov
- Department of Neurosurgery, Novosibirsk Research Institution of Circulation Pathology, Novosibirsk, Russia
| | - Timur Shayakhmetov
- Department of Neurosurgery, Novosibirsk Research Institution of Circulation Pathology, Novosibirsk, Russia
| | - Anton Gorbatykh
- Department of Neurosurgery, Novosibirsk Research Institution of Circulation Pathology, Novosibirsk, Russia
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Shotar E, Pistocchi S, Haffaf I, Bartolini B, Jacquens A, Nouet A, Chiras J, Degos V, Sourour NA, Clarençon F. Early Rebleeding after Brain Arteriovenous Malformation Rupture, Clinical Impact and Predictive Factors: A Monocentric Retrospective Cohort Study. Cerebrovasc Dis 2017; 44:304-312. [DOI: 10.1159/000479120] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 06/30/2017] [Indexed: 11/19/2022] Open
Abstract
Background: Brain arteriovenous malformations (BAVMs) are a leading cause of intracranial hemorrhage in young adults. This study aimed to identify individual predictive factors of early rebleeding after BAVM rupture and determine its impact on prognosis. Methods: Early rebleeding was defined as a spontaneous intracranial hemorrhage within 30 days of BAVM rupture in patients with nonobliterated BAVMs. One hundred fifty one patients with 158 BAVM hemorrhagic events admitted to a tertiary care center during 14 years were included. Univariate followed by multivariate logistic regression was performed to assess the impact of early rebleeding on in-hospital mortality and modified Rankin Scale (mRS) score beyond 3 months and to identify independent predictors of early rebleeding. Results: Eight early rebleeding events were observed, 6 of which occurred during the first 7 days. Early rebleeding was independently and significantly associated with poor outcome (mRS ≥3 beyond 3 months, p = 0.004) but not with in-hospital mortality (p = 0.9). Distal flow-related aneurysms (p = 0.009) and altered consciousness with a Glasgow coma scale score of 3 (p = 0.01) were independently associated with early rebleeding. Conclusions: Early rebleeding is a severe complication that can occur after BAVM-related hemorrhage. Distal flow-related aneurysms and initial altered consciousness are associated with early rebleeding.
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27
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Osada Y, Endo H, Sato K, Matsumoto Y, Endo T, Fujimura M, Tominaga T. Successful presurgical endovascular management of venous sinus thrombosis associated with high-grade cerebral arteriovenous malformation: A case report. Interv Neuroradiol 2017; 23:656-660. [PMID: 28893127 DOI: 10.1177/1591019917728255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
We report a case of a 39-year-old man presenting with a high-grade left parieto-occipital arteriovenous malformation (AVM) complicated by superior sagittal sinus (SSS) stenosis, seven years after the first presentation. Magnetic resonance imaging revealed a newly developed perilesional edema. Venous sinus stenosis acutely progressed to occlusion and induced multiple intracerebral hemorrhages. An emergent balloon venoplasty of the SSS successfully recanalized the thrombosed sinus. Further, multistage transarterial nidus embolization was performed followed by surgical resection, resulting in a complete eradication of the large AVM. The emergence of perilesional edema is a key radiological feature for the early recognition of a newly developed venous drainage route disturbance, which would result in hemorrhagic events. Venous sinus thrombosis is a rare cause of drainage route disturbance in cerebral AVMs. For such cases, the recanalization of venous drainage concomitant with flow reduction by performing transarterial embolization is effective in preventing further hemorrhage, which enables a safe performance of subsequent radical surgery.
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Affiliation(s)
- Yoshinari Osada
- 1 Department of Neurosurgery and Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Hidenori Endo
- 1 Department of Neurosurgery and Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan.,2 Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenichi Sato
- 1 Department of Neurosurgery and Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Yasushi Matsumoto
- 1 Department of Neurosurgery and Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Toshiki Endo
- 1 Department of Neurosurgery and Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Miki Fujimura
- 2 Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Teiji Tominaga
- 2 Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Hsu SK, Chang CJ, Su IC. Rendering a ruptured arteriovenous malformation more susceptible to spontaneous obliteration as a possible treatment strategy for cerebral AVM. J Surg Case Rep 2017; 2017:rjx073. [PMID: 28458878 PMCID: PMC5400483 DOI: 10.1093/jscr/rjx073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 03/04/2017] [Accepted: 03/31/2017] [Indexed: 11/30/2022] Open
Abstract
Spontaneous regression of cerebral arteriovenous malformation (AVM) is a rare phenomenon, but its occurrence is an important consideration in treatment planning. A 58-year-old male was found to have a high-flow AVM of Spetzler–Martin Grade III. Before his scheduled treatment, the AVM ruptured with a large parenchymal hemorrhage. Following emergency decompressive surgery, a targeted embolization procedure was performed to obliterate the ruptured weak point and to reduce the shunting flow. The residual AVM became a malformation harboring angio-architectural factors favoring spontaneous obliteration. Together with other favorable clinical factors, including prior parenchymal hemorrhage and neurosurgical intervention, the residual AVM spontaneously regressed in 2 months. This case highlighted a possible treatment strategy in that, for a ruptured AVM in which definite treatment is not possible, an alternative is to treat the AVM into a situation in which as many favorable factors as possible for spontaneous AVM regression are present.
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Affiliation(s)
- Szu-Kai Hsu
- Division of Neurosurgery, Department of Surgery, Taipei Cathay General Hospital, Taipei, Taiwan.,Department of Nursing, Tzu Hui Institute of Technology, Pingtung County, Taiwan
| | - Chih-Ju Chang
- Division of Neurosurgery, Department of Surgery, Taipei Cathay General Hospital, Taipei, Taiwan.,Department of Medicine, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - I-Chang Su
- Division of Neurosurgery, Department of Surgery, Taipei Cathay General Hospital, Taipei, Taiwan.,Department of Medicine, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
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29
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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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30
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Frey S, Haine A, Kammer R, von Tengg-Kobligk H, Obrist D, Baumgartner I. Hemodynamic Characterization of Peripheral Arterio-venous Malformations. Ann Biomed Eng 2017; 45:1449-1461. [PMID: 28324193 DOI: 10.1007/s10439-017-1821-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/15/2017] [Indexed: 01/06/2023]
Abstract
Peripheral arterio-venous malformations (pAVMs) are congenital vascular anomalies that require treatment, due to their severe clinical consequences. The complexity of lesions often leads to misdiagnosis and ill-planned treatments. To improve disease management, we developed a computational model to quantify the hemodynamic effects of key angioarchitectural features of pAVMs. Hemodynamic results were used to predict the transport of contrast agent (CA), which allowed us to compare our findings to digital subtraction angiography (DSA) recordings of patients. The model is based on typical pAVM morphologies and a generic vessel network that represents realistic vascular feeding and draining components related to lesions. A lumped-parameter description of the vessel network was employed to compute blood pressure and flow rates. CA-transport was determined by coupling the model to a 1D advection-diffusion equation. Results show that the extent of hemodynamic effects of pAVMs, such as arterial steal and venous hypertension, strongly depends on the lesion type and its vascular architecture. Dimensions of shunting vessels strongly influence hemodynamic parameters. Our results underline the importance of the dynamics of CA-transport in diagnostic DSA images. In this context, we identified a set of temporal CA-transport parameters, which are indicative of the presence and specific morphology of pAVMs.
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Affiliation(s)
- Sabrina Frey
- ARTORG Center for Biomedical Engineering Research, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland.
| | - A Haine
- Division of Angiology, Swiss Cardiovascular Center, University of Bern, Bern University Hospital, Bern, Switzerland
| | - R Kammer
- Division of Angiology, Swiss Cardiovascular Center, University of Bern, Bern University Hospital, Bern, Switzerland
| | - H von Tengg-Kobligk
- Department of Diagnostic, Interventional and Pediatric Radiology, University of Bern, Bern University Hospital, Bern, Switzerland
| | - D Obrist
- ARTORG Center for Biomedical Engineering Research, University of Bern, Murtenstrasse 50, 3008, Bern, Switzerland
| | - I Baumgartner
- Division of Angiology, Swiss Cardiovascular Center, University of Bern, Bern University Hospital, Bern, Switzerland
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Kumar YK, Mehta SB, Ramachandra M. Numerical modeling of vessel geometry to measure hemodynamics parameters non-invasively in cerebral arteriovenous malformation. Biomed Mater Eng 2017; 27:613-631. [PMID: 28234245 DOI: 10.3233/bme-161613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cerebral arteriovenous malformations (CAVM) are congenital lesions that contain a cluster of multiple arteriovenous shunts (NIDUS). Cardiac arrhythmia in CAVM patients causes irregular changes in blood flow and pressure in the NIDUS area. This paper proposes the framework for creating the lumped model of tortuous vessel structure near NIDUS based on radiological images. This lumped model is to analyze flow variations, with various combinations of the transient electrical signals, which simulate similar conditions of cardiac arrhythmia in CAVM patients. This results in flow variation at different nodes of the lumped model. Here we present two AVM patients with evaluation of 150 vessels locations as node points, with an accuracy of 93%, the sensitivity of 95%, and specificity of 94%. The calculated p-value is smaller than the significance level of 0.05.
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Affiliation(s)
- Y Kiran Kumar
- Philips Research, Research scholar, Manipal University, India
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32
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Hsu CY, Ghaffari M, Alaraj A, Flannery M, Zhou XJ, Linninger A. Gap-free segmentation of vascular networks with automatic image processing pipeline. Comput Biol Med 2017; 82:29-39. [PMID: 28135646 DOI: 10.1016/j.compbiomed.2017.01.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 01/18/2017] [Accepted: 01/19/2017] [Indexed: 10/20/2022]
Abstract
Current image processing techniques capture large vessels reliably but often fail to preserve connectivity in bifurcations and small vessels. Imaging artifacts and noise can create gaps and discontinuity of intensity that hinders segmentation of vascular trees. However, topological analysis of vascular trees require proper connectivity without gaps, loops or dangling segments. Proper tree connectivity is also important for high quality rendering of surface meshes for scientific visualization or 3D printing. We present a fully automated vessel enhancement pipeline with automated parameter settings for vessel enhancement of tree-like structures from customary imaging sources, including 3D rotational angiography, magnetic resonance angiography, magnetic resonance venography, and computed tomography angiography. The output of the filter pipeline is a vessel-enhanced image which is ideal for generating anatomical consistent network representations of the cerebral angioarchitecture for further topological or statistical analysis. The filter pipeline combined with computational modeling can potentially improve computer-aided diagnosis of cerebrovascular diseases by delivering biometrics and anatomy of the vasculature. It may serve as the first step in fully automatic epidemiological analysis of large clinical datasets. The automatic analysis would enable rigorous statistical comparison of biometrics in subject-specific vascular trees. The robust and accurate image segmentation using a validated filter pipeline would also eliminate operator dependency that has been observed in manual segmentation. Moreover, manual segmentation is time prohibitive given that vascular trees have more than thousands of segments and bifurcations so that interactive segmentation consumes excessive human resources. Subject-specific trees are a first step toward patient-specific hemodynamic simulations for assessing treatment outcomes.
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Affiliation(s)
- Chih-Yang Hsu
- Department of Bioengineering, University of Illinois at Chicago, 851 S. Morgan St, 218 SEO, M/C 063, Chicago, IL 60607-7000, USA
| | - Mahsa Ghaffari
- Department of Bioengineering, University of Illinois at Chicago, 851 S. Morgan St, 218 SEO, M/C 063, Chicago, IL 60607-7000, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Michael Flannery
- Center for MR Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Xiaohong Joe Zhou
- Department of Bioengineering, University of Illinois at Chicago, 851 S. Morgan St, 218 SEO, M/C 063, Chicago, IL 60607-7000, USA; Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA; Department of Radiology, University of Illinois at Chicago, Chicago, IL, USA; Center for MR Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Andreas Linninger
- Department of Bioengineering, University of Illinois at Chicago, 851 S. Morgan St, 218 SEO, M/C 063, Chicago, IL 60607-7000, USA; Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA.
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Hsu CY, Schneller B, Alaraj A, Flannery M, Zhou XJ, Linninger A. Automatic recognition of subject-specific cerebrovascular trees. Magn Reson Med 2017; 77:398-410. [PMID: 26778056 PMCID: PMC4947568 DOI: 10.1002/mrm.26087] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 11/23/2015] [Accepted: 11/23/2015] [Indexed: 12/14/2022]
Abstract
PURPOSE An image filter designed for reconstructing cerebrovascular trees from MR images is described. Current imaging techniques capture major cerebral vessels reliably, but often fail to detect small vessels, whose contrast is suppressed due to limited resolution, slow blood flow rate, and distortions around bifurcations or nonvascular structures. An incomplete view of angioarchitecture limits the information available to physicians. METHODS A novel Hessian-based filter for contrast-enhancement in MR angiography and venography for blood vessel reconstruction without introducing dangling segments is presented. We quantify filter performance with receiver-operating-characteristic and dice-similarity-coefficient analysis. Total extracted vascular length, number-of-segments, volume, surface-to-distance, and positional error are calculated for validation. RESULTS Reconstruction of cerebrovascular trees from MR images of six volunteers show that the new filter renders more complete representations of subject-specific cerebrovascular networks. Validation with phantom models shows the filter correctly detects blood vessels across all length scales without failing at bifurcations or distorting diameters. CONCLUSION The novel filter can potentially improve the diagnosis of cerebrovascular diseases by delivering metrics and anatomy of the vasculature. It also facilitates the automated analysis of large datasets by computing biometrics free of operator subjectivity. The high quality reconstruction enables computational mesh generation for subject-specific hemodynamic simulations. Magn Reson Med 77:398-410, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Chih-Yang Hsu
- Department of Bioengineering, University of Illinois at Chicago, 851 S. Morgan St, 218 SEO, M/C 063, Chicago, IL 60607-7000, USA
| | - Ben Schneller
- Department of Bioengineering, University of Illinois at Chicago, 851 S. Morgan St, 218 SEO, M/C 063, Chicago, IL 60607-7000, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Michael Flannery
- Center for MR Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Xiaohong Joe Zhou
- Department of Bioengineering, University of Illinois at Chicago, 851 S. Morgan St, 218 SEO, M/C 063, Chicago, IL 60607-7000, USA
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
- Department of Radiology, University of Illinois at Chicago, Chicago, IL, USA
- Center for MR Research, University of Illinois at Chicago, Chicago, IL, USA
| | - Andreas Linninger
- Department of Bioengineering, University of Illinois at Chicago, 851 S. Morgan St, 218 SEO, M/C 063, Chicago, IL 60607-7000, USA
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
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Tong X, Wu J, Lin F, Cao Y, Zhao Y, Wang S, Zhao J. Cerebellar Arteriovenous Malformations: Clinical Feature, Risk of Hemorrhage and Predictors of Posthemorrhage Outcome. World Neurosurg 2016; 92:206-217. [PMID: 27178234 DOI: 10.1016/j.wneu.2016.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/02/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We aimed to summarize the clinical presentation, risk of hemorrhage, and predictors of posthemorrhage outcome in patients with cerebellar arteriovenous malformations (AVMs). METHODS We searched our AVM database at Beijing Tiantan Hospital and identified 225 patients with cerebellar AVMs between the year 2000 and 2015. The clinical presentation and hemorrhage risk were analyzed in all patients. Further analysis of predictors for immediate posthemorrhage outcome was performed in patients with ruptured AVMs. Posthemorrhage modified Rankin Scale (mRS) scores were dichotomized into nonsevere outcome (mRS ≤3) and severe outcome (mRS >3). Univariate and multivariate logistic regression analyses were applied to test the risk factors of hemorrhage and predictors of severe outcome. RESULTS Of the 225 patients, 197 (88%) presented with hemorrhage. Patients with initial hemorrhage were much younger than those with unruptured AVMs (univariate: P = 0.003; multivariate: P = 0.002). Single arterial supply (odds ratio [OR], 2.846; 95% confidence interval [CI], 1.022-7.922) and exclusively deep venous drainage (OR, 3.361; 95% CI, 1.045-10.813) were the other 2 independent risk factors for hemorrhagic presentation. Regarding the neurologic outcome immediately after hemorrhagic presentation, we used 3 models of multivariate logistic regression. Severe neurologic outcome (mRS >3) was associated with eloquent or deep AVM location, associated aneurysm, and the presence of intraventricular hemorrhage (all P < 0.05). CONCLUSION Cerebellar AVMs have an aggressive nature of hemorrhage. Younger age, single feeding artery, and exclusively deep venous drainage were independent risk factors for hemorrhagic presentation. Eloquent location, associated aneurysm, and presence of intraventricular hemorrhage may predict severe immediate posthemorrhage outcome.
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Affiliation(s)
- Xianzeng Tong
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Fuxin Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China.
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
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Alexander MD, Cooke DL, Hallam DK, Kim H, Hetts SW, Ghodke BV. Less can be more: Targeted embolization of aneurysms associated with arteriovenous malformations unsuitable for surgical resection. Interv Neuroradiol 2016; 22:445-51. [PMID: 27066813 DOI: 10.1177/1591019916641316] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 02/15/2016] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION To mitigate risks of hemorrhage, high-risk features of brain arteriovenous malformations (BAVMs) can be targeted to reduce the risk of rupture. Previous investigation has examined embolization of a pedicle supplying a high-risk feature; this study examines embolization targeted specifically at aneurysms associated with BAVMs. MATERIALS AND METHODS Patients with BAVMs treated at two high-volume neurointerventional services were retrospectively reviewed. Patients treated with intention to occlude only the associated aneurysm itself were analyzed. Demographic and lesion characteristics were identified, as were technical and clinical outcomes. Adverse events were defined as hemorrhage, new seizure, and death. RESULTS Thirty-two patients met inclusion criteria out of 1103 patients treated during the study period. Twenty-seven (84.4%) BAVMs were acutely ruptured, all with the aneurysm identified as the hemorrhage source. Twenty-four (75.0%) lesions involved eloquent territory. There were equal numbers of feeding artery and nidus aneurysms. Follow-up data were available for a total of 101.3 patient-years for a mean follow-up time of 2.9 years. One patient died; the remaining 31 patients had improved functional status at last contact. Annualized rate of hemorrhage after treatment was 1.0%; rate of adverse events after treatment was 3.0%. Excluding time after confirmed occlusion following radiosurgery, annualized rates were 1.4% and 4.8%, respectively. CONCLUSION In inoperable BAVMs, targeted embolization of associated aneurysms can be performed safely and effectively. This should be considered in high-risk lesions prior to radiosurgery or in cases when no other treatment options are available. Such intervention warrants further investigation.
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Affiliation(s)
- Matthew D Alexander
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, USA
| | | | - Helen Kim
- Department of Anesthesia and Perioperative Care, University of California San Francisco, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, USA
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Interventional Therapy of Brain and Spinal Arteriovenous Malformations. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00067-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Zhang R, Zhu W, Su H. Vascular Integrity in the Pathogenesis of Brain Arteriovenous Malformation. ACTA NEUROCHIRURGICA. SUPPLEMENT 2016; 121:29-35. [PMID: 26463919 DOI: 10.1007/978-3-319-18497-5_6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Brain arteriovenous malformation (bAVM) is an important cause of intracranial hemorrhage (ICH), particularly in the young population. ICH is the first clinical symptom in about 50 % of bAVM patients. The vessels in bAVM are fragile and prone to rupture, causing bleeding into the brain. About 30 % of unruptured and non-hemorrhagic bAVMs demonstrate microscopic evidence of hemosiderin in the vascular wall. In bAVM mouse models, vascular mural cell coverage is reduced in the AVM lesion, accompanied by vascular leakage and microhemorrhage. In this review, we discuss possible signaling pathways involved in abnormal vascular development in bAVM.
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Affiliation(s)
- Rui Zhang
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, 1001 Potrero Avenue, 1363, San Francisco, CA, 94110, USA
| | - Wan Zhu
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, 1001 Potrero Avenue, 1363, San Francisco, CA, 94110, USA
| | - Hua Su
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, 1001 Potrero Avenue, 1363, San Francisco, CA, 94110, USA.
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Torné R, Rodríguez-Hernández A, Arikan F, Romero-Chala F, Cicuéndez M, Vilalta J, Sahuquillo J. Posterior fossa arteriovenous malformations: Significance of higher incidence of bleeding and hydrocephalus. Clin Neurol Neurosurg 2015; 134:37-43. [PMID: 25938563 DOI: 10.1016/j.clineuro.2015.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 03/03/2015] [Accepted: 04/05/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Ramon Torné
- Department of Neurological Surgery, Vall d'Hebron University Hospital, Paseo Vall D'Hebron 119-129, 08035 Barcelona, Spain; Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain.
| | - Ana Rodríguez-Hernández
- Department of Neurological Surgery, Vall d'Hebron University Hospital, Paseo Vall D'Hebron 119-129, 08035 Barcelona, Spain
| | - Fuat Arikan
- Department of Neurological Surgery, Vall d'Hebron University Hospital, Paseo Vall D'Hebron 119-129, 08035 Barcelona, Spain; Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| | - Fabián Romero-Chala
- Department of Neurological Surgery, Vall d'Hebron University Hospital, Paseo Vall D'Hebron 119-129, 08035 Barcelona, Spain; Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| | - Marta Cicuéndez
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| | - Jordi Vilalta
- Department of Neurological Surgery, Vall d'Hebron University Hospital, Paseo Vall D'Hebron 119-129, 08035 Barcelona, Spain; Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| | - Juan Sahuquillo
- Department of Neurological Surgery, Vall d'Hebron University Hospital, Paseo Vall D'Hebron 119-129, 08035 Barcelona, Spain; Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
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Choudhri O, Ivan ME, Lawton MT. Transvenous Approach to Intracranial Arteriovenous Malformations. Neurosurgery 2015; 77:644-51; discussion 652. [DOI: 10.1227/neu.0000000000000869] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
A compartmental conceptualization of intracranial arteriovenous malformations (AVMs) allows recognition of feeding arteries, an intervening plexiform nidus, and draining veins. AVM therapy involves eliminating the nidus, which is the source of hemorrhage, without compromising normal arterial and venous drainage of the brain. Traditional methods of AVM therapy through microsurgery and endovascular embolization involve arterial devascularization, with preservation of AVM venous drainage, until the nidus is excluded. The transvenous approach in treating vascular malformations was popularized by successful treatment models for dural arteriovenous fistulas. More recently, high-flow intracranial AVMs are being managed with transvenous endovascular approaches, although this novel technique has its challenges and perils. We review the current literature on transvenous AVM therapy and highlight its role for AVM therapy in the present day.
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Affiliation(s)
- Omar Choudhri
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michael E. Ivan
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Michael T. Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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40
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Davis MC, Deveikis JP, Harrigan MR. Clinical Presentation, Imaging, and Management of Complications due to Neurointerventional Procedures. Semin Intervent Radiol 2015; 32:98-107. [PMID: 26038618 DOI: 10.1055/s-0035-1549374] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Neurointervention is a rapidly evolving and complex field practiced by clinicians with backgrounds ranging from neurosurgery to radiology, neurology, cardiology, and vascular surgery. New devices, techniques, and clinical applications create exciting opportunities for impacting patient care, but also carry the potential for new iatrogenic injuries. Every step of every neurointerventional procedure carries risk, and a thorough appreciation of potential complications is fundamental to maximizing safety. This article presents the most frequent and dangerous iatrogenic injuries, their presentation, identification, prevention, and management.
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Affiliation(s)
- Matthew C Davis
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - John P Deveikis
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark R Harrigan
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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41
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Torné R, Rodríguez-Hernández A, Lawton MT. Intraoperative arteriovenous malformation rupture: causes, management techniques, outcomes, and the effect of neurosurgeon experience. Neurosurg Focus 2015; 37:E12. [PMID: 25175431 DOI: 10.3171/2014.6.focus14218] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intraoperative rupture can transform an arteriovenous malformation (AVM) resection. Blood suffuses the field and visualization is lost; suction must clear the field and the hand holding the suction device is immobilized; the resection stalls while hemostasis is being reestablished; the cause and site of the bleeding may be unclear; bleeding may force technical errors and morbidity from chasing the source into eloquent white matter; and AVM bleeding can be so brisk that it overwhelms the neurosurgeon. The authors reviewed their experience with this dangerous complication to examine its causes, management, and outcomes. METHODS From a cohort of 591 patients with AVMs treated surgically during a 15-year period, 32 patients (5%) experienced intraoperative AVM rupture. Their prospective data and medical records were reviewed. RESULTS Intraoperative AVM rupture was not correlated with presenting hemorrhage, but had a slightly higher incidence infratentorially (7%) than supratentorially (5%). Rupture was due to arterial bleeding in 18 patients (56%), premature occlusion of a major draining vein in 10 (31%), and nidal penetration in 4 (13%). In 14 cases (44%), bleeding control was abandoned and the AVM was removed immediately ("commando resection"). The incidence of intraoperative rupture was highest during the initial 5-year period (9%) and dropped to 3% and 4% in the second and third 5-year periods, respectively. Ruptures due to premature venous occlusion and nidal penetration diminished with experience, whereas those due to arterial bleeding remained steady. Despite intraoperative rupture, 90% of AVMs were completely resected initially and all of them ultimately. Intraoperative rupture negatively impacted outcome, with significantly higher final modified Rankin Scale scores (mean 2.8) than in the overall cohort (mean 1.5; p < 0.001). CONCLUSIONS Intraoperative AVM rupture is an uncommon complication caused by pathological arterial anatomy and by technical mistakes in judging the dissection distance from the AVM margin and in mishandling or misinterpreting the draining veins. The decrease in intraoperative rupture rate over time suggests the existence of a learning curve. In contrast, intraoperative rupture due to arterial bleeding reflects the difficulty with dysplastic feeding vessels and deep perforator anatomy rather than neurosurgeon experience. The results demonstrate that intraoperative AVM rupture negatively impacts patient outcome, and that skills in managing this catastrophe are critical.
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Affiliation(s)
- Ramon Torné
- Department of Neurological Surgery, Vall d'Hebron Hospital, Universitat Autònoma de Barcelona, Spain
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Cao C, Sourour N, Reina V, Nouet A, Di Maria F, Chiras J, Cornu P, Clarençon F. Spontaneous thrombosis of the main draining vein revealing an unruptured brain arteriovenous malformation. Interv Neuroradiol 2015; 21:222-6. [PMID: 25964440 DOI: 10.1177/1591019915581989] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Haemorrhage is the most frequent revealing condition of brain arteriovenous malformations (bAVMs). We report a rare case of unruptured parietal bAVM revealed by spontaneous thrombosis of the main draining vein, responsible for a focal neurological deficit. The bAVM was embolized in emergency conditions; complete regression of the neurological symptoms was observed within five days after the embolization. Potential mechanisms of such spontaneous thrombosis of the bAVM's main drainage pathway as well as an exhaustive review of the literature concerning this rare revealing condition are presented and discussed.
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Affiliation(s)
- Catherine Cao
- Department of Neurosurgery, Dijon University Hospital, France
| | - Nader Sourour
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris VI University, France
| | - Vincent Reina
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris VI University, France
| | - Aurélien Nouet
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris VI University, France
| | - Federico Di Maria
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris VI University, France
| | - Jacques Chiras
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris VI University, France
| | - Philippe Cornu
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris VI University, France
| | - Frédéric Clarençon
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris VI University, France
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Mouchtouris N, Jabbour PM, Starke RM, Hasan DM, Zanaty M, Theofanis T, Ding D, Tjoumakaris SI, Dumont AS, Ghobrial GM, Kung D, Rosenwasser RH, Chalouhi N. Biology of cerebral arteriovenous malformations with a focus on inflammation. J Cereb Blood Flow Metab 2015; 35:167-75. [PMID: 25407267 PMCID: PMC4426734 DOI: 10.1038/jcbfm.2014.179] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 09/05/2014] [Accepted: 09/22/2014] [Indexed: 01/01/2023]
Abstract
Cerebral arteriovenous malformations (AVMs) entail a significant risk of intracerebral hemorrhage owing to the direct shunting of arterial blood into the venous vasculature without the dissipation of the arterial blood pressure. The mechanisms involved in the growth, progression and rupture of AVMs are not clearly understood, but a number of studies point to inflammation as a major contributor to their pathogenesis. The upregulation of proinflammatory cytokines induces the overexpression of cell adhesion molecules in AVM endothelial cells, resulting in enhanced recruitment of leukocytes. The increased leukocyte-derived release of metalloproteinase-9 is known to damage AVM walls and lead to rupture. Inflammation is also involved in altering the AVM angioarchitecture via the upregulation of angiogenic factors that affect endothelial cell proliferation, migration and apoptosis. The effects of inflammation on AVM pathogenesis are potentiated by certain single-nucleotide polymorphisms in the genes of proinflammatory cytokines, increasing their protein levels in the AVM tissue. Furthermore, studies on metalloproteinase-9 inhibitors and on the involvement of Notch signaling in AVMs provide promising data for a potential basis for pharmacological treatment of AVMs. Potential therapeutic targets and areas requiring further investigation are highlighted.
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Affiliation(s)
- Nikolaos Mouchtouris
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - David M Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa, USA
| | - Mario Zanaty
- 1] Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA [2] Department of Neurosurgery, University of Iowa, Iowa City, Iowa, USA
| | - Thana Theofanis
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Dale Ding
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Stavropoula I Tjoumakaris
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - George M Ghobrial
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - David Kung
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Nohra Chalouhi
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
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Puccinelli F, Deiva K, Bellesme C, Durand P, Chevret L, Husson B, Sachet M, Ducreux D, Saliou G. Cerebral venous thrombosis after embolization of pediatric AVM with jugular bulb stenosis or occlusion: management and prevention. Eur J Paediatr Neurol 2014; 18:766-73. [PMID: 25130940 DOI: 10.1016/j.ejpn.2014.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 06/29/2014] [Accepted: 07/16/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Thrombosis of cerebral arteriovenous malformation after embolization is rare, but can involve the normal venous network with extensive venous thrombosis. We report angioarchitecture findings, our management and prevention strategy for this complication in pediatric AVMs. METHODS In this 5.5-year retrospective series, we reviewed records of 13 patients under 15 years who were anticoagulated after embolization. In our initial experience 4 children who didn't receive any prophylactic anticoagulation presented with extensive venous thrombosis after embolization (group 1). Following this, nine children with similar angioarchitecture and embolization modalities were treated with prophylactic anticoagulation immediately after embolization (group 2). We analyzed the type of AVM, angioarchitecture, dose of prophylactic anticoagulant, efficacy/complications of treatment and late outcome. RESULTS All patients in group 1 had severe jugular bulb stenosis/occlusion associated with cerebral venous dilatation. In group 2 with similar angioarchitecture, only three patients (33%) developed extensive thrombosis. In both groups, thrombosis occurred within two days of treatment in six children and two weeks in one child. The diagnosis was suspected on intracranial hypertension in five patients and occulomotor disorder in one. One was asymptomatic. All children were treated with therapeutic doses of LMWH (anti-Xa: 0.5-1). No hemorrhagic complications occurred. Good venous remodeling was observed in all but one patient. CONCLUSION Anticoagulation in extensive venous thrombosis after AVM embolization in children appears to be safe and effective. In cases with angioarchitectural features of dilatation of the cerebral venous network and occlusion/severe stenosis of the jugular bulbs, full dose anticoagulation may be required to prevent thrombosis.
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Affiliation(s)
- F Puccinelli
- Service de Neuroradiologie, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France; National Referral Center for Neurovascular Malformations in Children, France
| | - K Deiva
- Service de Neurologie pédiatrique, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - C Bellesme
- Service de Neurologie pédiatrique, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - P Durand
- Service de Réanimation pédiatrique, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - L Chevret
- Service de Réanimation pédiatrique, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - B Husson
- Service de Radiologie pédiatrique, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - M Sachet
- Service de Neuroradiologie, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France; National Referral Center for Neurovascular Malformations in Children, France
| | - D Ducreux
- Service de Neuroradiologie, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France; National Referral Center for Neurovascular Malformations in Children, France
| | - G Saliou
- Service de Neuroradiologie, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France; National Referral Center for Neurovascular Malformations in Children, France.
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Bendok BR, El Tecle NE, El Ahmadieh TY, Koht A, Gallagher TA, Carroll TJ, Markl M, Sabbagha R, Sabbagha A, Cella D, Nowinski C, Dewald JPA, Meade TJ, Samson D, Batjer HH. Advances and innovations in brain arteriovenous malformation surgery. Neurosurgery 2014; 74 Suppl 1:S60-73. [PMID: 24402494 DOI: 10.1227/neu.0000000000000230] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Arteriovenous malformations (AVMs) of the brain are very complex and intriguing pathologies. Since their initial description by Luschka and Virchow in the middle of the 19th century, multiple advances and innovations have revolutionized their management and surgical treatment. Here, we review the historical landmarks in the surgical treatment of AVMs and then illustrate the most recent and futuristic technologies aiming to improve outcomes in AVM surgeries. In particular, we examine potential advances in patient selection, imaging, surgical technique, neuroanesthesia, and postoperative neuro-rehabilitation and quantitative assessments. Finally, we illustrate how concurrent advances in radiosurgery and endovascular techniques might present new opportunities to treat AVMs more safely from a surgical perspective.
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Affiliation(s)
- Bernard R Bendok
- Northwestern Memorial Hospital, Departments of *Neurological Surgery, ‡Radiology, §Otolaryngology, and ¶Anesthesiology, Chicago, Illinois; ‖Northwestern University, McCormick School of Engineering, Department of Biomedical Engineering, Evanston, Illinois; Northwestern University, #Neuropsychology Institute, **Department of Medical Social Sciences, ‡‡Department of Physical Therapy and Human Movement Sciences, and §§Department of Chemistry, Chicago, Illinois; ¶¶University of Texas Southwestern, Department of Neurological Surgery, Dallas, Texas
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Delye H, Thines L, Zairi F, Allaoui M, Lejeune JP. Rupture of a cerebellar arteriovenous malformation following thrombosis of the ipsilateral transverse sinus. Rev Neurol (Paris) 2014; 170:464-5. [PMID: 24726039 DOI: 10.1016/j.neurol.2013.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 12/20/2013] [Indexed: 11/16/2022]
Affiliation(s)
- H Delye
- Department of neurosurgery, division of neurosciences and locomotive system, Lille university hospital, avenue Émile-Laine, 59037 Lille cedex, France; Department of neurosurgery, university medical centre, street Radboud, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - L Thines
- Department of neurosurgery, division of neurosciences and locomotive system, Lille university hospital, avenue Émile-Laine, 59037 Lille cedex, France; Université Lille Nord de France, CS 90005, 59044 Lille cedex, France.
| | - F Zairi
- Department of neurosurgery, division of neurosciences and locomotive system, Lille university hospital, avenue Émile-Laine, 59037 Lille cedex, France; Université Lille Nord de France, CS 90005, 59044 Lille cedex, France
| | - M Allaoui
- Department of neurosurgery, division of neurosciences and locomotive system, Lille university hospital, avenue Émile-Laine, 59037 Lille cedex, France; Université Lille Nord de France, CS 90005, 59044 Lille cedex, France
| | - J-P Lejeune
- Department of neurosurgery, division of neurosciences and locomotive system, Lille university hospital, avenue Émile-Laine, 59037 Lille cedex, France; Université Lille Nord de France, CS 90005, 59044 Lille cedex, France
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Chang HJ, Su FJ, Huang YC, Chen SH. Spontaneous spinal epidural hemorrhage from intense piano playing. Am J Emerg Med 2014; 32:688.e3-5. [PMID: 24418452 DOI: 10.1016/j.ajem.2013.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 12/03/2013] [Indexed: 11/26/2022] Open
Abstract
Spontaneous spinal epidural hematoma (SSEH) is a rare but real neurosurgical emergency. It is caused by atraumatic rupture of the vertebral epidural vein that results in nerve root or spinal cord compression. Most cases of SSEH have a multifactorial etiology, including congenital and acquired coagulopathies; platelet dysfunction; vascular malformation; tumors; uncontrolled hypertension; pregnancy; and, very rarely, activities requiring Valsalva. Herein we reported the case of a young pianist who was attacked by SSEH during piano practice. Playing the piano is a joyful, relaxing entertainment; however, this musical activity can be a highly demanding physical and mental exercise for pianists. Emotional and expressive performance, especially in professional performing, has been reported to result in significant increase of sympathetic and decrease of parasympathetic activities and thus influence the cardiorespiratory variables. The increased biomechanical stress from fluctuating hemodynamics was thought to trigger the rupture of her spinal arteriovenous malformation.
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Affiliation(s)
- Hui-Ju Chang
- Department of Emergency Medicine, Chiayi Christian Hospital, Chiayi City, 60002, Taiwan
| | - Fang Jy Su
- Department of Emergency Medicine, Chiayi Christian Hospital, Chiayi City, 60002, Taiwan
| | - Ying C Huang
- Department of Emergency Medicine, Chiayi Christian Hospital, Chiayi City, 60002, Taiwan; Department of Emergency Medicine, Medical Center & School of Medicine, Kaohsiung Medical University.
| | - Shih-Han Chen
- Division of Neurosurgery, Department of Surgery, Chiayi Christian Hospital
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Rahal JP, Malek AM. Benefit of cone-beam computed tomography angiography in acute management of angiographically undetectable ruptured arteriovenous malformations. J Neurosurg 2013; 119:1015-20. [DOI: 10.3171/2013.4.jns1390] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Ruptured arteriovenous malformations (AVMs) are a frequent cause of intracerebral hemorrhage (ICH). In some cases, compression from the associated hematoma in the acute setting can partially or completely occlude an AVM, making it invisible on conventional angiography techniques. The authors report on the successful use of cone-beam CT angiography (CBCT-A) to precisely identify the underlying angioarchitecture of ruptured AVMs that are not visible on conventional angiography.
Methods
Three patients presented with ICH for which they underwent examination with CBCT-A in addition to digital subtraction angiography and other imaging modalities, including MR angiography and CT angiography. All patients underwent surgical evacuation due to mass effect from the hematoma. Clinical history, imaging studies, and surgical records were reviewed. Hematoma volumes were calculated.
Results
In all 3 cases, CBCT-A demonstrated detailed anatomy of an AVM where no lesion or just a suggestion of a draining vein had been seen with other imaging modalities. Magnetic resonance imaging demonstrated enhancement in 1 patient; CT angiography demonstrated a draining vein in 1 patient; 2D digital subtraction angiography and 3D rotational angiography demonstrated a suggestion of a draining vein in 2 cases and no finding in the third. In the 2 patients in whom CBCT-A was performed prior to surgery, the demonstrated AVM was successfully resected without evidence of a residual lesion. In the third patient, CBCT-A allowed precise targeting of the AVM nidus using Gamma Knife radiosurgery.
Conclusions
Cone-beam CT angiography should be considered in the evaluation and subsequent treatment of ICH due to ruptured AVMs. In cases in which the associated hematoma compresses the AVM nidus, CBCT-A can have higher sensitivity and anatomical accuracy than traditional angiographic modalities, including digital subtraction angiography.
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Pan J, He H, Feng L, Viñuela F, Wu Z, Zhan R. Angioarchitectural characteristics associated with complications of embolization in supratentorial brain arteriovenous malformation. AJNR Am J Neuroradiol 2013; 35:354-9. [PMID: 23886744 DOI: 10.3174/ajnr.a3643] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Embolization is an important therapeutic technique in brain arteriovenous malformations; however, little has been reported on the factors contributing to complications. We retrospectively reviewed a large series of supratentorial brain AVMs to identify the angioarchitectural characteristics that might be associated with the complications of embolization and poor clinical outcomes. MATERIALS AND METHODS The clinical and angiographic features of 130 consecutive patients with supratentorial brain AVMs embolized with ethylene-vinyl alcohol copolymer in our hospital from 2005-2008 were retrospectively reviewed. None of these patients had prior embolization. Complications were classified as transient neurologic deficits, persistent neurologic deficits, and death. Univariate and multivariate analyses were conducted to assess the angiographic features in patients with and without complications. RESULTS Twenty-three complications occurred in 130 embolization procedures, 13 (10%) were transient neurologic deficits (9 ischemic and 4 hemorrhagic), 9 (6.92%) were persistent neurologic deficits (7 ischemic and 2 hemorrhagic), and 1 death occurred. By univariate analyses, eloquent cortex (OR, 2.57; 95% CI, 1.08-3.42) and exclusive deep venous drainage (OR, 4.56; 95% CI, 1.28-9.67) were correlated with procedural complications. The impaction of eloquent cortical location (P = .001) and exclusive deep venous drainage (P = .035) on complications were also demonstrated by multivariate analysis. Eloquent cortex mainly resulted in permanent ischemic neurologic deficit; occlusion of drainage vein was significantly correlated with periprocedural hemorrhage in supratentorial brain AVMs with subtotal and partial embolization. CONCLUSIONS In a retrospective study on supratentorial brain AVMs with first-time embolization, 6.92% of patients had permanent neurologic deficit or death. Eloquent cortical location and exclusive deep venous drainage were associated with complications.
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Affiliation(s)
- J Pan
- From the Department of Neurosurgery (J.P., R.Z.), The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Pan J, Feng L, Vinuela F, He H, Wu Z, Zhan R. Angioarchitectural characteristics associated with initial hemorrhagic presentation in supratentorial brain arteriovenous malformations. Eur J Radiol 2013; 82:1959-63. [PMID: 23763861 DOI: 10.1016/j.ejrad.2013.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/03/2013] [Accepted: 05/10/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The difference in arterial supply, venous drainage, functional localization in supratentorial and infratentorial compartments may contribute to the conflicting results about risk factors for hemorrhage in published case series of brain arteriovenous malformation (bAVM). Further investigation focused on an individual brain compartment is thus necessary. This retrospective study aims to identify angioarchitectural characteristics associated with the initial hemorrhagic event of supratentorial bAVMs. MATERIALS AND METHODS The clinical and angiographic features of 152 consecutive patients with supratentorial bAVMs who presented to our hospital from 2005 to 2008 were retrospectively reviewed. All these patients had new diagnosis of bAVM. Univariate (χ(2) test) and multivariate analyses were conducted to assess the angiographic features in patients with and without initial hemorrhagic presentations. A probability value of less than 0.05 was considered statistically significant in each analysis. RESULTS In 152 patients with supratentorial AVMs, 70.6% of deep and 52.5% of superficial sbAVMs presented with hemorrhage. The deep location was correlated with initial hemorrhagic presentation in univariate analysis (χ(2)=3.499, p=0.046) but not in the multivariate model (p=0.144). There were 44 sbAVMs with perforating feeders, 39 (88.6%) of which bled at a significantly higher rate than those with terminal feeders (χ(2)=25.904, p=0.000). 87.5% (21/24) of exclusive deep venous drainage presented with hemorrhage, a significantly higher rate than those of the other type of venous drainage (χ(2)=11.099, p=0.004). All 10 patients with both perforating feeders and exclusive deep draining vein presented with initial hemorrhage. Hemorrhagic presentation was correlated with perforating feeders (p=0.000) and exclusive deep draining vein (p=0.007) in multivariate analysis as well. CONCLUSIONS Supratentorial bAVMs with perforating feeders and deep venous drainage have a higher risk of hemorrhage. In contrast with many previous reports, AVM location was not associated with hemorrhagic presentation in adjusted analyses. The correlation between deep location and initial hemorrhage in univariate analysis might be caused by the involved perforating feeders and deep draining vein in the deep located AVMs.
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Affiliation(s)
- Jianwei Pan
- Department of Neurosurgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310006, China.
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