1
|
Ghorbani M, Griessenauer CJ, Wipplinger C, Jabbour P, Asl MK, Rahbarian F, Mortazavi A. Adenosine-induced transient circulatory arrest in transvenous embolization of cerebral arteriovenous malformations. Neuroradiol J 2021; 34:509-516. [PMID: 33657933 DOI: 10.1177/1971400921998972] [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: 11/15/2022] Open
Abstract
Due to advances in interventional techniques, the transvenous approach may present an effective treatment option for embolization of brain arteriovenous malformations (AVMs). Contrary to the transarterial method, the transvenous approach can only be utilized in a specific subset of patients and is not suitable as a standard procedure for all AVM lesions. While this technique can be helpful in certain patients, careful patient selection to ensure patient safety and favorable clinical outcomes is important. However, especially in high-flow AVMs, targeted deposition of embolic materials through a transvenous access can be challenging. Therefore, a temporary flow arrest may prove helpful. Transient cardiac arrest by use of adenosine has been applied in cerebrovascular surgery but is not common for endovascular embolization. Adenosine-induced arrest and systemic hypotension may be a feasible, safe method to reduce flow and help endovascular transvenous embolization of certain AVMs. Our study evaluated the efficiency and safety of adenosine-induced circulatory arrest for transvenous embolization of cerebral AVMs.
Collapse
Affiliation(s)
- Mohammad Ghorbani
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Iran
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health System, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | | | - Pascal Jabbour
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Thomas Jefferson University Hospital, USA
| | - Mahdi Kadkhodazadeh Asl
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Iran
| | - Farhad Rahbarian
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Iran
| | - Abolghasem Mortazavi
- Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Iran
| |
Collapse
|
2
|
Zaki Ghali G, Zaki Ghali MG, Zaki Ghali E. Transvenous embolization of arteriovenous malformations. Clin Neurol Neurosurg 2018; 178:70-76. [PMID: 30731326 DOI: 10.1016/j.clineuro.2018.08.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/06/2018] [Accepted: 08/12/2018] [Indexed: 10/28/2022]
Abstract
Embolization of arteriovenous malformations is characteristically used as part of a multimodal treatment approach, pre-operatively to facilitate microsurgical resection or as a preradiosurgical adjunct. The concept of AVM cure via embolization alone has gained popularity in recent years. Embolization of AVMs has been most commonly performed transarterially, with the transvenous route traditionally eschewed given concern over precipitating premature venous occlusion and consequent hemorrhage. However, the transvenous approach in treating AVMs offers several distinct advantages compared to the transarterial route and can be used in instances when the latter is not feasible, with several series having proven its efficacy and safety. Conceptually, AVM embolization performed via the transvenous route achieves complete obliteration by directly and facilely targeting the nidus. Nidal embolisate penetration is facilitated by control of arterial inflow via systemic or local hypotension. Innovation in endovascular strategies has led to significantly improved obliteration rates. The experience with transvenous AVM embolization is reviewed and discussed.
Collapse
Affiliation(s)
- George Zaki Ghali
- United States Environmental Protection Agency, Arlington, VA 22202, USA; Department of Toxicology, Purdue University, West Lafayette, IN 47907, USA
| | - Michael George Zaki Ghali
- Department of Neurological Surgery, Houston Methodist Hospital, 6560 Fannin Street, Houston, 77030, TX, United States; Deptartment of Neurological Surgery, Baylor College of Medicine, Houston, TX 77030, US.
| | - Emil Zaki Ghali
- Department of Medicine, Inova Alexandria Hospital, Alexandria 22304, USA; Department of Urological Surgery, El Gomhoureya General Hospital, Alexandria, Egypt
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Lv X, Song C, He H, Jiang C, Li Y. Transvenous retrograde AVM embolization: Indications, techniques, complications and outcomes. Interv Neuroradiol 2017; 23:504-509. [PMID: 28675345 PMCID: PMC5624411 DOI: 10.1177/1591019917716817] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective Transvenous retrograde arteriovenous malformation (AVM) embolization (TRAE) has been proposed. The present study was to review the techniques, their conjunctions and effectiveness. Methods Eligible related articles were identified by searching the PubMed and Web of Science databases using "transvenous" and "arteriovenous malformation." Results A total of 16 eligible studies, with 60 cases of AVM treated with TRAE, were analyzed. Prior to TRAE procedure, transarterial Onyx 18 was performed in 23 (38.3%), cyanoacrylate in three (5%) and coiling in two (3.3%), neurosurgery in one (1.7%) and radiosurgery in three (5%). These prior treatments were used to reduce the size of the nidus to <3 cm and TRAE was performed. One anterior choroidal artery aneurysm was coiled before TRAE. Systemic hypotension (blood pressure<100 mmHg) occurred in six (10%) patients and local hypotension (proximal arterial temporary balloon protection) in five (8.3%) patients. Complete obliteration was achieved in 56 (93.3%) AVMs, four (6.7%) with residual, of which one was supplemented with radiosurgery. During mean one-year follow-up (1 month to 3.2 years), there were five cases (8.3%) of permanent disability and one (1.7%) mortality resulting from initial hemorrhage. Fifty-four (90%) patients were independent (mRS ≤ 2) at follow-up. Ruptured AVMs and Spetzler-Martin I-III were associated with a high cure rate. Conclusion According to previous reports, selected AVMs could undergo TRAE. TRAE is safe and curative with Onyx after the nidus size is reduced sufficiently by transarterial embolization, neurosurgery or radiosurgery, with or without the aid of proximal arterial temporary balloon protection.
Collapse
Affiliation(s)
- Xianli Lv
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, People’s Republic of China
| | - Cao Song
- Neurosurgery Department, Jilin Center Hospital, People’s Republic of China
| | - Hongwei He
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, People’s Republic of China
| | - Chuhan Jiang
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, People’s Republic of China
| | - Youxiang Li
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, People’s Republic of China
- Youxiang Li, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Tiantan, Xili, 6, Dongcheng, Beijing, 100050, China.
| |
Collapse
|
5
|
Ivanov AY, Petrov AE, Vershinina EA, Galagudza MM, Vlasov TD. Evidence of active regulation of cerebral venous tone in individuals undergoing embolization of brain arteriovenous malformations. J Appl Physiol (1985) 2013; 115:1666-71. [PMID: 24114702 DOI: 10.1152/japplphysiol.00951.2013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cerebral venous drainage is generally believed to be regulated primarily by hydrodynamic forces. To gain further insight into the regulation of this process, we investigated the response of blood flow velocity and cross-sectional area (CSA) of the internal jugular veins (IJVs) to local hemodynamic shifts. All procedures and assessments were performed on patients (n = 30) undergoing embolization of brain arteriovenous malformations (AVMs). The procedure efficiency was verified by the postembolization reduction in time-averaged maximum blood flow velocities, as well as the elevation of pulsatility index and resistance index in the arterial feeders. In cerebral veins, the dominant IJV pressure remained unchanged during the procedure. At the same time, AVM embolization caused a significant reduction in maximal CSA (84 ± 7.6 to 68 ± 7.7 mm(2), P < 0.05) and minimal CSA (68 ± 7.0 to 51 ± 7.0 mm(2), P < 0.01) of the IJV located ipsilateral to the AVM, while the maximal linear blood flow velocity in the IJV remained unchanged (71 ± 4.9 and 85 ± 8.4 cm/s, P = 0.098). Consistent with previously published studies, the data obtained provide further evidence of active regulation of the venous outflow, probably mediated by certain neurogenic and/or endothelium-dependent mechanisms.
Collapse
Affiliation(s)
- Alexey Y Ivanov
- Division of Vascular Surgery, A. L. Polenov Research Institute of Neurosurgery, St. Petersburg, Russian Federation
| | | | | | | | | |
Collapse
|
6
|
Rossitti S. Pathophysiology of increased cerebrospinal fluid pressure associated to brain arteriovenous malformations: The hydraulic hypothesis. Surg Neurol Int 2013; 4:42. [PMID: 23607064 PMCID: PMC3622353 DOI: 10.4103/2152-7806.109657] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 02/28/2013] [Indexed: 11/11/2022] Open
Abstract
Background: Brain arteriovenous malformations (AVMs) produce circulatory and functional disturbances in adjacent as well as in remote areas of the brain, but their physiological effect on the cerebrospinal fluid (CSF) pressure is not well known. Methods: The hypothesis of an intrinsic disease mechanism leading to increased CSF pressure in all patients with brain AVM is outlined, based on a theory of hemodynamic control of intracranial pressure that asserts that CSF pressure is a fraction of the systemic arterial pressure as predicted by a two-resistor series circuit hydraulic model. The resistors are the arteriolar resistance (that is regulated by vasomotor tonus), and the venous resistance (which is mechanically passive as a Starling resistor). This theory is discussed and compared with the knowledge accumulated by now on intravasal pressures and CSF pressure measured in patients with brain AVM. Results: The theory provides a basis for understanding the occurrence of pseudotumor cerebri syndrome in patients with nonhemorrhagic brain AVMs, for the occurrence of local mass effect and brain edema bordering unruptured AVMs, and for the development of hydrocephalus in patients with unruptured AVMs. The theory also contributes to a better appreciation of the pathophysiology of dural arteriovenous fistulas, of vein of Galen aneurismal malformation, and of autoregulation-related disorders in AVM patients. Conclusions: The hydraulic hypothesis provides a comprehensive frame to understand brain AVM hemodynamics and its effect on the CSF dynamics.
Collapse
Affiliation(s)
- Sandro Rossitti
- Department of Neurosurgery, University Hospital, Linköping, Sweden
| |
Collapse
|
7
|
Fu B, Zhao JZ, Yu LB. The application of ultrasound in the management of cerebral arteriovenous malformation. Neurosci Bull 2009; 24:387-94. [PMID: 19037325 DOI: 10.1007/s12264-008-1013-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Ultrasound is used in the diagnosis, treatment and follow-up of cerebral arteriovenous malformation (AVM). Several parameters including flow velocity, flow volume, resistance index, pulsatility index, vasomotor reactivity and their influencing factors are reviewed. The applications of ultrasound in the preoperative evaluation, intraoperative monitor and postoperative follow-up of AVM, are summarized. Although some limits exist, ultrasound can provide more reliable information about AVM, if lesions are classified according to their characteristics, compared in different conditions between preoperation and postoperation, feeding and non-feeding side, patients and healthy adults, and if ultrasound method is combined with other examinations and different developed ultrasound techniques. With the appearance and development of new ultrasound technique, its application will be wider in management of AVM.
Collapse
Affiliation(s)
- Bing Fu
- Department of neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | | |
Collapse
|
8
|
Schreiber SJ, Stolz E, Valdueza JM. Transcranial ultrasonography of cerebral veins and sinuses. EUROPEAN JOURNAL OF ULTRASOUND : OFFICIAL JOURNAL OF THE EUROPEAN FEDERATION OF SOCIETIES FOR ULTRASOUND IN MEDICINE AND BIOLOGY 2002; 16:59-72. [PMID: 12470851 DOI: 10.1016/s0929-8266(02)00051-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Transcranial ultrasonography has become a valuable diagnostic tool for the bed-side evaluation of cerebral hemodynamics. While the assessment of arterial blood flow is well established, analysis of venous hemodynamics by transcranial ultrasonography is a new application of the method. The present review summarises the current state of transcranial venous ultrasound in adults by means of transcranial Doppler (TCD) and transcranial colour-coded duplex sonography (TCCS). It gives a critical overview regarding current and possible future clinical applications of the techniques.
Collapse
Affiliation(s)
- S J Schreiber
- Department of Neurology, University Hospital Charité, Schumannstr 20/21, 10098, Berlin, Germany
| | | | | |
Collapse
|
9
|
Morgan M, Winder M. Haemodynamics of arteriovenous malformations of the brain and consequences of resection: a review. J Clin Neurosci 2001; 8:216-24. [PMID: 11386794 DOI: 10.1054/jocn.2000.0795] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The physiological manifestations of arteriovenous fistulae in humans have been studied since the 18th century. However, confusion regarding concepts of cerebral 'steal', 'normal perfusion breakthrough', and 'congestive hyperaemia' continue. Although the advent of more accurate monitoring of pressures and flows within the brain has provided useful information to help understand some of these proposed pathological hypotheses, disagreement still exists. The purpose of this review is to examine the current physiological data in attempt to explain the clinicopathological manifestations of arteriovenous malformations of the brain and the consequences of their removal.
Collapse
Affiliation(s)
- M Morgan
- North and West Cerebrovascular Unit, Department of Surgery, The University of Sydney, Australia
| | | |
Collapse
|
10
|
Murayama Y, Massoud TF, Viñuela F. Hemodynamic changes in arterial feeders and draining veins during embolotherapy of arteriovenous malformations: an experimental study in a swine model. Neurosurgery 1998; 43:96-104; discussion 104-6. [PMID: 9657195 DOI: 10.1097/00006123-199807000-00064] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Transcatheter assessment of changes in draining vein (DV) flow velocity has been proposed recently as a potentially useful procedure for hemodynamic monitoring of the progression of embolotherapy in cerebral arteriovenous malformations (AVMs). We compared and contrasted changes in hemodynamic parameters of arterial feeders (AFs) and DVs during experimental AVM embolotherapy. METHODS Carotid-jugular fistula-type AVM models were surgically created in eight swine. Pre- and postembolization transcatheter mean AF and DV pressures, DV-time average spectral peak velocity, and AF and DV pulsatility indices were assessed. An expression, the peak systolic velocity minus end-diastolic velocity (Vs - Ved), was also used in evaluating the transvenous Doppler spectra. Pre- and postembolization hemodynamic parameters were compared statistically. RESULTS Pre-embolization DV flow was pulsatile (Vs - Ved, 12 +/- 4.8 cm/s), with a mean DV velocity of 39.3 +/- 11.4 cm per second. Postembolization, this changed to a less/nonpulsatile pattern (Vs - Ved, 5.4 +/- 2.7 cm/s; P = 0.0035) with a lower mean DV-average spectral peak velocity of 7.0 +/- 3.1 cm per second (P = 0.0001). The mean DV pressure was also reduced from 52.0 +/- 8.2 to 45.5 +/- 8.7 mm Hg (P = 0.0023). The mean AF pressure increased from a mean of 79.5 +/- 15.5 to 96.8 +/- 16.2 mm Hg (P = 0.0004). The DV pulsatility index values also increased from a mean of 0.3 +/- 0.2 to 1.1 +/- 0.5 (P = 0.0003). Periembolization objective hemodynamic changes were detected in the DVs earlier than were the visually subjective angiographic changes observed within the nidus. CONCLUSION This preliminary study indicates that transvenous assessment of average spectral peak velocity and wave pattern (Vs - Ved) may be useful in the hemodynamic evaluation of AVM shunting. The convergence of these two parameters to a range less than 10 cm per second after nidus embolization may afford a theoretical advantage over AF pressure measurements when used for objective and quantitative monitoring of endovascular embolotherapy.
Collapse
Affiliation(s)
- Y Murayama
- Division of Interventional Neuroradiology and Leo G. Rigler Radiological Research Center, University of California, Los Angeles School of Medicine, 90024, USA
| | | | | |
Collapse
|