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Lin JY, Lu CF, Hu YS, Yang HC, Liu YT, Loo JK, Lee KL, Liao CY, Chang FC, Liou KD, Lin CJ. Magnetic resonance radiomics-derived sphericity correlates with seizure in brain arteriovenous malformations. Eur Radiol 2024; 34:588-599. [PMID: 37553487 DOI: 10.1007/s00330-023-09982-6] [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: 01/01/2023] [Revised: 04/14/2023] [Accepted: 05/29/2023] [Indexed: 08/10/2023]
Abstract
OBJECTIVES Angioarchitectural analysis of brain arteriovenous malformations (BAVMs) is qualitative and subject to interpretation. This study quantified the morphology of and signal changes in the nidal and perinidal areas by using MR radiomics and compared the performance of MR radiomics and angioarchitectural analysis in detecting epileptic BAVMs. MATERIALS AND METHODS From 2010 to 2020, a total of 111 patients with supratentorial BAVMs were retrospectively included and grouped in accordance with the initial presentation of seizure. Patients' angiograms and MR imaging results were analyzed to determine the corresponding angioarchitecture. The BAVM nidus was contoured on time-of-flight MR angiography images. The perinidal brain parenchyma was contoured on T2-weighted images, followed by radiomic analysis. Logistic regression analysis was performed to determine the independent risk factors for seizure. ROC curve analysis, decision curve analysis (DCA), and calibration curve were performed to compare the performance of angioarchitecture-based and radiomics-based models in diagnosing epileptic BAVMs. RESULTS In multivariate analyses, low sphericity (OR: 2012.07, p = .04) and angiogenesis (OR: 5.30, p = .01) were independently associated with a high risk of seizure after adjustment for age, sex, temporal location, and nidal volume. The AUC for the angioarchitecture-based, MR radiomics-based, and combined models was 0.672, 0.817, and 0.794, respectively. DCA confirmed the clinical utility of the MR radiomics-based and combined models. CONCLUSIONS Low nidal sphericity and angiogenesis were associated with high seizure risk in patients with BAVMs. MR radiomics-derived tools may be used for noninvasive and objective measurement for evaluating the risk of seizure due to BAVM. CLINICAL RELEVANCE STATEMENT Low nidal sphericity was associated with high seizure risk in patients with brain arteriovenous malformation and MR radiomics may be used as a noninvasive and objective measurement method for evaluating seizure risk in patients with brain arteriovenous malformation. KEY POINTS • Low nidal sphericity was associated with high seizure risk in patients with brain arteriovenous malformation. • The performance of MR radiomics in detecting epileptic brain arteriovenous malformations was more satisfactory than that of angioarchitectural analysis. • MR radiomics may be used as a noninvasive and objective measurement method for evaluating seizure risk in patients with brain arteriovenous malformation.
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Affiliation(s)
- Jih-Yuan Lin
- Department of Radiology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou District, Taipei City, 112, Taiwan
| | - Chia-Feng Lu
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou District, Taipei City, 112, Taiwan
| | - Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou District, Taipei City, 112, Taiwan
- Department of Radiology, Taipei Hospital, Ministry of Health and Welfare, No. 127, Su-Yuan Rd., Hsin-Chuang Dist., New Taipei City, 24213, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou District, Taipei City, 112, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan
| | - Yo-Tsen Liu
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou District, Taipei City, 112, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan
- Brain Research Centre, National Yang Ming Chiao Tung University College of Medicine, No. 155, Sec. 2, Linong St., Beitou District, Taipei City, 112, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou District, Taipei City, 112, Taiwan
| | - Jing Kai Loo
- Department of Radiology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou District, Taipei City, 112, Taiwan
| | - Kang-Lung Lee
- Department of Radiology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou District, Taipei City, 112, Taiwan
| | - Chien-Yi Liao
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX, USA
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou District, Taipei City, 112, Taiwan
| | - Kang-Du Liou
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou District, Taipei City, 112, Taiwan
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 11217, Taipei City, Taiwan.
- School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Beitou District, Taipei City, 112, Taiwan.
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Bustuchina Vlaicu M. New approaches for brain arteriovenous malformations-related epilepsy. Rev Neurol (Paris) 2023; 179:188-200. [PMID: 36180290 DOI: 10.1016/j.neurol.2022.05.011] [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: 09/23/2021] [Revised: 02/21/2022] [Accepted: 05/25/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The purpose of this review is to present the current literature and to highlight the most recent findings in brain arteriovenous malformations (bAVM)-related epilepsy research. METHODS We searched Medline, PubMed, Biblioinserm, Cochrane Central to study the latest research reports about the different factors that could be responsible for the genesis of bAVM-related epilepsy. We analyzed if epileptogenesis has any characteristics traits and its relation with the vascular malformation. The results of different treatments on epilepsy were considered. Typical errors that may lead towards incorrect or worse management of the seizures for these patients were also examined. RESULTS The development of bAVM results from multifactorial etiologies and bAVM-related epileptogenesis is likely specific for this pathology. Different types of evidence demonstrate a bidirectional relationship between bAVM and epilepsy. Currently, there is not enough published data to determine what may be the right management for these patients. CONCLUSIONS A better understanding of epileptogenesis in conjunction with knowledge of the complex alterations of structures and functions following bAVM-related seizures is necessary. Identification of biomarkers that can identify subgroups most likely to benefit from a specific intervention are needed to help guide clinical management. A new concept for the treatment of epilepsy related to an unruptured bAVM that cannot be treated invasively is proposed as well as new therapeutic perspectives. The next necessary step will be to propose additional algorithms to improve the development of future trials.
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Affiliation(s)
- M Bustuchina Vlaicu
- Pitié-Salpêtrière Hospital, Department of Neurosurgery, Paris, France; Inserm U0955, Translational Neuro-Psychiatry team, Créteil, France.
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Arteriovenous Malformations and Other Vascular Anomalies. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00030-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Current concepts and perspectives on brain arteriovenous malformations: A review of pathogenesis and multidisciplinary treatment. World Neurosurg 2021; 159:314-326. [PMID: 34339893 DOI: 10.1016/j.wneu.2021.07.106] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 11/23/2022]
Abstract
Brain arteriovenous malformations (bAVMs) are unusual vascular pathologies characterized by the abnormal aggregation of dilated arteries and veins in the brain parenchyma and for which the absence of a normal vascular structure and capillary bed leads to direct connections between arteries and veins. Although bAVMs have long been believed to be congenital anomalies that develop during the prenatal period, current studies show that inflammation is associated with AVM genesis, growth, and rupture. Interventional treatment options include microsurgery, stereotactic radiosurgery, and endovascular embolization, and management often comprises a multidisciplinary combination of these modalities. The appropriate selection of patients with brain arteriovenous malformations for interventional treatment requires balancing the risk of treatment complications against the risk of hemorrhaging during the natural course of the pathology; however, no definitive guidelines have been established for the management of brain arteriovenous malformations. In this paper, we comprehensively review the current basic and clinical studies on bAVMs and discuss the contemporary status of multidisciplinary management of bAVMs.
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Silent MRA: arterial spin labeling magnetic resonant angiography with ultra-short time echo assessing cerebral arteriovenous malformation. Neuroradiology 2020; 62:455-461. [PMID: 31898767 DOI: 10.1007/s00234-019-02345-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 12/09/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE MR angiography using the silent MR angiography algorithm (silent MRA), which combines arterial spin labeling and an ultrashort time echo, has not been used for the evaluation of cerebral arteriovenous malformations (CAVMs). We aimed to determine the usefulness of silent MRA for the evaluation of CAVMs. METHODS Twenty-nine CAVMs of 28 consecutive patients diagnosed by 4D CT angiography or digital subtraction angiography, who underwent both time-of-flight (TOF) MRA and silent MRA, were enrolled. Two observers independently assessed the TOF-MRA and silent MRA images of CAVMs. Micro AVM was defined as AVM with a nidus diameter less than 10 mm. The detection rate, visualization of the components, and accuracy of Spetzler-Martin grade were evaluated with statistical software R. RESULTS For all 29 CAVMs, 23 (79%) lesions were detected for TOF-MRA and all for silent MRA. Of 10 micro AVMs, only 4 (40%) lesions were detectable on TOF-MRA and all (100%) on silent MRA. The visibility of the nidus and drainer was significantly better for silent MRA than TOF-MRA (p < 0.001), while there was no significant difference in the feeder between the two sequences. The accuracy rates of the Spetzler-Martin grade for the TOF and silent MRA were 38% (11/29) and 79.3% (23/29), respectively (p < 0.001). CONCLUSIONS Silent MRA is useful for evaluating CAVM components and detecting micro AVM.
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Seizure Presentation in Patients with Brain Arteriovenous Malformations Treated with Stereotactic Radiosurgery: A Multicenter Study. World Neurosurg 2019; 126:e634-e640. [DOI: 10.1016/j.wneu.2019.02.104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/10/2019] [Accepted: 02/11/2019] [Indexed: 11/23/2022]
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Zhang B, Feng X, Peng F, Wang L, Guo EK, Zhang Y, Liu P, Wu Z, Liu A. Seizure predictors and outcome after Onyx embolization in patients with brain arteriovenous malformations. Interv Neuroradiol 2018; 25:124-131. [PMID: 30269666 DOI: 10.1177/1591019918801290] [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: 11/15/2022] Open
Abstract
BACKGROUND Brain arteriovenous malformation (bAVM)-related epilepsy can significantly affect patient quality of life. We aimed to identify the factors associated with seizures occurrence and evaluate the long-term outcome following Onyx embolization in bAVM patients. METHODS Between July 2014 and July 2016, 239 consecutive patients underwent treatment for bAVMs in our institute and were respectively analyzed. Demographics, seizure status and bAVM morphologic characteristics were recorded. Modified Engel classification was used to evaluate the long-term seizure outcomes. RESULTS Of 239 bAVM patients, 68 (28.5%) initially presented with seizures. Seizure occurrence was associated with cerebral hemorrhage history, frontal-temporal location and arterial borderzone location. Of the 37 patients who presented with initial seizures and were treated with Onyx embolization, 23 (62.2%) were treated with antiepileptic drugs (AEDs) before Onyx embolization. At the last follow-up visit, 19 (51.4%) of the 37 patients reached modified Engel class I outcome. Of the 23 patients who had ever been treated with AEDs, 12 (52.2%) were still taking AEDs at the last follow-up visit. Single-factor analysis showed that arterial borderzone location was significantly correlated with higher modified Engel class outcome ( p = 0.046). CONCLUSION Patients with bAVM hemorrhage history, frontal-temporal location and arterial borderzone location were associated with seizure occurrence. Seizure-free status was not obtained in AVM patients with arterial borderzone after embolization, though it may have benefits in other ways. The seizure-free mechanism of bAVM with Onyx embolization is worth further study.
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Affiliation(s)
- Baorui Zhang
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Feng
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fei Peng
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Luyao Wang
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Er Kang Guo
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yupeng Zhang
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Liu
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongxue Wu
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Aihua Liu
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Tong X, Wu J, Lin F, Cao Y, Zhao Y, Wang S, Zhao J. Risk Factors for Subsequent Hemorrhage in Patients with Cerebellar Arteriovenous Malformations. World Neurosurg 2016; 92:47-57. [DOI: 10.1016/j.wneu.2016.04.082] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 04/20/2016] [Accepted: 04/22/2016] [Indexed: 11/28/2022]
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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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Abstract
In a recent trial limited to arteriovenous malformations discovered not to have bled, medical management was superior to medical management plus intervention. The trial was halted after 226 randomizations and a mean follow-up of 3.3 years owing to a disparity favoring the medical arm. Eligible patients were selected as suitable for lesion eradication. The initial sample size of 800 and follow-up plans for a mean of 7 years were lowered and shortened, respectively, by the outcome data. An application for extended follow-up was given poor priority scores owing to estimations that the disparities in outcomes would not change significantly.
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Affiliation(s)
- J P Mohr
- Department of Neurology, Doris & Stanley Tananbaum Stroke Center, Neurological Institute, Columbia University Medical Center, 710 West 168th Street, New York, NY 10032, USA.
| | - Shadi Yaghi
- Department of Neurology, Doris & Stanley Tananbaum Stroke Center, Neurological Institute, Columbia University Medical Center, 710 West 168th Street, New York, NY 10032, USA
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Arteriovenous Malformations and Other Vascular Anomalies. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00030-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Angioarchitecture and Posttreatment Magnetic Resonance Imaging Characteristics of Brain Arteriovenous Malformations and Long-Term Seizure Control After Radiosurgery. World Neurosurg 2015; 87:277-82. [PMID: 26548816 DOI: 10.1016/j.wneu.2015.10.070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/16/2015] [Accepted: 10/17/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To corroborate which pretreatment angioarchitectural characteristics and posttreatment magnetic resonance imaging (MRI) features were associated with better seizure and antiepileptic drug outcomes in patients with brain arteriovenous malformations (AVMs) treated by Gamma Knife radiosurgery. METHODS During the period 2007-2010, 220 patients with intracranial AVMs undergoing radiosurgery at our hospital were evaluated. Imaging features on digital subtraction angiography and follow-up MRI, medical records, and direct patient interview were retrospectively assessed. Seizure outcome was assessed using the Engel classification and the status of antiepileptic drug use. RESULTS At the last follow-up, 21 of 31 patients (68%) who met the recruitment criteria had AVM obliteration on digital subtraction angiography or MRI. Seizure-free status (Engel class 1) was achieved in 20 patients (65%), and 13 of 20 (65%) seizure-free patients were medication-free. The presence of total obliteration at last imaging follow-up (P = 0.013), absent retrograde cortical veins on digital subtraction angiography before GKRS (P = 0.013), nidus <3.7 cm (P = 0.006), and lower modified radiosurgery-based AVM score (P = 0.026) were significant predictors of seizure-free outcome. The strongest independent predictor of seizure-free status was absence of retrograde veins (odds ratio = 9.9). No angioarchitectural feature, postradiosurgery imaging finding on MRI, or radiosurgical treatment parameter was a significant predictor of seizure control or cessation of medication in seizure-free patients. CONCLUSIONS This study suggests that radiosurgery provides favorable outcomes in patients with AVM-related epilepsy. Patients with intracranial AVMs can benefit from seizure control after GKRS before undergoing AVM obliteration. Absence of retrograde veins is associated with better seizure-free outcomes, regardless of the parenchymal changes after radiosurgery.
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Zammar SG, Hamade YJ, Aoun RJ, El Tecle NE, El Ahmadieh TY, Lall RR, Taub ZD, Swanson KR, Chandler JP, Bendok BR. Precision medicine in brain arteriovenous malformation management: arteries steal the show but veins may hold the crystal ball. Neurosurgery 2014; 75:N13-4. [PMID: 25406620 DOI: 10.1227/01.neu.0000457193.02158.c9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Samer G Zammar
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Bervini D, Morgan MK, Ritson EA, Heller G. Surgery for unruptured arteriovenous malformations of the brain is better than conservative management for selected cases: a prospective cohort study. J Neurosurg 2014; 121:878-90. [DOI: 10.3171/2014.7.jns132691] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The aim of this study was to identify patients who are likely to benefit from surgery for unruptured brain arteriovenous malformations (ubAVMs).
Methods
The authors' database was interrogated for the risk and outcome of hemorrhage after referral and the outcome from surgery. Furthermore, the outcome from surgery incorporated those cases excluded from surgery because of perceived greater risk (sensitivity analysis). Finally, a comparison was made for the authors' patients between the natural history and surgery. Data were collected for 427 consecutively enrolled patients with ubAVMs in a database that included patients who were conservatively managed. Kaplan-Meier analysis was performed on patients observed for more than 1 day to determine the risk of hemorrhage. Variables that may influence the risk of first hemorrhage were assessed using Cox proportional hazard regression models and Kaplan-Meier life table analyses from referral until the first occurrence of the following: hemorrhage, treatment, or last review. The outcome from surgery (leading to a new permanent neurological deficit with last review modified Rankin Scale [mRS] score > 1) was determined. Further sensitivity analysis was made to predict risk from surgery for the total ubAVM cohort by incorporating outcomes of surgical cases as well as cases excluded from surgery because of perceived risk, and assuming an adverse outcome for these excluded cases.
Results
A total of 377 patients with a ubAVM were included in the analysis of the risk of hemorrhage. The 5-year risk of hemorrhage for ubAVM was 11.5%. Hemorrhage resulted in an mRS score > 1 in 14 cases (88% [95% CI 63%–98%]). Patients with Spetzler-Ponce Class A ubAVMs treated by surgery (n = 190) had a risk from surgery of 1.6% (95% CI 0.3%–4.8%) for a permanent neurological deficit leading to an mRS score > 1 and 0.5% (95% CI < 0.1%–3.2%) for a permanent neurological deficit leading to an mRS score > 2. Patients with Spetzler-Ponce Class B ubAVMs treated by surgery (n = 107) had a risk from surgery of 14.0% (95% CI 8.6%–22.0%) for a permanent neurological deficit leading to an mRS score > 1. Sensitivity analysis of Spetzler-Ponce Class B ubAVMs, including those in patients excluded from surgery, showed that the true risk for surgically eligible patients may have been as high as 15.6% (95% CI 9.9%–23.7%) for mRS score > 1, had all patients who were perceived to have a greater risk experienced an adverse outcome. Patients with Spetzler-Ponce Class C ubAVMs treated by surgery (n = 44) had a risk from surgery of 38.6% (95% CI 25.7%–53.4%) for a permanent neurological deficit leading to an mRS score > 1. Sensitivity analysis of Class C ubAVMs, including those harbored by patients excluded from surgery, showed that the true risk for surgically eligible patients may have been as high as 60.9% (95% CI 49.2%–71.5%) for mRS score > 1, had all patients who were perceived to have a greater risk experienced an adverse outcome.
Conclusions
Surgical outcomes for Spetzler-Ponce Class A ubAVMs are better than those for conservative management.
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Affiliation(s)
| | | | | | - Gillian Heller
- 3Statistics Department, Macquarie University, Sydney, New South Wales, Australia
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Chen CJ, Chivukula S, Ding D, Starke RM, Lee CC, Yen CP, Xu Z, Sheehan JP. Seizure outcomes following radiosurgery for cerebral arteriovenous malformations. Neurosurg Focus 2014; 37:E17. [DOI: 10.3171/2014.6.focus1454] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Seizures are a common presentation of cerebral arteriovenous malformations (AVMs). The authors evaluated the efficacy of stereotactic radiosurgery (SRS) for the management of seizures associated with AVMs and identified factors influencing seizure outcomes following SRS for AVMs.
Methods
A systematic literature review was performed using PubMed. Studies selected for review were published in English, included at least 5 patients with both cerebral AVMs and presenting seizures treated with SRS, and provided post-SRS outcome data regarding obliteration of AVMs and/or seizures. Demographic, radiosurgical, radiological, and seizure outcome data were extracted and analyzed. All seizure outcomes were categorized as follows: 1) seizure free, 2) seizure improvement, 3) seizure unchanged, and 4) seizure worsened. Systematic statistical analysis was conducted to assess the effect of post-SRS AVM obliteration on seizure outcome.
Results
Nineteen case series with a total of 3971 AVM patients were included for analysis. Of these, 28% of patients presented with seizures, and data for 997 patients with available seizure outcome data who met the inclusion criteria were evaluated. Of these, 437 (43.8%) patients achieved seizure-free status after SRS, and 530 (68.7%) of 771 patients with available data achieved seizure control (seizure freedom or seizure improvement) following SRS. Factors associated with improved seizure outcomes following SRS for AVMs were analyzed in 9 studies. Seizure-free status was achieved in 82% and 41.0% of patients with complete and incomplete AVM obliteration, respectively. Complete AVM obliteration offered superior seizure-free rates compared with incomplete AVM obliteration (OR 6.13; 95% CI 2.16–17.44; p = 0.0007).
Conclusions
Stereotactic radiosurgery offers favorable seizure outcomes for AVM patients presenting with seizures. Improved seizure control is significantly more likely with complete AVM obliteration.
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Affiliation(s)
- Ching-Jen Chen
- 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Srinivas Chivukula
- 2 Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Dale Ding
- 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert M. Starke
- 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
- 3 Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chun-Po Yen
- 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Zhiyuan Xu
- 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P. Sheehan
- 1 Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
- 4 Department of Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
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Novakovic RL, Lazzaro MA, Castonguay AC, Zaidat OO. The diagnosis and management of brain arteriovenous malformations. Neurol Clin 2013; 31:749-63. [PMID: 23896503 DOI: 10.1016/j.ncl.2013.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Although uncommon in the general population, cerebral arteriovenous malformations (AVMs) can pose a significant health risk if a rupture occurs. Advances in noninvasive imaging have led to an increase in the identification of unruptured AVMs, presenting new challenges in management, given their poorly understood natural history. Over the past decade, there have been significant developments in the management and treatment of intracranial AVMs. This article discusses the pathophysiology, natural history, clinical presentations, and current treatment options, including multimodal approaches, for these vascular malformations.
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Affiliation(s)
- Roberta L Novakovic
- Neuroradiology Division, Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9178, USA
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Sturiale C, Rigante L, Puca A, Di Lella G, Albanese A, Marchese E, Di Rocco C, Maira G, Colicchio G. Angioarchitectural features of brain arteriovenous malformations associated with seizures: a single Center retrospective series. Eur J Neurol 2013; 20:849-55. [DOI: 10.1111/ene.12085] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 11/27/2012] [Indexed: 11/30/2022]
Affiliation(s)
- C.L. Sturiale
- Institute of Neurosurgery, Catholic University School of Medicine; Rome; Italy
| | - L. Rigante
- Institute of Neurosurgery, Catholic University School of Medicine; Rome; Italy
| | - A. Puca
- Institute of Neurosurgery, Catholic University School of Medicine; Rome; Italy
| | - G. Di Lella
- Institute of Bio-Imaging , Catholic University School of Medicine; Rome; Italy
| | - A. Albanese
- Institute of Neurosurgery, Catholic University School of Medicine; Rome; Italy
| | - E. Marchese
- Institute of Neurosurgery, Catholic University School of Medicine; Rome; Italy
| | - C. Di Rocco
- Institute of Neurosurgery, Catholic University School of Medicine; Rome; Italy
| | - G. Maira
- Institute of Neurosurgery, Catholic University School of Medicine; Rome; Italy
| | - G. Colicchio
- Institute of Neurosurgery, Catholic University School of Medicine; Rome; Italy
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Mossa-Basha M, Chen J, Gandhi D. Imaging of cerebral arteriovenous malformations and dural arteriovenous fistulas. Neurosurg Clin N Am 2012; 23:27-42. [PMID: 22107856 DOI: 10.1016/j.nec.2011.09.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Imaging plays a major role in the identification, grading, and treatment of cerebral arteriovenous malformations and cerebral dural arteriovenous fistulas. Digital subtraction angiography is the gold standard in the diagnosis and characterization of these vascular malformations, but advances in both magnetic resonance imaging and computed tomography, including advanced imaging techniques, have provided new tools for further characterizing these lesions as well as the surrounding brain structures that may be affected. This article discusses the role of conventional as well as advanced imaging modalities that are providing novel ways to characterize these vascular malformations.
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Affiliation(s)
- Mahmud Mossa-Basha
- Division of Neuroradiology, Russell H. Morgan Department of Radiology, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287, USA
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21
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Yashar P, Amar AP, Giannotta SL, Yu C, Pagnini PG, Liu CY, Apuzzo MLJ. Cerebral arteriovenous malformations: issues of the interplay between stereotactic radiosurgery and endovascular surgical therapy. World Neurosurg 2011; 75:638-47. [PMID: 21704930 DOI: 10.1016/j.wneu.2011.01.042] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 01/25/2011] [Accepted: 01/28/2011] [Indexed: 11/25/2022]
Abstract
Intracranial arteriovenous malformations (AVMs) are congenital lesions frequently diagnosed as a result of hemorrhage or other neurological symptoms. Prevention of such devastating neurological injury has promoted a variety of treatment strategies. The rich history of multimodal therapy in the treatment of AVMs includes microsurgery, endovascular embolization, and stereotactic radiosurgery (SRS). This article reviews the biology and natural history of AVMs, as well as their treatment with both SRS and endovascular neurosurgery. It considers various paradigms and goals of endovascular treatment, along with relevant issues such as the features of an AVM to be targeted. Issues of the interplay between SRS and endovascular neurosurgery include the compartments of an embolized AVM to contain within the radiosurgery plan, the radioprotective and radiosensitizing effects of the embolic agent, the durability of embolization, and the sequencing of embolization with respect to the radiosurgical treatment. Published literature on these topics is sparse, and the flimsiness of the data offers limited guidance.
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Affiliation(s)
- Parham Yashar
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Stapf C, Mohr J, Hartmann A, Mast H, Khaw A, Choi JH, Pile-Spellman J. Arteriovenous Malformations and Other Vascular Anomalies. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10031-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Starke RM, Komotar RJ, Hwang BY, Fischer LE, Garrett MC, Otten ML, Connolly ES. Treatment guidelines for cerebral arteriovenous malformation microsurgery. Br J Neurosurg 2009; 23:376-86. [DOI: 10.1080/02688690902977662] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Yamada S, Takagi Y, Nozaki K, Kikuta KI, Hashimoto N. Risk factors for subsequent hemorrhage in patients with cerebral arteriovenous malformations. J Neurosurg 2007; 107:965-72. [PMID: 17977268 DOI: 10.3171/jns-07/11/0965] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The aim of this study was to identify the natural history of untreated cerebral arteriovenous malformations (AVMs) and the risk factors for subsequent hemorrhage after an initial AVM diagnosis.
Methods
The authors studied 305 consecutive patients with AVMs at the Kyoto University Hospital between 1983 and 2005. These patients were followed up until the first subsequent hemorrhage, the start of any treatment, or the end of 2005. Possible risk factors that were investigated included age at initial diagnosis, sex, type of initial presentation, size and location of the AVM nidus, and the venous drainage pattern. Subsequent hemorrhage occurred in 26 patients from the hemorrhagic group during 380 patient–years, and in 16 patients from the nonhemorrhagic group during 512 patient–years.
Results
The annual bleeding rate in the hemorrhagic group was 6.84% after the initial hemorrhage; however, that rate decreased in the first 5 years (15.42% in the first year, 5.32% in the subsequent 4 years, and 1.72% in more than 5 years). In the nonhemorrhagic group (annual bleeding rate of 3.12%), the patients initially presenting with headaches (annual bleeding rate of 6.48%) or asymptomatic presentations (annual bleeding rate of 6.44%) had a higher risk for subsequent hemorrhage. Conversely, those patients presenting with seizures (annual bleeding rate of 2.20%) or neurological deficits (annual bleeding rate of 1.73%) had a lower risk. A significantly increased risk (p < 0.05) of rebleeding was found among children (hazard ratio [HR] = 2.69), females (HR = 2.93), or patients with deep-seated AVMs (HR = 3.07).
Conclusions
Children, females, and patients with deep-seated AVMs had a threefold increased risk of rebleeding after an initial cerebral AVM. This increased risk was highest in the first year after the initial hemorrhage, and thereafter gradually decreased.
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Hartmann A, Mast H, Choi JH, Stapf C, Mohr JP. Treatment of arteriovenous malformations of the brain. Curr Neurol Neurosci Rep 2007; 7:28-34. [PMID: 17217851 DOI: 10.1007/s11910-007-0018-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The treatment of ruptured and unruptured brain arteriovenous malformations (AVMs) is driven by the need to prevent incident or recurrent intracranial hemorrhages. Improving feasibility of the rapidly developing endovascular, neurosurgical, and radiotherapeutic procedures leads to invasive treatment of an increasing number of neurologically intact patients with accidentally diagnosed AVMs. Recent data confirm that the natural history risk of unruptured AVMs is significantly lower than the risk of those presenting with rupture, and the treatment risk of invasive management of unruptured AVMs seems higher than their natural history risk. The treatment decision algorithm for these patients remains unsettled, as no randomized clinical trial data exist on the benefit of invasive AVM treatment for patients with bled or with unbled AVMs. The recently launched study A Randomized Trial of Unruptured Brain AVMs (ARUBA) will be the first trial randomizing patients with nonhemorrhaged AVMs to invasive versus conservative management.
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Affiliation(s)
- Andreas Hartmann
- Stroke Unit, Department of Neurology, Charité Hochschulmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany.
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Abstract
INTRODUCTION Brain arteriovenous malformations (AVMs) constitute a neurovascular disorder that comes to clinical attention mainly in young adults in their mid thirties. Associated symptoms often require neurological treatment for symptomatic seizures (focal or generalized), headaches (episodic or chronic), progressive neurological deficits, or spontaneous AVM rupture leading to intracerebral, intraventricular, and/or subarachnoid hemorrhage. STATE OF ART Little data exist in the medical literature regarding the natural history risk of the disease and no controlled studies are available on the risk of invasive AVM treatment (endovascular, neurosurgery, radiotherapy). PERSPECTIVES This review focuses on all aspects of neurological brain AVM management and discusses possible predictors of the natural history risk as well as the benefit and risk of invasive treatment. CONCLUSIONS AVM patient management is ideally based on a trans-disciplinary approach via a neurovascular team of neurologists, neuroradiologists, neurosurgeons, and radiotherapists. A newly diagnosed AVM does not necessarily represent an a priori indication for interventional treatment. The decision in favor or against therapy mainly depends on clinical criteria (ruptured versus unruptured AVM, neurological exam, patient age and co-morbidity, etc.) and the angioarchitecture of the malformation. The ARUBA study is going to be the first randomized clinical trial comparing the risk of invasive treatment versus non-invasive management.
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Affiliation(s)
- C Stapf
- Service de Neurologie, Hôpital Lariboisière, Paris.
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Biondi A, Le Jean L, Capelle L, Duffau H, Marsault C. Fatal hemorrhagic complication following endovascular treatment of a cerebral arteriovenous malformation. J Neuroradiol 2006; 33:96-104. [PMID: 16733423 DOI: 10.1016/s0150-9861(06)77238-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Evaluation of the natural history of brain Arteriovenous Malformations (AVMs) including its morbidity and mortality is a crucial point in the management of patients having a cerebral AVM. The risks associated with the AVM natural history, especially regarding the occurrence of an hemorrhage, have to be compared to the risks due to the therapeutic approach. In the literature, the risk of annual bleeding of an AVM is estimated from 2 to 4%. Morbidity from AVM rupture is estimated from 13% to 50% with a risk of mortality reported from 3 to 30%. Endovascular treatment is an efficient tool in the therapy of these lesions. However, AVM embolization remains a difficult procedure. Complications of the endovascular treatment must be evaluated in relation to the potential risk associated to the AVM natural history. After AVM endovascular treatment, morbidity with permanent neurological deficit is reported in 0.4% to 12.5% of patients and mortality in 0.4% to 7.5%. In more recent reports, after brain AVM embolization, a permanent neurological deficit is estimated to occur in 9% of patients and death in 2%. Hemorrhage appears the most frequent and serious complication in the endovascular treatment of a brain AVM. We report a case of fatal hemorrhagic complication following endovascular treatment of a cerebral AVM in a 20 year old patient. This case contributes to remind that embolization, even in specialized centers with experience in the management of this pathology, can be followed by a poor and even fatal outcome. In most cases, the treatment is performed in order to protect the patient of a potential risk. Consequently, the complication of the embolization must always be carefully considered and discussed between the medical team, the patient and its family for planning the AVM endovascular treatment.
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Affiliation(s)
- A Biondi
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, University of Paris VI.
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Abstract
Arteriovenous malformations of the brain (AMB) can cause stroke when they rupture. Epidemiological and imaging research has found that about 50% of patients with AMB present with haemorrhage, and the other 50% either present with non-focal symptoms, such as headache, seizure, or focal neurological deficit, or have no symptoms and the lesion is found during unrelated investigations. Treatment for arteriovenous malformations aims to prevent and resolve haemorrhage and is a growing interdisciplinary challenge. Although treatment uses enormous resources, there have been few studies on the risk-benefit ratios for treatment of unruptured AMB and the best approaches.
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Pierot L, Cognard C, Spelle L. [Cerebral arteriovenous malformations: evaluation of the hemorrhagic risk and its morbidity]. J Neuroradiol 2005; 31:369-75. [PMID: 15687954 DOI: 10.1016/s0150-9861(04)97018-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Evaluation of the hemorrhagic risk associated with intracranial arteriovenous malformation is a keypoint question for physicians involved in the management of these patients. Indeed, this hemorrhagic risk including its morbid-mortality consequences has to be balanced with the therapeutic risk. All the published studies have estimated the annual bleeding risk between 2 to 4%; a first hemorrhagic event is associated with an increased risk of a new bleeding. Mortality associated with AVM bleeding is estimated between 10 to 15%, with a 50% risk of morbidity. Factors associated with an increased risk of bleeding include existence of aneurysms (intranidal or flow related pedicular, proximal or distal) and some venous drainage patterns such as deep venous drainage or venous stenosis.
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Affiliation(s)
- L Pierot
- Service de Radiologie, Hôpital Maison-Blanche, 45 rue Cognacq-Jay, 51092 REIMS Cedex, France.
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Mohr J, Hartmann A, Mast H, Pile-Spellman J, Schumacher HC, Stapf C. Arteriovenous Malformations and Other Vascular Anomalies. Stroke 2004. [DOI: 10.1016/b0-44-306600-0/50019-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
Stroke is the most common life-threatening neurologic disease and the leading cause of serious long-term disability. The advent of new treatment options for selected patients suffering ischemic stroke (such as systemic administration of tissue plasminogen activator or catheter-guided intra-arterial thrombolysis), the structural reorganization of patient care facilities into stroke units, and interdisciplinary cerebrovascular centers have broadened the scope of possible therapeutic interventions in the acute and post-acute phase after cerebral ischemia. This review summarizes currently available and recommended treatment modalities for acute ischemic stroke from an interdisciplinary perspective, including medical, neurointerventional, and neurosurgical therapies.
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Affiliation(s)
- C Stapf
- The Neurological Institute, Columbia University College of Physicians and Surgeons, 710 West 168th Street, New York, New York 10032, USA
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Stapf C, Mohr JP, Pile-Spellman J, Solomon RA, Sacco RL, Connolly ES. Epidemiology and natural history of arteriovenous malformations. Neurosurg Focus 2001; 11:e1. [PMID: 16466233 DOI: 10.3171/foc.2001.11.5.2] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The epidemiology and natural history of cerebral arteriovenous malformations (AVMs) remains incompletely elucidated. Several factors are responsible. With regard to the incidence and prevalence of AVMs, the results of prior studies have suffered because of the retrospective design, the use of nonspecific ICD-9 codes, and a focus on small genetically isolated populations. Recent data from the New York Islands AVM Hemorrhage Study, an ongoing, prospective, population-based survey determining the incidence of AVM-related hemorrhage and the associated rates of morbidity and mortality in a zip code–defined population of 10 million people, suggests that the AVM detection rate is 1.21/100,000 person-years (95% confidence interval [CI] 1.02–1.42) and the incidence of AVM-hemorrhage is 0.42/100,000 person-years (95% CI 0.32–0.55). Contemporaneous data from the Northern Manhattan Stroke Study, a prospective, longitudinal population-based study of nearly 150,000 patients in which the focus is to define the incidence of stroke, suggest the crude incidence for first-ever AVM-related hemorrhage to be 0.55/100,000 person-years (95% CI 0.11–1.61). Efforts are ongoing to study the natural history of both ruptured and unruptured AVMs in these datasets to examine the relevance of prior studies of patients selected for conservative follow up in Finland. In addition, data are being gathered to determine whether risk factors for future hemorrhage, which have previously been established in small case series, are valid when applied to whole populations. Together, these data should help inform therapeutic decisionmaking.
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Affiliation(s)
- C Stapf
- Columbia Arteriovenous Malformation Study Project, Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA
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