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Brunozzi D, Stone McGuire L, Hossa J, Atwal G, Charbel FT, Alaraj A. Preoperative embolization of brain arteriovenous malformation and efficacy in intraoperative blood loss reduction: a quantitative study. J Neurointerv Surg 2024; 16:541-547. [PMID: 37402571 DOI: 10.1136/jnis-2023-020142] [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: 02/03/2023] [Accepted: 06/13/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Embolization of brain arteriovenous malformations (bAVMs) is often used as adjuvant therapy to microsurgical resection to reduce the high-risk features of bAVMs such as large size and high flow. However, the effect of preoperative embolization on surgical performance and patient outcome has shown mixed results. Heterogeneity in treatment goals, selection criteria, and unpredictable changes in bAVM hemodynamics after partial embolization may account for these uncertain findings. In this study we use an objective quantitative technique to assess the impact of preoperative embolization on intraoperative blood loss (IBL). METHODS Patients with bAVM treated with microsurgical resection only or in combination with preoperative embolization from 2012 to 2022 were retrospectively reviewed. Patients were included if quantitative magnetic resonance angiography was performed prior to any treatment. Correlation of baseline bAVM flow, volume, and IBL was evaluated between the two groups. Additionally, bAVM flow prior to and after embolization was compared. RESULTS Forty-three patients were included, 31 of whom required preoperative embolization (20 had more than one session). Mean bAVM initial flow (362.3 mL/min vs 89.6 mL/min, p=0.001) and volume (9.6 mL vs 2.8 mL, p=0.001) were significantly higher in the preoperative embolization group; flow decreased significantly after embolization (408.0 mL/min vs 139.5 mL/min, p<0.001). IBL was comparable between the two groups (258.6 mL vs 141.3 mL, p=0.17). Linear regression continued to show a significant difference in initial bAVM flow (p=0.03) but no significant difference in IBL (p=0.53). CONCLUSION Patients with larger bAVMs who underwent preoperative embolization had comparable IBL to those with smaller bAVMs undergoing only surgical treatment. Preoperative embolization of high-flow bAVMs facilitates surgical resection, reducing the risk of IBL.
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Affiliation(s)
- Denise Brunozzi
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Laura Stone McGuire
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jessica Hossa
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Gursant Atwal
- 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
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
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2
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Roberts R, Hadi M, Ram C, Affan M. What the Diagnostic Neuroradiologist Needs to Know About Diseases of the Cerebral Veins. Semin Roentgenol 2024; 59:172-190. [PMID: 38880516 DOI: 10.1053/j.ro.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/10/2024] [Accepted: 02/20/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Rebecca Roberts
- Department of Neurology, University of Minnesota, Minneapolis, MN
| | - Mohiuddin Hadi
- Department of Radiology, University of Louisville, Louisville, KY
| | - Chithra Ram
- Department of Radiology, University of Louisville, Louisville, KY
| | - Muhammad Affan
- Department of Neurology, University of Minnesota, Minneapolis, MN.
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Pacini A, Shotar E, Granger B, Maizeroi-Eugène F, Delaitre M, Talbi A, Boch AL, Valéry CA, Premat K, Drir M, Lenck S, Mounayer C, Sourour NA, Clarençon F. Nidus Compacity Determined by Semi-Automated Segmentation is a Strong Quantitative Predictor of Brain Arterio-Venous Malformation Cure. Clin Neuroradiol 2023; 33:1095-1104. [PMID: 37378842 DOI: 10.1007/s00062-023-01313-y] [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: 11/30/2022] [Accepted: 05/22/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND AND OBJECTIVE A compact nidus is a well-known feature of good outcome after treatment in brain arteriovenous malformations (bAVM). This item, included in the "Supplementary AVM grading system" by Lawton, is subjectively evaluated on DSA. The present study aimed to assess whether quantitative nidus compacity along with other angio-architectural bAVM features were predictive of angiographic cure or the occurrence of procedure-related complications. MATERIALS AND METHODS Retrospective analysis of 83 patients prospectively collected data base between 2003 to 2018 having underwent digital subtraction 3D rotation angiography (3D-RA) for pre-therapeutic assessment of bAVM. Angio-architectural features were analyzed. Nidus compacity was measured with a dedicated segmentation tool. Univariate and multivariate analyses were performed to test the association between these factors and complete obliteration or complication. RESULTS Compacity was the only significant factor associated with complete obliteration in our predictive model using logistic multivariate regression; the area under the curve for compacity predicting complete obliteration was excellent (0.82; 95% CI 0.71-0.90; p < 0.0001). The threshold value maximizing the Youden index was a compacity > 23% (sensitivity 97%; specificity 52%; 95% CI 85.1-99.9; p = 0.055). No angio-architectural factor was associated with the occurrence of a complication. CONCLUSION Nidus high compacity quantitatively measured on 3D-RA, using a dedicated segmentation tool is predictive of bAVM cure. Further investigation and prospective studies are warranted to confirm these preliminary results.
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Affiliation(s)
- Aurélien Pacini
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital. APHP, Paris, France.
| | - Eimad Shotar
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital. APHP, Paris, France
| | - Benjamin Granger
- Department of Public Health, Pitié-Salpêtrière Hospital. APHP, Paris, France
- INSERM UMR 1136, Sorbonne University, Paris, France
| | | | | | - Atika Talbi
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital. APHP, Paris, France
| | - Anne-Laure Boch
- Department of Neurosurgery, Pitié-Salpêtrière Hospital. APHP, Paris, France
| | | | - Kévin Premat
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital. APHP, Paris, France
| | - Mehdi Drir
- Department of Neuro-intensive care, Pitié-Salpêtrière Hospital. APHP, Paris, France
| | - Stéphanie Lenck
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital. APHP, Paris, France
| | - Charbel Mounayer
- Department of Interventional Neuroradiology, Limoges University Hospital, Limoges, France
| | - Nader-Antoine Sourour
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital. APHP, Paris, France
| | - Frédéric Clarençon
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital. APHP, Paris, France
- INSERM UMR 1136, Sorbonne University, Paris, France
- GRC BioFast, Sorbonne University, Paris, France
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Netliukh A, Kobyletskyi O, Salo V, Prokopenko N, Sukhanov A. A complex approach to the treatment of arteriovenous IV-V degree malformations according to Spetzler‒Martin scale. Clinical case. UKRAINIAN INTERVENTIONAL NEURORADIOLOGY AND SURGERY 2023. [DOI: 10.26683/2786-4855-2022-3(41)-46-58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Four therapeutic approaches have been developed for the treatment of arteriovenous malformations (AVMs): microsurgery, radiosurgery, embolization, and conservative treatment. The lack of consensus regarding the choice of treatment method and the different specializations of the doctor who are onvolved to the patient with AVM often determine the wrong treatment strategy. We performed a prospective analysis of the results of AVM of the IV degree according to Spetzler‒Martin scale, 4–5 points on the Buffalo scale complex treatment, based on clinical and tomographic data after the use of partial endovascular embolization and radical microsurgical removal of the AVM node assisted by cell saving technology. According to cerebral angiography 4 months follow-up there is no visible AVM vessels, the malformation was completely resected.Treatment of large and giant AVMs (IV and V degrees according to the Spetzler‒Martin scale) requires tailored surgical treatment approache using endovascular, microsurgical and radiosurgical techniques, but in many cases without achieving a radical result. The use of cell saver technology is necessary to reduce the risks of intraoperative complications associated with blood loss during microsurgical intervention, and enables radical removal of the AVM and recovery of the patient. The role of cell saver technology is crucial in vascular microsurgical interventions, which are often accompanied by a significant volume of blood loss, ensuring rapid autologous hemotransfusion and restoration of circulating blood volume. Endovascular embolization is a necessary step to reduce the risks of intraoperative complications during microsurgical intervention, which, together with the use of cell saver technology, makes it possible to achieve radical AVM removal and patient recovery.
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5
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White TG, A Shah K, Fraser M, Turpin J, Teron I, W Link T, Dehdashti AR, Woo HH. FLAIR hyperintense vessels on MRI post brain arteriovenous malformation embolization: A novel finding associated with post-procedure intraparenchymal hemorrhage. Interv Neuroradiol 2022:15910199221146585. [PMID: 36572982 DOI: 10.1177/15910199221146585] [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 Brain arteriovenous malformations (BAVMs) are frequently managed by endovascular embolization with a growing number of centers embolizing with intent to cure. Hemorrhage post-embolization is a severe and poorly understood complication. We present a novel imaging finding associated with post-embolization hemorrhage that has significantly impacted the management of patients at our institution. METHODS A retrospective review of all patients undergoing embolization of BAVM at a single center was performed. Post-embolization magnetic resonance imaging (MRI) was reviewed for the presence of T2 fluid-attenuated inversion recovery (FLAIR) hyperintense vessels (FHVs). Bivariate analysis was performed to determine associations between patient characteristics and risk of hemorrhage. RESULTS A total of 50 patients underwent 75 embolization procedures. Forty-six post-embolization MRIs were available for review. There were four hemorrhages and 100% of those presented with FHV. In contrast, only 11.9% of embolization procedures without post-procedural hemorrhage had FHVs on MRI. In total, 18.7% of embolizations led to some morbidity or mortality, with only 6.7% leading to permanent morbidity or mortality. In bivariate analysis, only the presence of FHVs was correlated with the risk of hemorrhage (p < 0.05). CONCLUSIONS This is the first series to describe the finding of hyperintense blood vessels on FLAIR imaging after embolization of BAVMs and correlate it with hemorrhage post embolization. This finding can help guide practitioners and potentially identify patients at risk of delayed hemorrhage post embolization.
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Affiliation(s)
- Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Kevin A Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Madison Fraser
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Ina Teron
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Thomas W Link
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
| | - Henry H Woo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA
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6
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Jha VC, Alam MS, Sinha VS. Comparative outcome of endovascular embolization with microsurgery in managing acute spontaneous cerebral hemorrhage in pediatric patients, an institutional experience. Childs Nerv Syst 2022; 39:963-974. [PMID: 36571597 DOI: 10.1007/s00381-022-05785-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/06/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES A few previous studies have reported the role of embolization with curative intent in the treatment of the early phase of a spontaneous cerebral hemorrhage in pediatric patients, and its efficacy needs to be compared with surgery at the same time risk factors for hemorrhage following early embolization in such patients need to be evaluated. METHODS From a pool of 80 pediatric (< 18 years) who had undergone treatment for ruptured AVM with hemorrhage at our center between July 2018 and July 2022, we identified 36 patients with spontaneous bleeding due to AVM. Out of which, 20 were treated solely by embolization (group 1), while the remaining patients were treated surgically (with and without adjuvant embolization) (group 2). RESULT Spetzler-Martin's grading of the lesion suggested seven lesions < 3 and 13 lesions ≥ 3 in the embolization group. Similarly, seven lesions were < 3 and nine ≥ 3 Spetzler-Martin grade in the surgery group. Incomplete embolization was associated with hemorrhage in two patients treated with curative intent and four patients treated with embolization as adjuvant in the surgery group (p = 0.01). On follow-up, 18 patients in the embolization group and 12 in the surgery group had Glasgow outcome scores ≥ 4 (p = 0.273). CONCLUSION In the pediatric age group, incomplete embolization is the significant risk factor for hemorrhage in AVMs treated after a hemorrhagic stroke. Embolization with curative intent is as effective as surgery in treating such lesions as adjuvant embolization with careful patient selection.
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Affiliation(s)
- Vikas Chandra Jha
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India.
| | | | - Vivek Sharan Sinha
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India
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7
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Park MT, Essibayi MA, Srinivasan VM, Catapano JS, Graffeo CS, Lawton MT. Surgical management outcomes of intracranial arteriovenous malformations after preoperative embolization: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:3499-3510. [PMID: 36168072 DOI: 10.1007/s10143-022-01860-x] [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: 07/28/2022] [Revised: 08/03/2022] [Accepted: 09/11/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Preoperative embolization for brain arteriovenous malformations (AVMs) has been shown to mitigate morbidity for high-risk AVMs, chiefly by reducing lesional blood flow before resection. However, associated risks include postembolization AVM rupture, and the effect of preoperative embolization on outcome remains uncertain. We performed a meta-analysis of the literature on preoperative embolization for microsurgically treated AVMs. METHODS A systematic review and meta-analysis were conducted of all English-language publications reporting clinical outcomes after combined embolization and surgical resection for AVMs. Single- and 2-arm analyses were performed using random-effects modeling. RESULTS Thirty-six studies with 2108 patients were included in this analysis. Most patients (90.6%) who underwent embolization had at least a 50% obliteration of AVMs on posttreatment preoperative angiography, with a mean rate of obliteration of approximately 80% (range 28.8-100%). Among patients who had combined treatment, 3.4% (95% confidence interval [CI] 2.1-4.6%) experienced embolization-related hemorrhagic complications before surgery. Both treatment groups achieved excellent postsurgical complete resection rates (odds ratio [OR] 1.05; 95% CI 0.60-1.85). Neither the clinical outcome (OR 1.42; 95% CI 0.84-2.40) nor the total number of hemorrhagic complications (OR 1.84; 95% CI 0.88-3.85) was significantly different between the treatment groups. CONCLUSIONS In this meta-analysis, preoperative embolization appears to have substantially reduced the lesional volume with active AV shunting before AVM resection. Anecdotally, preoperative embolization facilitates safe and efficient resection; however, differences in outcomes were not significant. The decision to pursue preoperative embolization remains a nuanced decision based on individual lesion anatomy and treatment team experience.
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Affiliation(s)
- Marian T Park
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd., Phoenix, AZ, 85013, USA
| | - Muhammed Amir Essibayi
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd., Phoenix, AZ, 85013, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd., Phoenix, AZ, 85013, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd., Phoenix, AZ, 85013, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd., Phoenix, AZ, 85013, USA
| | - Michael T Lawton
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd., Phoenix, AZ, 85013, USA.
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8
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A Rational Approach to the Management of Cerebral Arteriovenous Malformations. World Neurosurg 2022; 159:338-347. [DOI: 10.1016/j.wneu.2021.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/11/2021] [Accepted: 08/11/2021] [Indexed: 11/21/2022]
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9
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Catapano JS, Srinivasan VM, Rumalla K, Koester SW, Kimata AR, Ma KL, Labib MA, Baranoski JF, Cole TS, Rutledge C, Ducruet AF, Albuquerque FC, Spetzler RF, Lawton MT. Effects of Preoperative Embolization on Spetzler-Martin Grade I and II Arteriovenous Malformations: A Propensity-Adjusted Analysis. Neurosurgery 2022; 90:92-98. [PMID: 34982875 DOI: 10.1227/neu.0000000000001741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 08/21/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cerebral arteriovenous malformations (AVMs) with low Spetzler-Martin grades (I and II) are associated with good neurological outcomes after microsurgical resection; however, the use of preoperative embolization for these lesions is controversial. OBJECTIVE To compare the neurological outcomes of preoperative embolization with no embolization in patients with low-grade AVMs. METHODS Patients with a Spetzler-Martin grade I or II AVM who underwent microsurgical resection during January 1, 1997, through December 31, 2019, were analyzed. Patients undergoing preoperative embolization were compared with patients not undergoing embolization. A propensity score was constructed from baseline characteristics and used to match intervention (embolization) and control (nonembolization) groups in a 1:1 ratio. The primary outcome was poor neurological status on last follow-up examination, defined as a modified Rankin Scale score >2 and a modified Rankin Scale score worse at follow-up than at the preoperative examination. RESULTS Of the 603 patients analyzed, 310 (51.4%) underwent preoperative embolization and 293 (48.6%) did not. Patients in the embolization cohort compared with those in the nonembolization cohort had a higher percentage of Spetzler-Martin grade II AVMs (71.6% vs 52.6%, P < .001) and a lower percentage of hemorrhage (41% vs 55%, P = .001). After propensity score matching, no differences were found between paired cohorts (each N = 203) for baseline characteristics with a significant reduction in absolute standardized mean differences. No significant differences were found in primary outcomes between treatment groups in the matched or unmatched cohorts. CONCLUSION Preoperative embolization of low-grade Spetzler-Martin AVMs is not associated with improved neurological outcomes after microsurgical resection.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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10
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Thompson KP, Nelson J, Kim H, Weinsheimer SM, Marchuk DA, Lawton MT, Krings T, Faughnan ME. Utility of modified Rankin Scale for brain vascular malformations in hereditary hemorrhagic telangiectasia. Orphanet J Rare Dis 2021; 16:390. [PMID: 34538258 PMCID: PMC8451134 DOI: 10.1186/s13023-021-02012-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Approximately 10% of hereditary hemorrhagic telangiectasia (HHT) patients harbour brain vascular malformations (VMs). Intracranial hemorrhage (ICH) from brain VMs can lead to death or morbidity, while treatment options for brain VMs also have associated morbidity. The modified Rankin Scale (mRS) may provide an approach to identifying HHT-brain VM patients with poor outcomes, and their predictors. We aimed to measure the relationship between mRS score and brain VM, brain VM number, as well as other aspects of HHT, at enrollment and during prospective follow-up. Methods 1637 HHT patients (342 with brain VMs) were recruited from 14 HHT centres of the Brain Vascular Malformation Consortium since 2010 and followed prospectively (mean = 3.4 years). We tested whether the presence of brain VM, other HHT organ involvement, and HHT mutation genotype were associated with worse mRS scores at baseline and during follow-up, using linear mixed models, adjusting for age, sex, and year of visit. Results Presence of brain VMs was not associated with worse mRS score at baseline and there was no significant worsening of mRS with prospective follow-up in these patients; 92% had baseline mRS of 0–2. HHT-related gastrointestinal (GI) bleeding was associated with worse mRS scores at baseline (0.37, 95% CI 0.26–0.47, p < 0.001), as were history of anemia (0.35, 95% CI 0.27–0.43, p < 0.001) and liver VMs (0.19, 95% CI 0.09–0.30, p < 0.001). Presence of pulmonary arteriovenous malformations (AVMs) was not associated with worse mRS scores at baseline. mRS score was not associated with either HHT genotype (Endoglin vs ACVRL1). Only GI bleeding was associated with a significantly worsening mRS during prospective follow-up (0.64, 95% CI 0.21–1.08, p = 0.004). Conclusion Most HHT-brain VM patients had good functional capacity (mRS scores 0–2) at baseline that did not change significantly over 3.4 mean years of follow-up, suggesting that mRS may not be useful for predicting or measuring outcomes in these patients. However, HHT patients with GI bleeding, anemia history or liver VMs had worse mRS scores, suggesting significant impact of these manifestations on functional capacity. Our study demonstrates the insensitivity of the mRS as an outcomes measure in HHT brain VM patients and reinforces the continued need to develop outcomes measures, and their predictors, in this group.
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Affiliation(s)
- K P Thompson
- 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
| | - J Nelson
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - H Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - S M Weinsheimer
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - D A Marchuk
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC, USA
| | - M T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - T Krings
- Division of Neurosurgery, Department of Medical Imaging, Department of Surgery, University of Toronto, Toronto, Canada.,Division of Neuroradiology, Toronto Western Hospital, Univeristy Health Network, Toronto, Canada
| | - M 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.
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11
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Koch MJ, Bram R, Amin-Hanjani S. Commentary: Does Variceal Drainage Affect Arteriovenous Malformation Obliteration and Hemorrhage Rates After Stereotactic Radiosurgery? A Case-Matched Analysis. Neurosurgery 2021; 89:E219-E220. [PMID: 34318880 DOI: 10.1093/neuros/nyab281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/12/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Matthew J Koch
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Richard Bram
- 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
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12
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Catapano JS, Frisoli FA, Nguyen CL, Wilkinson DA, Majmundar N, Cole TS, Baranoski JF, Whiting AC, Kim H, Ducruet AF, Albuquerque FC, Cooke DL, Spetzler RF, Lawton MT. Spetzler-Martin Grade III Arteriovenous Malformations: A Multicenter Propensity-Adjusted Analysis of the Effects of Preoperative Embolization. Neurosurgery 2021; 88:996-1002. [PMID: 33427287 DOI: 10.1093/neuros/nyaa551] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 11/04/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Spetzler-Martin (SM) grade III arteriovenous malformations (AVMs) are at the boundary of safe operability, and preoperative embolization may reduce surgical risks. OBJECTIVE To evaluate the benefits of preoperative AVM embolization by comparing neurological outcomes in patients with grade III AVMs treated with or without preoperative embolization. METHODS All microsurgically treated grade III AVMs were identified from 2011 to 2018 at 2 medical centers. Neurological outcomes, measured as final modified Rankin Scale scores (mRS) and changes in mRS from preoperative baseline to last follow-up evaluation, were compared in patients with and without preoperative embolization. RESULTS Of the 102 patients with grade III AVMs who were treated microsurgically, 57 (56%) underwent preoperative embolization. Significant differences were found between the patients with and without embolization in AVM eloquence (74% vs 93%, P = .02), size ≥ 3 cm (47% vs 73%, P = .01), diffuseness (7% vs 22%, P = .04), and mean final mRS (1.1 vs 2.0, P = .005). Poor outcomes were more frequent in patients without embolization (38%) than with embolization (7%) (final mRS > 2; P < .001). Propensity-adjusted analysis revealed AVM resection without embolization was a risk factor for poor outcome (mRS score > 2; odds ratio, 4.2; 95% CI, 1.1-16; P = .03). CONCLUSION Nonembolization of SM grade III AVMs is associated with an increased risk of poor neurological outcomes after microsurgical resection. Preoperative embolization of intermediate-grade AVMs selected because of large AVM size, surgical inaccessibility of feeding arteries, and high flow should be employed more often than anticipated, even in the context of increasing microsurgical experience with AVMs.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Fabio A Frisoli
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Candice L Nguyen
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - D Andrew Wilkinson
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Neil Majmundar
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Alexander C Whiting
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Helen Kim
- University of California, San Francisco, San Francisco, California
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Daniel L Cooke
- University of California, San Francisco, San Francisco, California
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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13
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Wang M, Jiao Y, Zeng C, Zhang C, He Q, Yang Y, Tu W, Qiu H, Shi H, Zhang D, Kang D, Wang S, Liu AL, Jiang W, Cao Y, Zhao J. Chinese Cerebrovascular Neurosurgery Society and Chinese Interventional & Hybrid Operation Society, of Chinese Stroke Association Clinical Practice Guidelines for Management of Brain Arteriovenous Malformations in Eloquent Areas. Front Neurol 2021; 12:651663. [PMID: 34177760 PMCID: PMC8219979 DOI: 10.3389/fneur.2021.651663] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/20/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: The aim of this guideline is to present current and comprehensive recommendations for the management of brain arteriovenous malformations (bAVMs) located in eloquent areas. Methods: An extended literature search on MEDLINE was performed between Jan 1970 and May 2020. Eloquence-related literature was further screened and interpreted in different subcategories of this guideline. The writing group discussed narrative text and recommendations through group meetings and online video conferences. Recommendations followed the Applying Classification of Recommendations and Level of Evidence proposed by the American Heart Association/American Stroke Association. Prerelease review of the draft guideline was performed by four expert peer reviewers and by the members of Chinese Stroke Association. Results: In total, 809 out of 2,493 publications were identified to be related to eloquent structure or neurological functions of bAVMs. Three-hundred and forty-one publications were comprehensively interpreted and cited by this guideline. Evidence-based guidelines were presented for the clinical evaluation and treatment of bAVMs with eloquence involved. Topics focused on neuroanatomy of activated eloquent structure, functional neuroimaging, neurological assessment, indication, and recommendations of different therapeutic managements. Fifty-nine recommendations were summarized, including 20 in Class I, 30 in Class IIa, 9 in Class IIb, and 2 in Class III. Conclusions: The management of eloquent bAVMs remains challenging. With the evolutionary understanding of eloquent areas, the guideline highlights the assessment of eloquent bAVMs, and a strategy for decision-making in the management of eloquent bAVMs.
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Affiliation(s)
- Mingze Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaofan Zeng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaoqi Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Wenjun Tu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hancheng Qiu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dezhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - A-Li Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Gamma Knife Center, Beijing Neurosurgical Institute, Beijing, China
| | - Weijian Jiang
- Department of Vascular Neurosurgery, Chinese People's Liberation Army Rocket Army Characteristic Medical Center, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
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14
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Does Endovascular Treatment with Curative Intention Have Benefits for Treating High-Grade Arteriovenous Malformation versus Radiosurgery? Efficacy, Safety, and Cost-Effectiveness Analysis. World Neurosurg 2021; 149:e178-e187. [PMID: 33618042 DOI: 10.1016/j.wneu.2021.02.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The treatment of high-grade arteriovenous malformations (AVMs) remains challenging. Microsurgery provides a rapid and complete occlusion compared with other options but is associated with undesirable morbidity and mortality. The aim of this study was to compare the occlusion rates, incidence of unfavorable outcomes, and cost-effectiveness of embolization and stereotactic radiosurgery (SRS) as a curative treatment for high-grade AVMs. METHODS A retrospective series of 57 consecutive patients with high-grade AVM treated with embolization or SRS, with the aim of achieving complete occlusion, was analyzed. Demographic, clinical, and angioarchitectonic variables were collected. Both treatments were compared for the occlusion rate and procedure-related complications. In addition, a cost-effectiveness analysis was performed. RESULTS Thirty patients (52.6%) were men and 27 (47.4%) were women (mean age, 39 years). AVMs were unruptured in 43 patients (75.4%), and ruptured in 14 patients (24.6%). The presence of deep venous drainage, nidus volume, perforated arterial supply, and eloquent localization was more frequent in the SRS group. Complications such as hemorrhage or worsening of previous seizures were more frequent in the embolization group. No significant differences were observed in the occlusion rates or in the time necessary to achieve occlusion between the groups. The incremental cost-effectiveness ratio for endovascular treatment versus SRS was $53.279. CONCLUSIONS Both techniques achieved similar occlusion rates, but SRS carried a lower risk of complications. Staged embolization may be associated with a greater risk of hemorrhage, whereas SRS was shown to have a better cost-effectiveness ratio. These results support SRS as a better treatment option for high-grade AVMs.
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15
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Nico L, Magro E, Ognard J, Fahed R, Salazkin I, Gevry G, Darsaut T, Raymond J, Gentric JC. Comparing N-hexyl cyanoacrylate (Magic Glue) and N-butyl cyanoacrylate (NBCA) for neurovascular embolization using the pressure cooker technique: An experimental study in swine. J Neuroradiol 2021; 48:486-491. [PMID: 33418056 DOI: 10.1016/j.neurad.2020.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/23/2020] [Accepted: 12/23/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The pressure cooker (PC) technique uses a second microcatheter to produce a proximal occlusion to prevent the reflux of liquid embolic agent (LEA) injected through a more distal microcatheter, and can be used to treat arteriovenous malformations and dural arteriovenous fistulae. The liquid embolic Magic Glue (MG) (N-hexyl cyanoacrylate (NHCA)) has been introduced as an alternative to N-butyl cyanoacrylate (NBCA). Our goals were to compare the extent of embolization of rete mirabile with or without the PC technique using NBCA or MG, and to compare the proximal occlusions obtained with MG or NBCA while using the PC technique in a renal arterial model. METHODS Rete mirabile were embolized with (n = 4) and without (n = 4) the PC technique, using MG (n = 4) or NBCA (n = 4). A renal arterial model was then used to study the characteristics of the MG plug (n = 10) used for the PC technique, and resistance to catheter withdrawal as compared to NBCA (n = 4). Specimens were analyzed macro- and microscopically and compared to angiographic results. RESULTS Extent of rete embolization with CYA agents was not significantly greater when using the PC technique. Results were similar with both types of cyanoacrylate (p = 0.657). The force necessary to withdraw the microcatheter was less with MG than with NBCA (p = 0.035). CONCLUSION MG was similar to NBCA in extent of rete embolization. Less traction force was necessary to withdraw trapped non-detachable microcatheters using MG compared to NBCA.
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Affiliation(s)
- Lorena Nico
- Division of Interventional Neuroradiology, Department of Radiology, University Hospital of Brest, France
| | - Elsa Magro
- Department of Neurosurgery, University Hospital of Brest. Bd. Tanguy Prigent, 29609 Brest Cedex, France; Laboratory of Medical Information Processing - LaTIM INSERM UMR 1101, Brest, France
| | - Julien Ognard
- Division of Interventional Neuroradiology, Department of Radiology, University Hospital of Brest, France; Laboratory of Medical Information Processing - LaTIM INSERM UMR 1101, Brest, France
| | - Robert Fahed
- Department of Medicine, Division of Neurology, Ottawa Hospital, Ottawa, Canada
| | - Igor Salazkin
- Interventional Neuroradiology Laboratory, Research Centre, University of Montreal Hospital (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Guylaine Gevry
- Interventional Neuroradiology Laboratory, Research Centre, University of Montreal Hospital (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Tim Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Science Centre, Edmonton, Alberta, Canada
| | - Jean Raymond
- Interventional Neuroradiology Laboratory, Research Centre, University of Montreal Hospital (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada; Department of Radiology, University of Montreal Hospital (CHUM), Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Jean-Christophe Gentric
- Division of Interventional Neuroradiology, Department of Radiology, University Hospital of Brest, France; Western Brittany Thrombosis Study Group - GETBO EA3878, Brest, France.
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16
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Rodriguez-Calienes A, Bustamante-Paytan D, Camacho K, Mayoria-Vargas A, Saal-Zapata G, Rodriguez-Varela R. Early Outcomes and Complications of Endovascular Treatment of Cerebral Arteriovenous Malformations in Pediatric Patients. Pediatr Neurosurg 2021; 56:116-124. [PMID: 33601400 DOI: 10.1159/000513577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 12/03/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Arteriovenous malformations (AVMs) are the commonest cause of hemorrhagic stroke in children. Endovascular embolization is a feasible treatment modality, but cure rates are heterogenous from one series to another. We aimed to describe the immediate obliteration rates and periprocedural complications of embolization of pediatric AVMs. METHODS Between 2011 and 2019, participants below 18 years of age with AVMs treated by the same neurosurgeon at a single center were included. The clinical features, immediate angiographic results, and periprocedural complications were retrospectively collected from the clinical records. RESULTS Thirty-four embolization sessions were performed on 20 children (12 females with a mean age of 13). Intracranial hemorrhage was the most common presentation (75%), and the majority were frontal (30%) and basal ganglia (30%) lesions. An immediate complete angiographic obliteration was achieved in 9 patients (45%) with low-grade lesions (Spetzler-Martin grade I and II). NBCA was the most common embolic agent used (52.9%). Complications were reported in 3 (8.8%) out of 34 sessions. Two of them were intraoperative perforations with clinical consequences. A slight cortical hemorrhage during the procedure was observed in 1 patient without clinical repercussions. DISCUSSION This single-surgeon single-center experience suggests that endovascular treatment is a safe and efficient treatment for pediatric AVMs. Pediatric prognostic scores for a suitable selection of candidates are needed. Further studies are required to validate these results.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru, .,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru,
| | - Diego Bustamante-Paytan
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru
| | - Kiara Camacho
- Facultad de Medicina Humana, Universidad Científica del Sur, Lima, Peru
| | - Angie Mayoria-Vargas
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru
| | - Giancarlo Saal-Zapata
- Departamento de Neurocirugía, Servicio de Neurocirugía Endovascular, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Rodolfo Rodriguez-Varela
- Departamento de Neurocirugía, Servicio de Neurocirugía Endovascular, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
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17
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Ruigrok YM. Management of Unruptured Cerebral Aneurysms and Arteriovenous Malformations. Continuum (Minneap Minn) 2020; 26:478-498. [PMID: 32224762 DOI: 10.1212/con.0000000000000835] [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] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Unruptured intracranial aneurysms and brain arteriovenous malformations (AVMs) may be detected as incidental findings on cranial imaging. This article provides a practical approach to the management of unruptured intracranial aneurysms and unruptured brain AVMs and reviews the risk of rupture, risk factors for rupture, preventive treatment options with their associated risks, and the approach of treatment versus observation for both types of vascular malformations. RECENT FINDINGS For unruptured intracranial aneurysms, scoring systems on the risk of rupture can help with choosing preventive treatment or observation with follow-up imaging. Although the literature provides detailed information on the complication risks of preventive treatment of unruptured intracranial aneurysms, individualized predictions of these procedural complication risks are not yet available. With observation with imaging, growth of unruptured intracranial aneurysms can be monitored, and prediction scores for growth can help determine the optimal timing of monitoring. The past years have revealed more about the risk of complications of the different treatment modalities for brain AVMs. A randomized clinical trial and prospective follow-up data have shown that preventive interventional therapy in patients with brain AVMs is associated with a higher rate of neurologic morbidity and mortality compared with observation. SUMMARY The risk of hemorrhage from both unruptured intracranial aneurysms and brain AVMs varies depending on the number of risk factors associated with hemorrhage. For both types of vascular malformations, different preventive treatment options are available, and all carry risks of complications. For unruptured intracranial aneurysms, the consideration of preventive treatment versus observation is complex, and several factors should be included in the decision making. Overall, it is recommended that patients with unruptured asymptomatic brain AVMs should be observed.
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18
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Chen CJ, Ding D, Derdeyn CP, Lanzino G, Friedlander RM, Southerland AM, Lawton MT, Sheehan JP. Brain arteriovenous malformations: A review of natural history, pathobiology, and interventions. Neurology 2020; 95:917-927. [PMID: 33004601 DOI: 10.1212/wnl.0000000000010968] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/08/2020] [Indexed: 11/15/2022] Open
Abstract
Brain arteriovenous malformations (AVMs) are anomalous direct shunts between cerebral arteries and veins that convalesce into a vascular nidus. The treatment strategies for AVMs are challenging and variable. Intracranial hemorrhage and seizures comprise the most common presentations of AVMs. However, incidental AVMs are being diagnosed with increasing frequency due to widespread use of noninvasive neuroimaging. The balance between the estimated cumulative lifetime hemorrhage risk vs the risk of intervention is often the major determinant for treatment. Current management options include surgical resection, embolization, stereotactic radiosurgery (SRS), and observation. Complete nidal obliteration is the goal of AVM intervention. The risks and benefits of interventions vary and can be used in a combinatorial fashion. Resection of the AVM nidus affords high rates of immediate obliteration, but it is invasive and carries a moderate risk of neurologic morbidity. AVM embolization is minimally invasive, but cure can only be achieved in a minority of lesions. SRS is also minimally invasive and has little immediate morbidity, but AVM obliteration occurs in a delayed fashion, so the patient remains at risk of hemorrhage during the latency period. Whether obliteration can be achieved in unruptured AVMs with a lower risk of stroke or death compared with the natural history of AVMs remains controversial. Over the past 5 years, multicenter prospective and retrospective studies describing AVM natural history and treatment outcomes have been published. This review provides a contemporary and comprehensive discussion of the natural history, pathobiology, and interventions for brain AVMs.
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Affiliation(s)
- Ching-Jen Chen
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Dale Ding
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Colin P Derdeyn
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Giuseppe Lanzino
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Robert M Friedlander
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Andrew M Southerland
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Michael T Lawton
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Jason P Sheehan
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ.
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19
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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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20
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Santin MDN, Todeschi J, Pop R, Baloglu S, Ollivier I, Beaujeux R, Proust F, Cebula H. A combined single-stage procedure to treat brain AVM. Neurochirurgie 2020; 66:349-358. [PMID: 32574612 DOI: 10.1016/j.neuchi.2020.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 02/04/2020] [Accepted: 03/07/2020] [Indexed: 11/29/2022]
Abstract
Complete resection of brain arteriovenous malformation (AVM) is a surgical challenge, mainly due to risk of intraoperative rupture. The objective of this feasibility study was to analyze complete resection rate at 3 months and clinical outcome at 6 months after treatment of brain AVM by combined single-stage embolization and surgical resection. A retrospective observational study from July 2015 to February 2019 was conducted at the Department of Neurosurgery of Strasbourg University Hospital, France. Decision to treat was taken on the basis of history of AVM rupture, symptomatic AVM, or morphologic risk factors for rupture. Complete resection rate was assessed on postoperative cerebral subtraction angiography at 3 months and clinical outcome at 6 months was evaluated on the modified Rankin Scale (mRS). In the 16 patients treated for symptomatic brain AVM, the rate of complete resection was 75%, resection with residual shunt 18.7%, and incomplete resection with residual nidus 6.3%. Good clinical outcome (mRS=0 or 1) was achieved in 81.3% of patients at 6 months. The transfusion rate was 7.1%. There were procedural complications in 12.5% of patients but no intraoperative ruptures. This combined single-stage procedure allows extensive preoperative embolization of the AVM, facilitating surgical microdissection by identifying the dissection plane and perforating arteries and allowing the operator to work in close contact with the nidus without fear of intraoperative rupture.
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Affiliation(s)
- M D N Santin
- Service de neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - J Todeschi
- Service de neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - R Pop
- Service de neuroradiologie interventionnelle, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - S Baloglu
- Service de neuroradiologie diagnostique (radiologie 2), hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - I Ollivier
- Service de neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - R Beaujeux
- Service de neuroradiologie interventionnelle, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - F Proust
- Service de neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
| | - H Cebula
- Service de neurochirurgie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France.
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Sato K, Matsumoto Y, Tominaga T, Satow T, Iihara K, Sakai N. Complications of Endovascular Treatments for Brain Arteriovenous Malformations: A Nationwide Surveillance. AJNR Am J Neuroradiol 2020; 41:669-675. [PMID: 32193193 DOI: 10.3174/ajnr.a6470] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/10/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Embolization is widely performed to treat brain arteriovenous malformations, but little has been reported on factors contributing to complications. We retrospectively reviewed a nationwide surveillance to identify risk factors contributing to complications and short-term clinical outcomes in the endovascular treatment of brain arteriovenous malformations. MATERIALS AND METHODS Data for endovascular treatment of brain arteriovenous malformations were extracted from the Japanese nationwide surveillance. Patient characteristics, brain arteriovenous malformation features, procedures, angiographic results, complications, and clinical outcomes at 30 days postprocedure were analyzed. RESULTS A total of 1042 endovascular procedures (788 patients; mean, 1.43 ± 0.85 procedures per patient) performed in 111 institutions from 2010 to 2014 were reviewed. Liquid materials were used in 976 procedures (93.7%): to perform presurgical embolization in 638 procedures (61.2%), preradiosurgical embolization in 160 (15.4%), and as sole endovascular treatment in 231 (22.2%). Complete or near-complete obliteration of brain arteriovenous malformations was obtained in 386 procedures (37.0%). Procedure-related complications occurred in 136 procedures (13.1%), including hemorrhagic complications in 59 (5.7%) and ischemic complications in 57 (5.5%). Univariate analysis identified deep venous drainage, associated aneurysms, infratentorial location, and preradiosurgical embolization as statistically significant risk factors for complications. Multivariate analysis showed that embolization of brain arteriovenous malformations in the infratentorial location was significantly associated with complications. Patients with complications due to endovascular procedures had worse clinical outcomes 30 days after the procedures than those without complications. CONCLUSIONS Complications arising after endovascular treatment of brain arteriovenous malformations are not negligible even though they may play a role in adjunctive therapy, especially in the management of infratentorial brain arteriovenous malformations.
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Affiliation(s)
- K Sato
- From the Department of Neuroendovascular Therapy (K.S., Y.M.), Kohnan Hospital, Sendai, Japan
| | - Y Matsumoto
- From the Department of Neuroendovascular Therapy (K.S., Y.M.), Kohnan Hospital, Sendai, Japan
| | - T Tominaga
- Department of Neurosurgery (T.T.), Tohoku Graduate School of Medicine, Sendai, Japan
| | - T Satow
- Department of Neurosurgery (T.S.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - K Iihara
- Department of Neurosurgery (K.I.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - N Sakai
- Department of Neurosurgery (N.S.), Kobe City Medical Center General Hospital, Kobe, Japan
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Subat YW, Dasenbrock HH, Gross BA, Patel NJ, Frerichs KU, Du R, Aziz-Sultan MA. Periprocedural intracranial hemorrhage after embolization of cerebral arteriovenous malformations: a meta-analysis. J Neurosurg 2019; 133:1417-1427. [PMID: 31518979 DOI: 10.3171/2019.5.jns183204] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 05/21/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The primary goal of the treatment of cerebral arteriovenous malformations (AVMs) is angiographic occlusion to eliminate future hemorrhage risk. Although multimodal treatment is increasingly used for AVMs, periprocedural hemorrhage after transarterial embolization is a potential endovascular complication that is only partially understood and merits quantification. METHODS Searching the period between 1990 and 2019, the authors of this meta-analysis queried the PubMed and Embase databases for studies reporting periprocedural hemorrhage (within 30 days) after liquid embolization (using cyanoacrylate or ethylene vinyl alcohol copolymer) of AVMs. Random effects meta-analysis was used to evaluate the pooled rate of flow-related hemorrhage (those attributed to alterations in AVM dynamics), technical hemorrhage (those related to procedural complications), and total hemorrhage. Meta-regression was used to analyze the study-level predictors of hemorrhage, including patient age, Spetzler-Martin grade, hemorrhagic presentation, embolysate used, intent of treatment (adjuvant vs curative), associated aneurysms, endovascular angiographic obliteration, year of study publication, and years the procedures were performed. RESULTS A total of 98 studies with 8009 patients were included in this analysis, and the mean number of embolization sessions per patient was 1.9. The pooled flow-related and total periprocedural hemorrhage rates were 2.0% (95% CI 1.5%-2.4%) and 2.6% (95% CI 2.1%-3.0%) per procedure and 3.4% (95% CI 2.6%-4.2%) and 4.8% (95% CI 4.0%-5.6%) per patient, respectively. The mortality and morbidity rates associated with hemorrhage were 14.6% and 45.1%, respectively. Subgroup analyses revealed a pooled total hemorrhage rate per procedure of 1.8% (95% CI 1.0%-2.5%) for adjuvant (surgery or radiosurgery) and 4.6% (95% CI 2.8%-6.4%) for curative intent. The treatment of aneurysms (p = 0.04) and larger patient populations (p < 0.001) were significant predictors of a lower hemorrhage rate, whereas curative intent (p = 0.04), angiographic obliteration achieved endovascularly (p = 0.003), and a greater number of embolization sessions (p = 0.03) were significant predictors of a higher hemorrhage rate. There were no significant differences in periprocedural hemorrhage rates according to the years evaluated or the embolysate utilized. CONCLUSIONS In this study-level meta-analysis, periprocedural hemorrhage was seen after 2.6% of transarterial embolization procedures for cerebral AVMs. The adjuvant use of endovascular embolization, including in the treatment of associated aneurysms and in the presurgical or preradiosurgical setting, was a study-level predictor of significantly lower hemorrhage rates, whereas more aggressive embolization involving curative intent and endovascular angiographic obliteration was a predictor of a significantly higher total hemorrhage rate.
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Affiliation(s)
- Yosuf W Subat
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 4Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; and
| | - Hormuzdiyar H Dasenbrock
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 3Department of Neurosurgery, Rush University, Chicago, Illinois
| | - Bradley A Gross
- 5Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Nirav J Patel
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - Kai U Frerichs
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - Rose Du
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts
| | - M Ali Aziz-Sultan
- 1Department of Neurological Surgery, Brigham and Women's Hospital
- 2Harvard Medical School, Boston, Massachusetts
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Zaki Ghali MG, Kan P, Britz GW. Curative Embolization of Arteriovenous Malformations. World Neurosurg 2019; 129:467-486. [DOI: 10.1016/j.wneu.2019.01.166] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
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Wang A, Mandigo GK, Feldstein NA, Sisti MB, Connolly ES, Solomon RA, Lavine SD, Meyers PM. Curative treatment for low-grade arteriovenous malformations. J Neurointerv Surg 2019; 12:48-54. [DOI: 10.1136/neurintsurg-2019-015115] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/12/2019] [Accepted: 06/16/2019] [Indexed: 11/03/2022]
Abstract
BackgroundSpetzler-Martin (SM) grade I-II (low-grade) arteriovenous malformations (AVMs) are often considered safe for microsurgery or radiosurgery. The adjunctive use of preoperative embolization to reduce surgical risk in these AVMs remains controversial.ObjectiveTo assess the safety of combined treatment of grade I-II AVMs with preoperative embolization followed by surgical resection or radiosurgery, and determine the long-term functional outcomes.MethodsWith institutional review board approval, a retrospective analysis was carried out on patients with ruptured and unruptured SM I-II AVMs between 2002 and 2017. Details of the endovascular procedures, including number of arteries supplying the AVM, number of branches embolized, embolic agent(s) used, and complications were studied. Baseline clinical and imaging characteristics were compared. Functional status using the modified Rankin Scale (mRS) before and after endovascular and microsurgical treatments was compared.Results258 SM I-II AVMs (36% SM I, 64% SM II) were identified in patients with a mean age of 38 ± 17 years. 48% presented with hemorrhage, 21% with seizure, 16% with headache, 10% with no symptoms, and 5% with clinical deficits. 90 patients (68%) in the unruptured group and 74 patients (59%) in the ruptured group underwent presurgical embolization (p = 0.0013). The mean number of arteries supplying the AVM was 1.44 and 1.41 in the unruptured and ruptured groups, respectively (p = 0.75). The mean number of arteries embolized was 2.51 in the unruptured group and 1.82 in the ruptured group (p = 0.003). n-Butyl cyanoacrylate and Onyx were the two most commonly used embolic agents. Four complications were seen in four patients (4/164 patients embolized): two peri-/postprocedural hemorrhage, one dissection, and one infarct. All patients undergoing surgery had a complete cure on postoperative angiography. Patients were followed up for a mean of 55 months. Good long-term outcomes (mRS score ≤ 2) were seen in 92.5% of patients with unruptured AVMs and 88.0% of those with ruptured AVMs. Permanent neurological morbidity occurred in 1.2%.ConclusionsCurative treatment of SM I-II AVMs can be performed using endovascular embolization with microsurgical resection or radiosurgery in selected cases, with very low morbidity and high cure rates. Compared with other published series, these outcomes suggest that preoperative embolization is a safe and effective adjunct to definitive surgical treatment. Long-term follow-up showed that patients with low-grade AVMs undergoing surgical resection or radiosurgery have good functional outcomes.
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Donzelli GF, Nelson J, McCoy D, McCulloch CE, Hetts SW, Amans MR, Dowd CF, Halbach VV, Higashida RT, Lawton MT, Kim H, Cooke DL. The effect of preoperative embolization and flow dynamics on resection of brain arteriovenous malformations. J Neurosurg 2019; 132:1836-1844. [PMID: 31100732 DOI: 10.3171/2019.2.jns182743] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 02/25/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Preoperative embolization of brain arteriovenous malformations (AVMs) is performed to facilitate resection, although its impact on surgical performance has not been clearly defined. The authors tested for associations between embolization and surgical performance metrics. METHODS The authors analyzed AVM cases resected by one neurosurgeon from 2006 to 2017. They tested whether cases with and without embolization differed from one another with respect to patient and AVM characteristics using t-tests for continuous variables and Fisher's exact tests for categorical variables. They used simple and multivariable regression models to test whether surgical outcomes (blood loss, resection time, surgical clip usage, and modified Rankin Scale [mRS] score) were associated with embolization. Additional regression analyses integrated the peak arterial afferent contrast normalized for the size of the region of interest (Cmax/ROI) into models as an additional predictor. RESULTS The authors included 319 patients, of whom 151 (47%) had preoperative embolization. Embolized AVMs tended to be larger (38% with diameter > 3 cm vs 19%, p = 0.001), less likely to have hemorrhaged (48% vs 63%, p = 0.013), or be diffuse (19% vs 29%, p = 0.045). Embolized AVMs were more likely to have both superficial and deep venous drainage and less likely to have exclusively deep drainage (32% vs 17% and 12% vs 23%, respectively; p = 0.002). In multivariable analysis, embolization was not a significant predictor of blood loss or mRS score changes, but did predict longer operating times (+29 minutes, 95% CI 2-56 minutes; p = 0.034) and increased clip usage (OR 2.61, 95% CI 1.45-4.71; p = 0.001). Cmax/ROI was not a significant predictor, although cases with large Cmax/ROI tended to have longer procedure times (+25 minutes per doubling of Cmax/ROI, 95% CI 0-50 minutes; p = 0.051). CONCLUSIONS In this series, preoperative embolization was associated with longer median resection times and had no association with intraoperative blood loss or mRS score changes.
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Affiliation(s)
| | | | | | - Charles E McCulloch
- 4Biostatistics and Epidemiology, UCSF Medical Center, San Francisco, California; and
| | | | | | | | | | | | - Michael T Lawton
- 5Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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Todnem N, Ward A, Nahhas M, Vender JR, Alleyne CH, Rahimi SY. A Retrospective Cohort Analysis of Hemorrhagic Arteriovenous Malformations Treated with Combined Endovascular Embolization and Gamma Knife Stereotactic Radiosurgery. World Neurosurg 2018; 122:e713-e722. [PMID: 30394359 DOI: 10.1016/j.wneu.2018.10.125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/17/2018] [Accepted: 10/19/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The management of brain arteriovenous malformations (AVMs) remains a controversial topic. Given the relatively low incidence, high heterogeneity, and high morbidity and mortality of these lesions, consensus on treatment strategies is an issue of concern to organized neurosurgery. The present retrospective analysis examined and quantified the outcomes of patients with an initial presentation of intracranial hemorrhage from a Spetzler-Martin grade III or IV AVM, later ruled out as surgical candidates. METHODS A total of 16 patients (5 females; 11 males) had presented with symptomatic hemorrhage confirmed by non-contrast-enhanced computed tomography and were deemed to not be surgical candidates owing to AVM location and/or architecture. The patients underwent combined endovascular embolization and gamma knife stereotactic radiosurgery (SRS). The modified Rankin scale was used to measure the clinical outcomes, comparing the scores at presentation, gamma knife treatment, and the last known follow-up examination. A radiographic evaluation was used to determine the level of AVM nidus involution after the procedure. RESULTS The present study identified 16 patients with ruptured high-grade AVMs of high surgical risk. All the patients had undergone immediate embolization with delayed SRS for treatment of the hemorrhage and nidus of the AVM. A statistically significant proportion of patients showed marked improvement in the modified Rankin scale scores. No subsequent repeat hemorrhage or any associated complications after embolization occurred in any patient. CONCLUSION These findings warrant consideration of endovascular embolization with adjuvant SRS as a powerful treatment option for cases with high surgical morbidity due to AVM characteristics.
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Affiliation(s)
- Nathan Todnem
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Ayobami Ward
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Michael Nahhas
- Department of Neurology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - John R Vender
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | | | - Scott Y Rahimi
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA.
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Link TW, Winston G, Schwarz JT, Lin N, Patsalides A, Gobin P, Pannullo S, Stieg PE, Knopman J. Treatment of Unruptured Brain Arteriovenous Malformations: A Single-Center Experience of 86 Patients and a Critique of the A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) Trial. World Neurosurg 2018; 120:e1156-e1162. [PMID: 30218805 DOI: 10.1016/j.wneu.2018.09.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 09/02/2018] [Accepted: 09/04/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) trial has received fierce criticism, including considerable selection bias, poor generalizability, questionable clinical practices (only 15.8% underwent surgical resection, the gold standard for arteriovenous malformation [AVM] treatment), and short follow-up (33 months) for a disease process that carries a life-long risk. In this study, we sought to present our own experience treating unruptured brain AVMs to provide supporting evidence of the ARUBA trial criticism. METHODS All cases of treated brain AVMs from 2004 to 2017 at our institution were retrospectively reviewed and included in the analysis if they met ARUBA trial inclusion criteria. The primary outcome was symptomatic stroke or death. Secondary outcomes included AVM obliteration, long-term clinical impairment (modified Rankin Scale score >1), and new major or minor postoperative deficit. RESULTS Of the 245 reviewed cases, 86 met the ARUBA trial criteria. Treatment included microsurgical resection alone (2.3%), preoperative embolization followed by microsurgical resection (62.8%), stereotactic radiosurgery alone (10.5%), embolization followed by stereotactic radiosurgery (15.1%), and embolization alone (9.3%). The primary outcome was met in 8.3%, new perioperative major and minor complications occurred in 5.8% and 12.8%, and long-term clinical impairment in 4.5%. AVM obliteration was observed in 92.4% overall and in 100% of patients who underwent surgical resection. CONCLUSIONS The criticism of the ARUBA trial is warranted, as our study found that treatment of unruptured brain AVMs has an acceptable safety profile when approached in a multidisciplinary manner at an experienced institution, using surgical resection as the primary treatment modality when applicable.
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Affiliation(s)
- Thomas W Link
- Department of Neurological Surgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA.
| | - Graham Winston
- Department of Neurological Surgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Justin T Schwarz
- Department of Neurological Surgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Ning Lin
- Department of Neurological Surgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Athos Patsalides
- Department of Neurological Surgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Pierre Gobin
- Department of Neurological Surgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Susan Pannullo
- Department of Neurological Surgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA; Department of Radiation Oncology, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Philip E Stieg
- Department of Neurological Surgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
| | - Jared Knopman
- Department of Neurological Surgery, Weill Cornell Medical School, New York Presbyterian Hospital, New York, New York, USA
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Ding D, Ilyas A, Sheehan JP. Contemporary Management of High-Grade Brain Arteriovenous Malformations. Neurosurgery 2018; 65:24-33. [DOI: 10.1093/neuros/nyy107] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/03/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Dale Ding
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Liu H, Liu W, Tan Z, Zeng Z, Yang H, Luo S, Wang L, Xi T, Xing Y. Promoting Immune Efficacy of the Oral Helicobacter pylori Vaccine by HP55/PBCA Nanoparticles against the Gastrointestinal Environment. Mol Pharm 2018; 15:3177-3186. [PMID: 30011213 DOI: 10.1021/acs.molpharmaceut.8b00251] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The immunogenicity of oral subunit vaccines is poor partly as a result of the harsh milieu of the gastrointestinal (GI) tract. For some pathogens that restrictedly inhabit the GI tract, a vaccine that works in situ may provide more potent protection than vaccines that operate parenterally. Yet, no appropriate delivery system is available for oral subunit vaccines. In this study, we designed HP55/poly( n-butylcyanoacrylate) (PBCA) nanoparticles (NPs) to carry Helicobacter pylori ( H. pylori) subunit vaccine CCF for oral administration in a prophylactic mice model. These NPs, which are synthesized using an interfacial polymerization method, protected the CCF antigen not only from the acidic pH in simulated gastric fluid (SGF, pH 1.2) but also from the proteolysis in simulated intestinal fluid (SIF, pH 7.4). Oral vaccination of mice with HP55/PBCA-CCF NPs promoted the production of serum antigen-specific antibodies, mucosal secretory IgA, and proinflammatory cytokines. Moreover, a Th1/Th17 response and augmented lymphocytes were found in the gastric tissue of HP55/PBCA-CCF NP-immunized mice, which might eventually limit H. pylori colonization. Collectively, these results indicate that HP55/PBCA NPs are promising carriers against the severe situation of the GI tract and thereby may be further utilized for other orally administrated vaccines or drugs.
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Affiliation(s)
- Hai Liu
- School of Life Science and Technology and Jiangsu Key Laboratory of Carcinogenesis and Intervention , China Pharmaceutical University , No.24 Tongjia xiang , Nanjing 210009 , PR China
| | - Wei Liu
- School of Life Science and Technology and Jiangsu Key Laboratory of Carcinogenesis and Intervention , China Pharmaceutical University , No.24 Tongjia xiang , Nanjing 210009 , PR China
| | - Zhoulin Tan
- School of Life Science and Technology and Jiangsu Key Laboratory of Carcinogenesis and Intervention , China Pharmaceutical University , No.24 Tongjia xiang , Nanjing 210009 , PR China
| | - Zhiqin Zeng
- School of Life Science and Technology and Jiangsu Key Laboratory of Carcinogenesis and Intervention , China Pharmaceutical University , No.24 Tongjia xiang , Nanjing 210009 , PR China
| | - Huimin Yang
- School of Life Science and Technology and Jiangsu Key Laboratory of Carcinogenesis and Intervention , China Pharmaceutical University , No.24 Tongjia xiang , Nanjing 210009 , PR China
| | - Shuanghui Luo
- School of Life Science and Technology and Jiangsu Key Laboratory of Carcinogenesis and Intervention , China Pharmaceutical University , No.24 Tongjia xiang , Nanjing 210009 , PR China
| | - Linlin Wang
- School of Life Science and Technology and Jiangsu Key Laboratory of Carcinogenesis and Intervention , China Pharmaceutical University , No.24 Tongjia xiang , Nanjing 210009 , PR China
| | - Tao Xi
- School of Life Science and Technology and Jiangsu Key Laboratory of Carcinogenesis and Intervention , China Pharmaceutical University , No.24 Tongjia xiang , Nanjing 210009 , PR China
| | - Yingying Xing
- School of Life Science and Technology and Jiangsu Key Laboratory of Carcinogenesis and Intervention , China Pharmaceutical University , No.24 Tongjia xiang , Nanjing 210009 , PR China
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Eskey CJ, Meyers PM, Nguyen TN, Ansari SA, Jayaraman M, McDougall CG, DeMarco JK, Gray WA, Hess DC, Higashida RT, Pandey DK, Peña C, Schumacher HC. Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e661-e689. [PMID: 29674324 DOI: 10.1161/cir.0000000000000567] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intracranial endovascular interventions provide effective and minimally invasive treatment of a broad spectrum of diseases. This area of expertise has continued to gain both wider application and greater depth as new and better techniques are developed and as landmark clinical studies are performed to guide their use. Some of the greatest advances since the last American Heart Association scientific statement on this topic have been made in the treatment of ischemic stroke from large intracranial vessel occlusion, with more effective devices and large randomized clinical trials showing striking therapeutic benefit. The treatment of cerebral aneurysms has also seen substantial evolution, increasing the number of aneurysms that can be treated successfully with minimally invasive therapy. Endovascular therapies for such other diseases as arteriovenous malformations, dural arteriovenous fistulas, idiopathic intracranial hypertension, venous thrombosis, and neoplasms continue to improve. The purpose of the present document is to review current information on the efficacy and safety of procedures used for intracranial endovascular interventional treatment of cerebrovascular diseases and to summarize key aspects of best practice.
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Cenzato M, Tartara F, D'Aliberti G, Bortolotti C, Cardinale F, Ligarotti G, Debernardi A, Fratianni A, Boccardi E, Stefini R, Zenga F, Boccaletti R, Lanterna A, Pavesi G, Ferroli P, Sturiale C, Ducati A, Cardia A, Piparo M, Valvassori L, Piano M. Unruptured Versus Ruptured AVMs: Outcome Analysis from a Multicentric Consecutive Series of 545 Surgically Treated Cases. World Neurosurg 2018; 110:e374-e382. [DOI: 10.1016/j.wneu.2017.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/30/2017] [Accepted: 11/02/2017] [Indexed: 10/18/2022]
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Galaktionov DM, Dubovoy AV, Kiselev VS, Sosnov AO, Ovsyannikov KS, Perfil'ev AM, Cherepanov AV. [Combination treatment of cerebral arteriovenous malformations using endovascular and microsurgical techniques]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2017; 81:26-32. [PMID: 28914868 DOI: 10.17116/neiro201781426-32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
MATERIAL AND METHODS The study included 40 patients with cerebral AVMs. In the study group, 14 (35%) patients underwent microsurgical resection without preliminary embolization (1st group), and 26 (65%) patients underwent combined treatment (endovascular embolization and microsurgical intervention, 2nd group). The first group included patients with S&M grade I-III AVMs, and the second group included patients with S&M grade II-V AVMs. Treatment outcomes were evaluated with allowance for completeness of AVM resection, operative blood loss, duration of surgery, changes in clinical and neurological impairments according to the modified Rankin scale, and rate of neurological and surgical complications. RESULTS According to postoperative findings, AVMs were totally resected in all patients. Persistent focal neurological symptoms developed in 2 (7.7%) cases in the second group; neurological complications occurred in 1 (7.1%) patient in the first group. The mean blood loss during resection of AVMs without preliminary embolization and embolized AVMs in patients with S&M grade I-III AVMs was 271.4 mL and 149.1 mL, respectively. The duration of surgery and blood loss did not differ significantly in microsurgery and combination treatment groups. CONCLUSION Combination treatment, including microsurgical intervention after endovascular embolization, is an effective treatment for AVMs, in particular for high grade (S&M grade III-V) AVMs. Teamwork and coordination among the surgeon, endovascular surgeon, and radiologist in treatment of AVMs is a prerequisite for a good outcome.
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Affiliation(s)
| | - A V Dubovoy
- Federal Center of Neurosurgery, Novosibirsk, Russia
| | - V S Kiselev
- Federal Center of Neurosurgery, Novosibirsk, Russia
| | - A O Sosnov
- Federal Center of Neurosurgery, Novosibirsk, Russia
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Derdeyn CP, Zipfel GJ, Albuquerque FC, Cooke DL, Feldmann E, Sheehan JP, Torner JC. Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2017. [DOI: 10.1161/str.0000000000000134] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Luksik AS, Law J, Yang W, Garzon-Muvdi T, Caplan JM, Colby G, Coon AL, Tamargo RJ, Huang J. Assessing the Role of Preoperative Embolization in the Surgical Management of Cerebral Arteriovenous Malformations. World Neurosurg 2017; 104:430-441. [PMID: 28512050 DOI: 10.1016/j.wneu.2017.05.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/01/2017] [Accepted: 05/04/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Preoperative embolization is established as an advantageous adjunct in multimodality treatment of cerebral arteriovenous malformations (AVMs). However, the benefit of preoperative embolization in AVMs with favorable surgical risk profile is debatable, because it has yet to be supported by evidence in comparative studies. In this study, we assessed outcome of surgically treated patients in a comparative setting. METHODS Our institutional AVM database of retrospectively and prospectively collected data between 1990 and 2015 was reviewed. Patients with complete clinical data who underwent surgical resection for AVMs were included. We performed a 1:1 ratio propensity score match for baseline variables that differed between patients with or without preoperative embolization. Differences in surgical risk and outcomes were evaluated between these 2 groups. RESULTS AVM size, eloquence, deep drainage, middle cerebral artery feeder, and ruptured presentation differed significantly between the 2 groups. Forty-eight patients without preoperative embolization were matched to 48 with embolization, with no significant differences in baseline variables or AVM characteristics between the 2 groups. We found no significant differences in AVM obliteration and postoperative modified Rankin Scale (mRS) score between embolized and nonembolized patients, respectively. Change in mRS score from preoperative score was also not significant, although more embolized patients had a decline in mRS score. Secondary outcome measures including duration of surgery (P = 0.172), intraoperative bleeding (P = 0.280), duration of hospitalization (P = 0.368), and postoperative symptoms were also similar between both groups. CONCLUSIONS Our data do not support substantial benefit of preoperative embolization for patients with a favorable surgical risk profile. Because of risks and costs with this intervention, the prudent use of preoperative embolization should be individually considered.
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Affiliation(s)
- Andrew S Luksik
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jody Law
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tomas Garzon-Muvdi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Geoffrey Colby
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Affiliation(s)
- Robert A Solomon
- From Columbia University College of Physicians and Surgeons and the Department of Neurological Surgery, New York Presbyterian Hospital, New York
| | - E Sander Connolly
- From Columbia University College of Physicians and Surgeons and the Department of Neurological Surgery, New York Presbyterian Hospital, New York
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Barone DG, Marcus HJ, Guilfoyle MR, Higgins JNP, Antoun N, Santarius T, Trivedi RA, Kirollos RW. Clinical Experience and Results of Microsurgical Resection of Arterioveonous Malformation in the Presence of Space-Occupying Intracerebral Hematoma. Neurosurgery 2017; 81:75-86. [DOI: 10.1093/neuros/nyx003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 01/14/2017] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND: Management of ruptured arteriovenous malformations (AVMs) with a mass-producing intracerebral hematoma (ICH) represents a surgical dilemma.
OBJECTIVE: To evaluate the clinical outcome and obliteration rates of microsurgical resection of AVM when performed concomitantly with evacuation of an associated space-occupying ICH.
METHODS: Data of patients with AVM were collected prospectively. Cases were identified in which an AVM was resected and an associated space-occupying ICH was evacuated at the same time, and divided into “group 1,” in which the surgery was performed acutely within 48 h of presentation (secondary to elevated intracranial pressure); and “group 2,” in which selected patients were operated upon in the presence of a liquefying ICH in the “subacute” stage. Clinical outcomes were assessed using the modified Rankin Scale, with a score of 0 to 2 considered a good outcome. Obliteration rates were assessed using postoperative angiography.
RESULTS: From 2001 to 2015, 131 patients underwent microsurgical resection of an AVM, of which 65 cases were included. In “group 1” (n = 21; Spetzler-Ponce class A = 13, class B = 5, and class C = 3), 11 of 21 (52%) had a good outcome and in 18 of 19 (95%) of those who had a postoperative angiogram the AVMs were completely obliterated. In “group 2” (n = 44; Spetzler-Ponce class A = 33, class B = 9, and class C = 2), 31 of 44 (93%) had a good outcome and 42 of 44 (95%) were obliterated with a single procedure. For supratentorial AVMs, the ICH cavity was utilized to provide an operative trajectory to a deep AVM in 11 cases, and in 26 cases the ICH cavity was deep to the AVM and hence facilitated the deep dissection of the nidus.
CONCLUSION: In selected patients the presence of a liquefying ICH cavity may facilitate the resection of AVMs when performed in the subacute stage resulting in a good neurological outcome and high obliteration rate.
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Affiliation(s)
| | - Hani J. Marcus
- Department of Neurosurgery, Adden-brooke's Hospital, Cambridge, UK
| | | | | | - Nagui Antoun
- Department of Neuroradiology, Adden-brooke's Hospital, Cambridge, UK
| | - Thomas Santarius
- Department of Neurosurgery, Adden-brooke's Hospital, Cambridge, UK
| | - Rikin A. Trivedi
- Department of Neurosurgery, Adden-brooke's Hospital, Cambridge, UK
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Marks MP, Marcellus ML, Santarelli J, Dodd RL, Do HM, Chang SD, Adler JR, Mlynash M, Steinberg GK. Embolization Followed by Radiosurgery for the Treatment of Brain Arteriovenous Malformations (AVMs). World Neurosurg 2017; 99:471-476. [PMID: 28017742 DOI: 10.1016/j.wneu.2016.12.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/10/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Michael P Marks
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA.
| | - Mary L Marcellus
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Justin Santarelli
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Robert L Dodd
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Huy M Do
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - John R Adler
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Michael Mlynash
- Department of Neurology, Stanford University Medical Center, Stanford, California, USA
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA; Department of Neurology, Stanford University Medical Center, Stanford, California, USA
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Ryu B, Ishikawa T, Kawamata T. Multimodal Treatment Strategy for Spetzler-Martin Grade III Arteriovenous Malformations of the Brain. Neurol Med Chir (Tokyo) 2017; 57:73-81. [PMID: 27169498 PMCID: PMC5341343 DOI: 10.2176/nmc.ra.2016-0056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The Spetzler–Martin (S–M) grading scale was developed to assess the risk of postoperative neurological complications after the surgical treatment of arteriovenous malformations (AVMs) of the brain. Treatment-associated morbidity and poor outcomes are particularly relevant to Grade III AVMs and improving the safety while attaining acceptable cure rates still poses a challenge. A multimodal treatment strategy combining surgery, embolization, and radiosurgery is recommended for S–M Grade III AVMs because of the surgical risk. Grade III AVMs are the heterogeneous group that has been further divided into subgroups according to the size, the location in eloquent cortex, and the presence of deep venous drainage. The risks associated with different treatment modalities vary depending on the subgroup, and the rating scales have been further refined to predict the risk more accurately and help determine the most appropriate treatment choice. Previous results for the treatment of S–M Grade III AVMs vary widely among studies, and the treatment modalities are also different in each study. Being familiar with previous treatment results is essential for improving treatment outcomes.
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Affiliation(s)
- Bikei Ryu
- Department of Neurosurgery, Tokyo Women's Medical University
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Gross BA, Moon K, Mcdougall CG. Endovascular management of arteriovenous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:59-68. [PMID: 28552159 DOI: 10.1016/b978-0-444-63640-9.00006-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Arteriovenous malformation (AVM) embolization can serve as a crucial adjunct before surgical resection, a partial approach to target high-risk features, or, rarely, as a curative approach for high-risk, surgically inaccessible lesions. Specifically, embolization is a welcome surgical adjunct to reduce the size of medium to large AVMs, to target perforator supply, and/or to target the deep portion of a nidus. In addition, a crucial role for embolization is the targeting of associated aneurysms, particularly in the setting of a ruptured lesion, regardless of the subsequent therapeutic modality. Rarely, a deep, small ruptured AVM that cannot be accessed surgically may be embolized with intent to cure. This chapter will review patient selection, technical nuances, and published results for AVM embolization. With appropriate patient selection and well-defined goals of embolization, the risk of procedural morbidity can be outweighed by its benefit.
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Affiliation(s)
- Bradley A Gross
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
| | - Karam Moon
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Cameron G Mcdougall
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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Pluronic P85-coated poly(butylcyanoacrylate) nanoparticles overcome phenytoin resistance in P-glycoprotein overexpressing rats with lithium-pilocarpine-induced chronic temporal lobe epilepsy. Biomaterials 2016; 97:110-21. [DOI: 10.1016/j.biomaterials.2016.04.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 04/07/2016] [Accepted: 04/20/2016] [Indexed: 01/16/2023]
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Another AVM Grading Scale … Really? World Neurosurg 2016; 92:537-539. [DOI: 10.1016/j.wneu.2016.06.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 06/09/2016] [Indexed: 11/17/2022]
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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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Gruber A, Bavinzski G, Kitz K, Barthelmes S, Mayr M, Knosp E. Multimodality Management of Cerebral Arteriovenous Malformations with Special Reference to AVM-Related Hemorrhages During Ongoing Staged Treatment. ACTA NEUROCHIRURGICA. SUPPLEMENT 2016; 123:153-8. [PMID: 27637643 DOI: 10.1007/978-3-319-29887-0_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
In this study we report and analyze the results of a multimodality management concept for intracranial arteriovenous malformations (AVMs), including microsurgery, embolization, and gamma knife radiosurgery. The study population consists of a consecutive series of 294 patients treated for 304 intracranial AVMs over a 10-year period.
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Affiliation(s)
- Andreas Gruber
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Klaus Kitz
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | | | - Magdalena Mayr
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria.
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Lopes DK, Moftakhar R, Straus D, Munich SA, Chaus F, Kaszuba MC. Arteriovenous malformation embocure score: AVMES. J Neurointerv Surg 2015; 8:685-91. [DOI: 10.1136/neurintsurg-2015-011779] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 05/29/2015] [Indexed: 11/03/2022]
Abstract
BackgroundCerebral arteriovenous malformations (CAVMs) may be treated with microsurgery, radiosurgery, endovascular surgery, or a combination of these modalities. Grading scales are available to aid the assessment of curative risk for microsurgery and radiosurgery. No grading system has been developed to assess the curative risk of endovascular surgery.ObjectiveTo report our retrospective application of the AVM embocure score to patients treated at our institution between 2005 and 2011MethodsWe performed a retrospective review of 39 patients with CAVM treated at our institution between 2005 and 2011 with the primary aim of achieving a curative embolization. After reviewing all the different variables associated with the conventional Onyx embolization technique for CAVMs, we identified the following as the most relevant characteristics influencing the chances for complete angiographic embolization and complication risk: the number of arterial pedicles and draining veins, size of AVM nidus, and vascular eloquence. We sought to develop a scoring system to assess the complication risk for a curative embolization of CAVM with liquid embolic Onyx (Covidien, Irvine, California, USA). We developed the AVM embocure score (AVMES). This scoring system ranges from 3 to 10 and is the arithmetic sum of the number of arterial pedicles feeding the AVM (≤3, 4–6, >6), the number of draining veins (≤3, 4–6, >6), the size of the AVM nidus in centimeters (≤3, 4–6, >6), and the vascular eloquence (0–1). We applied AVMES to the same cohort of patients and validated the predictability of complete angiographic embolization and expected clinical risk of complication.ResultsIn lesions with an AVMES of 3 (n=8), there was a 100% rate of complete AVM obliteration and 0% rate of major complications. In AVMES 4 (n=12) lesions, there was 75% complete obliteration rate, with 8% major morbidity. In AVMES 5 (n=9) lesions, there was 78% complete obliteration and 11% major morbidity. In AVMES >5 (n=10) there was 20% complete obliteration and 30% major morbidity. Receiver-operator curve analysis showed that this scoring system was robust in its discriminative ability, with an area under the curve (AUC) of 0.8356 for complete obliteration without complication, AUC=0.8240 for complete obliteration regardless of the presence of major morbidity, and AUC=0.7529 for major morbidity.ConclusionsThe AVMES complements existing scoring systems for microsurgery and radiosurgery. It provides a valuable tool for risk assessment during the complex decision-making process in treating AVMs that accounts for angioarchitectural features of particular relevance to endovascular surgeons.
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Abstract
An arteriovenous malformation is a tangle of dysplastic vessels (nidus) fed by arteries and drained by veins without intervening capillaries, forming a high-flow, low-resistance shunt between the arterial and venous systems. Arteriovenous malformations in the brain have a low estimated prevalence but are an important cause of intracerebral haemorrhage in young adults. For previously unruptured malformations, bleeding rates are approximately 1% per year. Once ruptured, the subsequent risk increases fivefold, depending on associated aneurysms, deep locations, deep drainage and increasing age. Recent findings from novel animal models and genetic studies suggest that arteriovenous malformations, which were long considered congenital, arise from aberrant vasculogenesis, genetic mutations and/or angiogenesis after injury. The phenotypical characteristics of arteriovenous malformations differ among age groups, with fistulous lesions in children and nidal lesions in adults. Diagnosis mainly involves imaging techniques, including CT, MRI and angiography. Management includes observation, microsurgical resection, endovascular embolization and stereotactic radiosurgery, alone or in any combination. There is little consensus on how to manage patients with unruptured malformations; recent studies have shown that patients managed medically fared better than those with intervention at short-term follow-up. By contrast, interventional treatment is preferred following a ruptured malformation to prevent rehaemorrhage. Management continues to evolve as new mechanistic discoveries and reliable animal models raise the possibility of developing drugs that might prevent the formation of arteriovenous malformations, induce obliteration and/or stabilize vessels to reduce rupture risk. For an illustrated summary of this Primer, visit: http://go.nature.com/TMoAdn.
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Abstract
OPINION STATEMENT Arteriovenous malformations (AVMs) pose a risk of morbidity and mortality throughout an affected patient's lifetime. Over the course of a patient's life, the risk of hemorrhage is approximately 1-4 % per year, and after an initial hemorrhage occurs, this risk may be higher. Other causes of morbidity include seizures, headaches, or progressive neurologic deficits. Once an AVM has been discovered, the utility of attempted obliteration or surgical resection compared to the risk of intervention should be entertained. The characteristics of the malformation as well as the patient's overall health status contribute to the decision to intervene on these lesions. For small lesions located in superficial areas without high-risk surgical characteristics (low-grade Spetzler-Martin grades), it is reasonable to consider surgical resection. In lesions that pose high-risk of complications from surgical removal, intra-arterial embolization, radiosurgery, or a combination of the two may be reasonable treatment options. Some AVMs at traditional high surgical risk may be amenable to partial embolization, allowing initially high-risk lesions to become better candidates for surgical resection. In some patients, particularly those who are older or who have multiple medical comorbidities, the risk of intervention as compared to the annual hemorrhage risk may warrant conservative management as opposed to intervention. The overall treatment strategy must be based on patient and AVM characteristics and careful risk-benefit ratio analysis.
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Ning X, Zhao C, Pang J, Ding Z, Wang Y, Xu K, Chen H, Li B, Luo QI. Experimental study of temperature-sensitive chitosan/β-glycerophosphate embolic material in embolizing the basicranial rete mirabile in swines. Exp Ther Med 2015; 10:316-322. [PMID: 26170955 DOI: 10.3892/etm.2015.2479] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 02/19/2015] [Indexed: 12/20/2022] Open
Abstract
The aim of the present study was to evaluate the feasibility of the non-adhesive temperature-sensitive liquid embolic material, chitosan/β-glycerophosphate (C/GP), in embolizing the basicranial rete mirabile (REM) in a swine model of cerebral arteriovenous malformation (cAVM). A total of 24 domestic swines were used as the experimental animals, among which 12 pigs underwent direct embolization of one side of the REM, while the other 12 pigs underwent embolization of the bilateral REM following anastomosis of the carotid artery and jugular vein. A super-selective microcatheter was introduced into the REM during the embolization procedure, and the C/GP hydrogel was injected until an image of the REM disappeared in the angiography examination. Further angiography examinations were performed after 2 and 6 weeks, and histological examination of the REM was performed after 6 weeks. Of the 24 domestic swines, 23 cases underwent successful thrombosis. Convulsions occurred in one case and that pig died during the embolization procedure. Following embolization, the angiography observations revealed that the embolized REM was no longer able to be developed, and adhesion of the microcatheter tip with the embolic agent did not occur. In addition, no apparent revascularization was observed in the angiography examinations performed at weeks 2 and 6. Therefore, the current preliminary study indicated that use of the non-adhesive temperature-sensitive embolic material was feasible for the embolization of cAVM; thus, C/GP may be used as an ideal embolic material for the treatment of cAVM.
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Affiliation(s)
- Xianbin Ning
- Department of Neurosurgery, The Affiliated Hospital of Beihua University, Jilin City, Jilin 132011, P.R. China
| | - Changfu Zhao
- Department of Neurosurgery, The Affiliated Hospital of Beihua University, Jilin City, Jilin 132011, P.R. China
| | - Jinfeng Pang
- Department of Neurosurgery, The Affiliated Hospital of Beihua University, Jilin City, Jilin 132011, P.R. China
| | - Zhaoyi Ding
- Department of Neurosurgery, The Affiliated Hospital of Beihua University, Jilin City, Jilin 132011, P.R. China
| | - Yubo Wang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Hao Chen
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Bingwei Li
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Q I Luo
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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Crowley RW, Ducruet AF, Kalani MYS, Kim LJ, Albuquerque FC, McDougall CG. Neurological morbidity and mortality associated with the endovascular treatment of cerebral arteriovenous malformations before and during the Onyx era. J Neurosurg 2015; 122:1492-7. [PMID: 25816081 DOI: 10.3171/2015.2.jns131368] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The widespread implementation of the embolic agent Onyx has changed the endovascular management of cerebral arteriovenous malformations (AVMs). Recent data suggest that outcomes following embolization and resection may have worsened in the Onyx era. It has been hypothesized that there may be increased complications with Onyx embolization and increased surgical aggressiveness in patients treated with Onyx. In this study the authors analyzed their institutional experience with the endovascular treatment of cerebral AVMs prior to and after the introduction of Onyx to determine factors associated with periprocedural neurological morbidity and mortality. METHODS A retrospective review was performed of all patients with cerebral AVMs undergoing embolization at the Barrow Neurological Institute from 1995 to 2012. RESULTS Endovascular treatment of 342 cerebral AVMs was performed over 446 treatment sessions (mean age 37.8 years, range 1-83 years). Clinical presentation included hemorrhage in 47.6%, seizures in 21.9%, headaches in 11.1%, and no symptoms in 10% of cases. The endovascular pretreatment strategy was preoperative in 78.9%, preradiosurgery in 9.1%, palliative in 5.3%, targeted in 4.4%, and curative in 2.3%. The median Spetzler-Martin grade was III. The mean number of arteries embolized was 3.5 (range 0-13 arteries), and the mean number of treatment sessions was 1.3 (range 1-4 sessions). Onyx was used in 105 AVMs (30.7%), and N-butyl cyanoacrylate (NBCA) without Onyx was used in 229 AVMs (67%). AVMs treated with Onyx had a higher mean number of arterial pedicles embolized than did NBCA cases (4.3 ± 2.7 vs 3.2 ± 2.4, respectively; p < 0.001) and a greater number of sessions (1.5 ± 0.7 vs 1.2 ± 0.5, respectively; p < 0.05). Unexpected immediate postprocedural permanent neurological deficits were present in 9.6% of AVMs, while transient deficits were present in 1.8%. There was 1 death (0.3%). Spetzler-Martin grade was not associated with differences in outcome, as permanent neurological deficits were observed in 12%, 9%, 13%, 11%, and 13% of AVMs for Spetzler-Martin Grades I-V, respectively (p = 0.91). The use of Onyx compared with NBCA was not associated with differences in periprocedural morbidity (p = 0.23). This lack of a difference persisted even when controlling for number of arteries and sessions (p = 0.14). Sex was not associated with differences in outcome. CONCLUSIONS Permanent and transient postprocedural neurological deficits were noted in 9.6% and 1.8% of all cases, respectively. AVM grade was not associated with endovascular outcome. Despite the greater number of sessions required and arteries embolized for Onyx cases, there was no statistically significant difference in the risk of neurological deficits following cerebral AVM embolization with Onyx and NBCA.
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Affiliation(s)
- R Webster Crowley
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Andrew F Ducruet
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - M Yashar S Kalani
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Louis J Kim
- 2Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Felipe C Albuquerque
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Cameron G McDougall
- 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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Li F, Deshaies E, Allott G, Gorji R. Transcranial Motor Evoked Potential Changes Induced by Provocative Testing during Embolization of Cerebral Arteriovenous Malformations in Patients under Total Intravenous Anesthesia. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/1086508x.2011.11079828] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Fenghua Li
- Department of Anesthesiology SUNY Upstate Medical University Syracuse, New York
| | - Eric Deshaies
- Department of Neurosurgery SUNY Upstate Medical University Syracuse, New York
| | - Geoffrey Allott
- Department of Neurology SUNY Upstate Medical University Syracuse, New York
| | - Reza Gorji
- Department of Anesthesiology SUNY Upstate Medical University Syracuse, New York
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