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Hirano Y, Shinya Y, Hasegawa H, Umekawa M, Iwagami M, Koizumi S, Katano A, Saito N. Sustaining consistent cobalt-60 dose rate enhances radiosurgical outcomes in brain arteriovenous malformation management. Radiother Oncol 2024; 197:110375. [PMID: 38857704 DOI: 10.1016/j.radonc.2024.110375] [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: 11/19/2023] [Revised: 04/24/2024] [Accepted: 06/03/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND AND PURPOSE The impact of cobalt-60 dose rate (Co-60 DR) on outcomes of stereotactic radiosurgery (SRS) for brain arteriovenous malformations (AVMs) remains fully elucidated. This study explored the association between Co-60 DR and SRS outcomes in AVM treatment. MATERIALS AND METHODS 772 AVM patients from 1990 to 2020 were included. High DR was defined as ≥ 2.4 Gy/min. AVM patients were categorized into 3 cohorts based on the nidus volume: small (<5 mL), medium (≥5 mL and < 10 mL), and large (≥10 mL). The primary endpoint was AVM obliteration; secondary endpoints included post-SRS hemorrhage. RESULTS Cumulative obliteration rates of the large AVM were significantly increased in the high DR group than those in the low DR group (84 % vs. 45 % at 5 years, log-rank test; p = 0.011). Multivariable analysis showed that the obliteration rate was significantly elevated for the high DR group in the large AVM cohort with an adjusted hazard ratio (HR) of 1.78 (95 % confidence interval [CI]: 1.00-3.17, p = 0.049). Post-SRS hemorrhage rates of the entire cohort were significantly decreased in the high DR group than in the low DR group (2.5 % vs. 5.3 % at 5 years, log-rank test; p = 0.035). Multivariable analysis revealed post-SRS hemorrhage was reduced in the high DR group with an adjusted HR of 0.47 (95 % CI: 0.24-0.92, p = 0.026). CONCLUSION High DR may lead to increased efficiency for large AVMs and decreased post-SRS hemorrhage in all AVM cases. Sustaining a higher Co-60 DR could potentially yield favorable outcomes for SRS for AVMs.
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Affiliation(s)
- Yudai Hirano
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Yuki Shinya
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan.
| | - Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Motoyuki Umekawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Masao Iwagami
- Department of Health Services Research, University of Tsukuba, Ibaraki 305-8577, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
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2
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Mochizuki T, Ryu B, Sato S, Niimi Y. Successful embolization of ventricular arteriovenous malformation supplied by the choroidal artery: A case report and literature review. Surg Neurol Int 2023; 14:254. [PMID: 37560570 PMCID: PMC10408606 DOI: 10.25259/sni_413_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/06/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Ventricular arteriovenous malformations (AVMs) are localized in the ventricles and are mainly fed by the anterior choroidal artery (AChoA) and posterior choroidal artery (PChoA). Surgical resection of ventricular AVMs is difficult as the lesions are localized deep in the brain. Therefore, endovascular treatment is expected to treat ventricular AVMs. However, embolization from the AChoA and PChoA carries the risk of ischemic complications. Even though there are some major reports on embolization strategies from the choroidal arteries, embolization of these arteries remains technically challenging. In this article, we report two successful cases of ventricular AVM embolization using AChoA and PChoA. CASE DESCRIPTION Case 1: A 34-year-old male presented with intraventricular hemorrhage (IVH). Subsequently, ventricular AVM embolization in the anterior horn was performed using n-butyl-2-cyanoacrylate (NBCA) through the AChoA and medial PChoA, and complete obliteration was observed without neurological deterioration. Case 2: A 71-year-old female presented with IVH. Subsequently, ventricular AVM embolization in the lateral ventricle was performed through the AChoA and lateral PChoA with Onyx and NBCA, and partial obliteration was observed without complications. Furthermore, Gamma Knife surgery for residual lesions resulted in complete obliteration. CONCLUSION Embolization through the choroidal arteries for ventricular AVMs is an effective curative or adjunctive treatment.
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Affiliation(s)
| | - Bikei Ryu
- Department of Neuroendovascular Therapy, Saint Luke’s International Hospital, Tokyo, Japan
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3
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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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4
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Koizumi S, Shojima M, Shinya Y, Ishikawa O, Hasegawa H, Miyawaki S, Nakatomi H, Saito N. Risk Factors of Brain Arteriovenous Malformation Embolization as Adjunctive Therapy: Single-Center 10-Year Experience. World Neurosurg 2022; 167:e1448-e1454. [PMID: 36130658 DOI: 10.1016/j.wneu.2022.09.069] [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: 05/27/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE In the multimodality treatment of complex brain arteriovenous malformations (AVMs), the role of endovascular embolization is not fully elucidated. To assess the risk of embolization, we retrospectively evaluated the outcomes of endovascular treatment for AVM, focusing on the embolization-related complications. METHODS The present study included patients with brain AVM who underwent embolization at our hospital between April 2011 and May 2021. Risk factors for peri- and postoperative complications were analyzed. RESULTS During the study period, 36 AVMs were treated during 58 embolization sessions. The goal of the embolization was preoperative in 24 (67%), pre-radiosurgical in 9 (25%), and palliative in 3 (8%) cases. The overall complication rate was 43% (25 of 58) per session and 36% (13 of 36) per patient. Ischemic and hemorrhagic complications were observed in 14 (24%) and 14 (24%) cases, respectively. n-Butyl cyanoacrylate (n-BCA) embolization was detected as the significant risk for postoperative hemorrhage in the univariate (79% vs. 36%, P = 0.012; Fisher exact test) and the multivariable analysis (odds ratio 4.90, 95% confidence interval 1.08-22.2, P = 0.039). The number of embolized feeder in a single session also tended to be higher in a hemorrhagic complication group (median 3.5 vs. 2.0, P = 0.11; Mann-Whitney U-test). CONCLUSIONS The risk of embolization in multimodality treatment for complex brain AVM was substantial. n-BCA embolization may carry a higher risk of postoperative hemorrhage. An accumulation of cases is awaited to investigate the effectiveness of minimal target embolization in the future.
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Affiliation(s)
- Satoshi Koizumi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan.
| | - Masaaki Shojima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan; Department of Neurosurgery, Teikyo University Hospital, Tokyo, Japan
| | - Yuki Shinya
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Osamu Ishikawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan; Department of Neurosurgery, Asama General Hospital, Nagano, Japan
| | - Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan; Department of Neurosurgery, Kyorin University Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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5
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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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6
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Impact of Neurovascular Comorbidities and Complications on Outcomes After Procedural Management of Arteriovenous Malformations. Clin Neurol Neurosurg 2022; 220:107349. [DOI: 10.1016/j.clineuro.2022.107349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 06/18/2022] [Accepted: 06/20/2022] [Indexed: 11/17/2022]
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7
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Rodriguez-Calienes A, Bustamante-Paytan D, Camacho-Caballero K, Mayoria-Vargas A, Rodríguez-Varela R, Saal-Zapata G. Single-center experience with endovascular treatment of cerebral arteriovenous malformations with intent to cure in pediatric patients. Childs Nerv Syst 2022; 38:343-351. [PMID: 34605999 DOI: 10.1007/s00381-021-05376-5] [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: 03/09/2021] [Accepted: 08/01/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE This study aimed to report the incidence of technical complications and immediate complete angiographic occlusion, identify associated factors with failure of complete occlusion and identify predictors of technical complications in a single-center experience of pediatric arteriovenous malformations (AVM) treated with endovascular treatment with intent to cure. METHODS Patients between 1 and 18 years of age undergoing endovascular embolization between 2011 and 2020 were included. RESULTS A total of 120 embolizations were performed in 69 patients. The most frequent clinical presentation was intracerebral hemorrhage (76.8%). Immediate obliteration of the malformations was achieved in 40 (58%) cases. The technical complication rate was 15%. AVM nidus size between 3 and 6 cm (OR: 3.91; 95% CI 1.1-13.85; p = 0.035) and the presence of multiple feeders (OR: 5.08; 95% CI 1.41-18.28; p = 0.074) were predictive of failure of immediate complete occlusion. The location of the temporal lobe (OR: 7.83; p = 0.048), deep venous drainage (OR: 4.67; p = 0.112), and the presence of an intranidal aneurysm (OR: 3.58; p = 0.134) were predictors of technical complications. CONCLUSIONS Embolization of pediatric AVMs with intent to cure shows a high rate of technical complications and acceptable immediate occlusion rates. Nidus size and the presence of multiple feeders were predictive of failure of complete occlusion, while temporal lobe location, deep venous drainage, and the presence of an intranidal aneurysm were predictors of technical complications. Further studies are needed to determine the best therapeutic approach in the pediatric population.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Alameda del Corregidor 1531, La Molina 15024, Lima, Peru
| | - Diego Bustamante-Paytan
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru. .,Facultad de Medicina Humana, Universidad de San Martín de Porres, Alameda del Corregidor 1531, La Molina 15024, Lima, Peru.
| | - Kiara Camacho-Caballero
- Facultad de Medicina Humana, Universidad Científica del Sur, Lima, Peru.,CHANGE, Research Working Group, Carrera de Medicina Humana, Universidad Cientifica del Sur, Lima, Peru
| | - Angie Mayoria-Vargas
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Alameda del Corregidor 1531, La Molina 15024, Lima, Peru
| | - Rodolfo Rodríguez-Varela
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
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8
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Capocci R, Bustuchina Vlaicu M, Shotar E, Mathon B, Delaitre M, Premat K, Talaat M, Talbi A, Boch AL, Lenck S, Carpentier A, Degos V, Sourour NA, Clarençon F. Benefits from Exclusion Treatment of Unruptured Brain Arteriovenous Malformations on Epilepsy in Adults. Clin Neuroradiol 2021; 32:749-760. [PMID: 34807285 DOI: 10.1007/s00062-021-01119-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/26/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE In approximately 30% of the patients, brain arteriovenous malformations (bAVMs) are revealed by seizures, which may alter the patients' quality of life. Our objective was to evaluate the benefits of exclusion treatment (radiosurgery, embolization and/or surgery) on posttherapeutic epilepsy in bAVM patients without intracranial hemorrhage prior to treatment. METHODS Our retrospective observational single-center study included all consecutive adult patients with an unruptured bAVM and epilepsy, treated at our institution from 1995 to 2019 and who were followed for at least 1 year. Data on angioarchitectural characteristics of bAVMs, on epilepsy and posttreatment modified Rankin Scale (mRS) were collected. The primary endpoint was a seizure-free status (defined as Engel class IA) after exclusion treatment versus conservative management. RESULTS In this study one hundred and one consecutive adult patients with bAVMs, epilepsy and without bAVM rupture before any treatment were included; 21 (21%) in the conservative management group vs. 80 (79%) in the exclusion treatment group. After exclusion treatment, 55% of the patients from the group were Engel IA after treatment vs. 10% of the conservative management group (odds ratio [OR] 11.37, 95% confidence interval [CI] 2.48-107.24, p < 0.001). CONCLUSION Our results suggest that exclusion treatment in unruptured bAVMs with epilepsy is associated with a higher seizure-free rate in comparison with conservative management. Data from randomized controlled studies are necessary to confirm these findings.
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Affiliation(s)
- Romain Capocci
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | | | - Eimad Shotar
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Bertrand Mathon
- Department of Neurosurgery, Pitie-Salpêtrière Hospital, Paris, France.,Sorbonne University Medical School, Paris, France
| | | | - Kévin Premat
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne University Medical School, Paris, France
| | - Maichael Talaat
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.,Department of Radiology, Zagazig University Hospital, Zagazig, Egypt
| | - Atika Talbi
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Anne-Laure Boch
- Department of Neurosurgery, Pitie-Salpêtrière Hospital, Paris, France
| | - Stéphanie Lenck
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Alexandre Carpentier
- Department of Neurosurgery, Pitie-Salpêtrière Hospital, Paris, France.,Sorbonne University Medical School, Paris, France
| | - Vincent Degos
- Sorbonne University Medical School, Paris, France.,Department of Neuro-Intensive Care, Pitie-Salpêtrière Hospital, Paris, France.,GRC BioFast. Paris VI University, Paris, France
| | - Nader Antoine Sourour
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France. .,Sorbonne University Medical School, Paris, France. .,GRC BioFast. Paris VI University, Paris, France.
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9
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Qureshi AM, Muthusami P, Krings T, Amirabadi A, Radovanovic I, Dirks P, Shroff M, Armstrong D, terBrugge K, Pereira VM. Clinical and Angioarchitectural Features of Hemorrhagic Brain Arterio-Venous Malformations in Adults and Children: Contrasts and Implications on Outcome. Neurosurgery 2021; 89:645-652. [PMID: 34270753 DOI: 10.1093/neuros/nyab251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 05/08/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Hemorrhage from brain arteriovenous malformations (bAVMs) is estimated at 3% per annum. Features influencing risk of hemorrhage include perforator/posterior circulation supply, associated aneurysms, and deep drainage. Children are more likely to present with bAVM bleeds. OBJECTIVE To analyze differences in bAVM angioarchitecture between children and adults and describe predictors of poor outcome. METHODS Data were collected from adult and pediatric tertiary referral hospitals. Demographic data, bleed location, treatment, and follow-up modified Rankin Scale (mRS) were collected. Angioarchitectural assessment included aneurysm presence, nidus morphology, perinidal angiogenesis, intranidal shunting, steal phenomenon, venous ectasia, venous stenosis, venous reflux, and pseudophlebitic pattern. Regression analyses conducted to determine predictors of mRS > 2. RESULTS A total of 270 adult and 135 pediatric ruptured bAVMs were assessed. Median age was 42 (adults) and 10.9 (children) yr. Intranidal aneurysms were more frequent in children (P = .012), whereas prenidal aneurysms were more common in adults (P < .01). Children demonstrated more perinidal angiogenesis (P = .04), whereas steal phenomenon was commoner in adults (P < .01). Venous ectasia (P < .01), reflux (P < .01), and pseudophlebitic pattern (P = .012) were more frequent in adults. Children had better outcome (mRS score ≤ 2) (P < .01). Older age (odds ratio [OR] = 1.02), eloquent location (OR = 2.5), multicompartmental hemorrhage (OR = 1.98), venous reflux (OR = 2.5), diffuse nidus (OR = 1.83), pseudophlebitic pattern (OR = 1.96), intranidal shunts (OR = 2), and no treatment (OR = 3.68) were significant predictors of mRS > 2. CONCLUSION Children are more likely to have intranidal aneurysms and perinidal angiogenesis, whereas adults have more prenidal aneurysms, venous ectasia, corticovenous reflux, and pseudophlebitic pattern. Eloquent location, diffuse nidus, intranidal shunts, venous reflux, and pseudophlebitic pattern predict poorer outcome.
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Affiliation(s)
- Ayman M Qureshi
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Canada.,Department of Diagnostic Imaging & Image Guided Therapy, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Prakash Muthusami
- Department of Diagnostic Imaging & Image Guided Therapy, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Timo Krings
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Canada
| | - Afsaneh Amirabadi
- Department of Diagnostic Imaging & Image Guided Therapy, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Ivan Radovanovic
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Canada
| | - Peter Dirks
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Manohar Shroff
- Department of Diagnostic Imaging & Image Guided Therapy, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Derek Armstrong
- Department of Diagnostic Imaging & Image Guided Therapy, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Karel terBrugge
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Canada
| | - Vitor M Pereira
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, Toronto, Canada
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10
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Yang R, Ren Y, Maingard J, Thijs V, Le DVA, Kok HK, Lee MJ, Hirsch JA, Chandra RV, Brooks DM, Asadi H. The 100 most cited articles in the endovascular treatment of brain arteriovenous malformations. Brain Circ 2021; 7:49-64. [PMID: 34189347 PMCID: PMC8191531 DOI: 10.4103/bc.bc_46_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/20/2020] [Accepted: 01/15/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The literature base for endovascular treatment of brain arteriovenous malformations (BAVMs) has grown exponentially in recent decades. Bibliometric analysis has been used to identify impactful articles in other medical specialties. The aim of this citation analysis was to identify and characterize the top 100 most cited articles in the field of endovascular BAVM treatment. METHODS The top-cited papers were identified by searching selected keywords ("endovascular treatment," "interventional treatment," "brain arteriovenous malformation," "emboliz(s)ation") on the Web of Science platform. The top 100 articles were ranked according to their number of citations. Each article was further evaluated to obtain predefined characteristics including citation(s) per year, year of publication, authorship, journal-title and impact factor, article topics, article type, and level of evidence. RESULTS The top 100 most cited articles for endovascular BAVM treatment were published between 1960 and 2014. The total number of citations for these articles ranged from 56 to 471 (median 85.5). Most articles (76%) were published between 1990 and 2009 in three journals (56%), originated in the USA (52%) followed by France (16%). The most common topic related to embolization agents and the majority of articles constituted level IV or V evidence. CONCLUSIONS This study provides a comprehensive overview of the most cited articles in the field of endovascular BAVM treatment. Our analysis recognizes key contributions from authors and institutions in the field and leads to a better understanding of the evidentiary framework for BAVM treatment.
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Affiliation(s)
- Runlin Yang
- Department of Radiology, Austin Hospital, Australia
| | - Yifan Ren
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Australia
| | - Julian Maingard
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Australia
- Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Australia
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia
| | - Vincent Thijs
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Monash University, Melbourne, Australia
| | - Dustin Viet Anh Le
- Interventional Neuroradiology Service, Monash Health, Monash University, Melbourne, Australia
| | - Hong Kuan Kok
- Department of Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Michael J Lee
- Department of Interventional Radiology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Joshua A Hirsch
- Interventional Neuroradiology Service, Massachusetts General Hospital, Boston, USA
| | - Ronil V Chandra
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Monash University, Melbourne, Australia
| | - Duncan Mark Brooks
- Interventional Radiology Service, Department of Radiology, Austin Hospital, Australia
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Monash University, Melbourne, Australia
| | - Hamed Asadi
- Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Australia
- School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia
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11
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Fiani B, Soula M, Sarhadi K, Nikolaidis D, Gautam N, Fiani NJ, Jenkins R, Rose A. Direct N-butyl-2-cyanoacrylate injections to the head and neck for percutaneous embolized devascularization. Surg Neurol Int 2021; 12:131. [PMID: 33880236 PMCID: PMC8053456 DOI: 10.25259/sni_154_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/12/2021] [Indexed: 11/30/2022] Open
Abstract
Background: N-butyl-2-cyanoacrylate (NBCA) has been used for vascular malformations since the 1980s; however, few studies have looked at applications, procedural techniques, and outcome throughout many institutions. Herein, we review applications, procedural techniques, previous literature, and outcomes for the use of NBCA specifically through percutaneous technique in treating head and neck vascular pathology. Methods: An extensive literature review using PubMed database with published literature containing “N-butyl-2-cyanoacrylate embolization,” was performed. No date restrictions were used. Cross-checking of articles was conducted to exclude duplicate articles. The articles were screened for their full text and English language availability. We finalized those articles pertaining to the topic. Results: The search yielded 1124 related articles. When comparing surgical resection to embolization with NBCA for cerebral AVMs, complications were similar in both groups and included hemorrhage (15%), residual AVM (6%), and cerebrospinal fluid leak (3%). Their mortality rate was 3% in both groups. Preoperative percutaneous embolization does show improved surgical outcomes. Conclusion: NBCA is a fast-acting liquid embolic material used in the treatment of a variety of vascular malformations and lesions of the head and neck. Investigations surrounding the use of NBCA injections as a new alternative embolic agent began in the 1980’s. Administration of NBCA has been shown to be useful in minimizing intraoperative blood loss and controlling acute hemorrhage. Performing percutaneous embolization with NBCA provides a successful alternative for surgeons when transcatheter embolization techniques may prove to be too difficult to perform. Embolization using NBCA will continue to play in integral role in the treatment of malignant lesions and vascular malformations. Continued research is warranted to improve safety, outcomes, and further develop clinical applications of NBCA.
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Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, California, United States
| | - Marisol Soula
- Grossman School of Medicine, New York University, New York, United States
| | - Kasra Sarhadi
- Department of Neurology, University of Washington, Main Hospital, Seattle, Washington State, United States
| | - Daniel Nikolaidis
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, United States
| | - Neha Gautam
- Department of Neurobiology, University of California Davis, Davis, California, United States
| | - Nicholas J Fiani
- Medical School, University of Medicine and Health Sciences, New York, United States
| | - Ryne Jenkins
- College of Osteopathic Medicine, Western University of Health Sciences, Pomona, California, United States
| | - Alexander Rose
- School of Medicine, University of New Mexico, Albuquerque, New Mexico, United States
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12
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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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13
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Alexander MD, Halbach VV, Hetts SW. "And do no harm": Complications in interventional neuroradiology. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:395-399. [PMID: 33272407 DOI: 10.1016/b978-0-444-64034-5.00021-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Complications are an unfortunate reality in the field of interventional neuroradiology. While complications cannot be eliminated entirely, their occurrence and severity can be mitigated by the competency achieved through training, knowledge of cerebrovascular anatomy and pathology, and well-conceived and executed plans crafted in conjunction with a multidisciplinary team. Frequent communication among the team throughout the entire process of care is vital. In the ensuing chapter, an overview is provided of the most common complication types-nontarget embolization and hemorrhage-followed by practical considerations for their management. Finally, the chapter concludes with a brief consideration of the emotional management for the patient, their loved ones, and the involved practitioners.
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Affiliation(s)
- Matthew D Alexander
- Departments of Radiology and Imaging Sciences, and Neurosurgery, University of Utah, Salt Lake City, UT, United States
| | - Van V Halbach
- Departments of Radiology and Biomedical Imaging, Neurological Surgery, Neurology, and Anesthesia and Perioperative Care, University of California San Francisco, School of Medicine, San Francisco, CA, United States
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States.
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14
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Youn SW, Lee J. From 2D to 4D Phase-Contrast MRI in the Neurovascular System: Will It Be a Quantum Jump or a Fancy Decoration? J Magn Reson Imaging 2020; 55:347-372. [PMID: 33236488 DOI: 10.1002/jmri.27430] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/16/2022] Open
Abstract
Considering the crosstalk between the flow and vessel wall, hemodynamic assessment of the neurovascular system may offer a well-integrated solution for both diagnosis and management by adding prognostic significance to the standard CT/MR angiography. 4D flow MRI or time-resolved 3D velocity-encoded phase-contrast MRI has long been promising for the hemodynamic evaluation of the great vessels, but challenged in clinical studies for assessing intracranial vessels with small diameter due to long scan times and low spatiotemporal resolution. Current accelerated MRI techniques, including parallel imaging with compressed sensing and radial k-space undersampling acquisitions, have decreased scan times dramatically while preserving spatial resolution. 4D flow MRI visualized and measured 3D complex flow of neurovascular diseases such as aneurysm, arteriovenous shunts, and atherosclerotic stenosis using parameters including flow volume, velocity vector, pressure gradients, and wall shear stress. In addition to the noninvasiveness of the phase contrast technique and retrospective flow measurement through the wanted windows of the analysis plane, 4D flow MRI has shown several advantages over Doppler ultrasound or computational fluid dynamics. The evaluation of the flow status and vessel wall can be performed simultaneously in the same imaging modality. This article is an overview of the recent advances in neurovascular 4D flow MRI techniques and their potential clinical applications in neurovascular disease. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY STAGE: 3.
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Affiliation(s)
- Sung Won Youn
- Department of Radiology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jongmin Lee
- Department of Radiology and Biomedical Engineering, Kyungpook National University School of Medicine, Daegu, Korea
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15
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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 2020; 133:1417-1427. [PMID: 31518979 DOI: 10.3171/2019.5.jns183204] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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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16
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De Sousa JMB, Iosif C, Sganzerla LZ, Rafie AN, Borodetsky V, Rouchaud A, Saleme S, Mounayer C. Selection of Patients for Treatment of Brain Arteriovenous Malformations by the Transvenous Approach: Relationship with Venous Anatomy and Risk of Hemorrhagic Complications. AJNR Am J Neuroradiol 2020; 41:2311-2316. [PMID: 33122201 DOI: 10.3174/ajnr.a6810] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/04/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intracranial hemorrhage represents a severe complication of brain arteriovenous malformation treatment. The aim of this cohort was to report the rate of hemorrhagic complications after transvenous endovascular embolization and analyze the potential angioarchitectural risk factors as well as clinical outcomes. MATERIALS AND METHODS During an 11-year period, 57 patients underwent transvenous endovascular embolization. All cases of hemorrhagic complications were identified. We analyzed the following variables: sex, age, hemorrhagic presentation, Spetzler-Martin grade, size of the AVM before the transvenous treatment, number of venous collectors, pattern of drainage, presence of dilated veins, and technical aspects. Univariate and multivariate multiple regression analyses were performed to evaluate the potential risk factors for procedure-related hemorrhagic complications. RESULTS Hemorrhagic complications (either intraprocedural or periprocedural) unrelated to a perforation due to micronavigation occurred in 8 (14.0%) procedures. Significant (mRS > 2) and persistent neurologic deficits were present in 2 (3.5%) patients at 6-month control. Larger nidi, especially >3 cm (P = .03), and a larger number of venous collectors have shown a statistically significant correlation with hemorrhagic complications. Only the number of venous collectors was identified as an independent predictor of hemorrhagic complications in the multivariate analysis (OR, 8.7; 95% confidence interval, 2.2-58.2) (P = .006). CONCLUSIONS Larger nidus sizes and an increased number of venous collectors may increase the risk of hemorrhagic complications when implementing transvenous endovascular treatment of AVMs. The technique is effective and promising, especially with small nidi and single venous collectors.
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Affiliation(s)
- J M B De Sousa
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - C Iosif
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - L Z Sganzerla
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - A N Rafie
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - V Borodetsky
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - A Rouchaud
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - S Saleme
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - C Mounayer
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
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17
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Hung YC, Mohammed N, Eluvathingal Muttikkal TJ, Kearns KN, Li CE, Narayan A, Schlesinger D, Xu Z, Sheehan JP. The impact of preradiosurgery embolization on intracranial arteriovenous malformations: a matched cohort analysis based on de novo lesion volume. J Neurosurg 2020; 133:1156-1167. [PMID: 31470409 DOI: 10.3171/2019.5.jns19722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The benefits and risks of pre-stereotactic radiosurgery (SRS) embolization have been reported in different studies. The goal of this study was to compare the long-term outcome of arteriovenous malformations (AVMs) treated with and without pre-SRS embolization. METHODS A database including 1159 patients with AVMs who underwent SRS was reviewed. The embolized group was selected by including AVMs with pre-SRS embolization, maximal diameter > 30 mm, and estimated volume > 8 ml. The nonembolized group was defined as AVMs treated by SRS alone with matched de novo nidus volume. Outcomes including incidences of favorable clinical outcome (obliteration without hemorrhage, cyst formation, worsening, or new seizures), obliteration, adverse effects, and angioarchitectural complexity were evaluated. RESULTS The study cohort comprised 17 patients in the embolized group (median AVM volume 17.0 ml) and 35 patients in the nonembolized group (median AVM volume 13.1 ml). The rates of obliteration (embolized cohort: 33%, 44%, and 56%; nonembolized cohort: 32%, 47%, and 47% at 4, 6, and 10 years, respectively) and favorable outcome were comparable between the 2 groups. However, the embolized group had a significantly higher incidence of repeat SRS (41% vs 23%, p = 0.012) and total procedures (median number of procedures 4 vs 1, p < 0.001), even with a significantly higher margin dose delivered at the first SRS (23 Gy vs 17 Gy, p < 0.001). The median angioarchitectural complexity score was reduced from 7 to 5 after embolization. Collateral flow and neovascularization were more frequently observed in the embolized nonobliterated AVMs. CONCLUSIONS Both embolization plus SRS and SRS alone were effective therapies for moderately large (8-39 ml) AVMs. Even with a significantly higher prescription dose at the time of initial SRS, the embolized group still required more procedures to reach final obliteration. The presence of collateral flow and neovascularization could be risk factors for a failure to obliterate following treatment.
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Affiliation(s)
- Yi-Chieh Hung
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
- 2Division of Neurosurgery, Department of Surgery, Chi-Mei Medical Center, Tainan, Taiwan
- 3Department of Recreation and Healthcare Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan; and
| | - Nasser Mohammed
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | - Kathryn N Kearns
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Chelsea Eileen Li
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Aditya Narayan
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - David Schlesinger
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Zhiyuan Xu
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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18
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Shellikeri S, Bai H, Setser RM, Hurst RW, Cahill AM. Association of intracranial arteriovenous malformation embolization with more rapid rate of perfusion in the peri-nidal region on color-coded quantitative digital subtraction angiography. J Neurointerv Surg 2020; 12:902-905. [PMID: 32188762 DOI: 10.1136/neurintsurg-2019-015776] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/11/2020] [Accepted: 02/15/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Hemodynamic alterations post-embolization of intracranial arteriovenous malformations (AVMs) may cause delayed edema/hemorrhage in brain parenchyma adjacent to the lesion. OBJECTIVE To quantify and compare cerebral perfusion changes in the peri-AVM territory pre- and post-embolization using color-coded quantitative digital subtraction angiography (q-DSA). METHODS Pediatric intracranial AVM embolization procedures performed over a 5 year period were included. DSA images of all patients were retrospectively assessed using syngo iFlow. Regions of interest (ROI) were selected on anteroposterior and lateral q-DSA views: three in the peri-AVM region; two in parenchyma distant from the AVM. Time-to-peak (TTP) contrast enhancement of ROIs and ∆TTP (TTP at the selected ROI minus TTP at either the ipsilateral internal carotid/vertebral artery) were measured. RESULT 19 pediatric patients with 19 AVMs (9 males/10 females, mean age 12 years) underwent intracranial AVM embolization: 15/19 AVMs were supplied by the anterior circulation and 4/19 by the posterior circulation. Blood flow was significantly slower post-embolization in the draining vein (19/19) (p<0.01), and the venous sinus outflow (17/19) (p<0.01), by mean difference of 2.01±1.31 s and 1.74±2.04 s. There was significantly increased peri-AVM parenchymal perfusion post-embolization (∆TTP=2.20±0.48 s) compared with pre-embolization (∆TTP=2.52±0.42 s), by an average ∆TTP of 0.33±0.53 s (p=0.014). In contrast, there was no perfusion difference (∆TTP=0.03±0.20 s, p=0.8) between pre- and post-embolization in the distant parenchyma. The size of the AVM was not correlated with change in peri-nidal parenchymal perfusion (r=-0.136, p=0.579). CONCLUSION This study demonstrates more rapid perfusion in the peri-nidal brain parenchyma post-embolization of the AVM, which supports the theory that increased perfusion in normal tissue surrounding the AVM after embolization may underlie some post-procedural complications.
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Affiliation(s)
- Sphoorti Shellikeri
- Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Harrison Bai
- Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | - Robert W Hurst
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne Marie Cahill
- Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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19
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Qureshi AI, Saeed O, Sahito S, Lobanova I, Liaqat J, Siddiq F, Gomez CR. Treatment Outcomes of Endovascular Embolization Only in Patients with Unruptured Brain Arteriovenous Malformations: A Subgroup Analysis of ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations). AJNR Am J Neuroradiol 2020; 41:676-680. [PMID: 32115419 DOI: 10.3174/ajnr.a6443] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 01/20/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular embolization only has been advocated for treatment of brain arteriovenous malformations in recent trials. Our aim was to evaluate the results of embolization only in a cohort of patients who were enrolled in the A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) study at 39 clinical sites in 9 countries. MATERIALS AND METHODS We analyzed the rates and severity of stroke and death in patients who underwent embolization only. Events were identified through in-person neurologic follow-up visits performed at 6-month intervals during the first 2 years and annually, with telephone contact every 6 months thereafter. All event-related data were reviewed by independent adjudicators. RESULTS Among 30 patients who had embolization planned, 26 underwent embolization only. A total of 13 stroke events were reported in the follow-up period among 26 subjects (ischemic, hemorrhagic, or both in 4, 7, and 2 subjects, respectively). The adverse event occurred after the first embolization in 11 of 13 patients. One patient had a major motor deficit, and 2 patients developed major visual field deficits. One event was fatal. The modified Rankin Scale score was 0-2 at last follow-up in 11 of the 12 stroke survivors. Estimated stroke-free survival was 46% at 12 months. CONCLUSIONS Although the rates of stroke and/or death were high in patients treated with embolization only in ARUBA, the rates of favorable outcomes following stroke were high during follow-up.
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Affiliation(s)
- A I Qureshi
- From the Zeenat Qureshi Stroke Institute (A.I.Q., O.S., S.S., I.L., J.L.), St. Cloud, Minnesota .,Department of Neurology (A.I.Q., C.R.G.) and
| | - O Saeed
- From the Zeenat Qureshi Stroke Institute (A.I.Q., O.S., S.S., I.L., J.L.), St. Cloud, Minnesota.,Department of Neurology (O.S.), University of Tennessee Health Science Center, Memphis, Tennessee
| | - S Sahito
- From the Zeenat Qureshi Stroke Institute (A.I.Q., O.S., S.S., I.L., J.L.), St. Cloud, Minnesota.,Department of Neurology (S.S.), JFK Medical Center, Edison, New Jersey
| | - I Lobanova
- From the Zeenat Qureshi Stroke Institute (A.I.Q., O.S., S.S., I.L., J.L.), St. Cloud, Minnesota
| | - J Liaqat
- From the Zeenat Qureshi Stroke Institute (A.I.Q., O.S., S.S., I.L., J.L.), St. Cloud, Minnesota.,Pakistan Emirates Military Hospital (J.L.), Rawalpindi, Pakistan
| | - F Siddiq
- Division of Neurological Surgery (F.S.), University of Missouri, Colombia, Missouri
| | - C R Gomez
- Department of Neurology (A.I.Q., C.R.G.) and
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20
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Dahl RH, Holtmannspötter M, Gutte H, Cortsen M, Hauerberg J, Benndorf G. Snaring of a Glued Microcatheter During Embolization of an Arteriovenous Malformation with N-Butyl Cyanoacrylate. World Neurosurg 2018; 120:343-348. [DOI: 10.1016/j.wneu.2018.08.120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/15/2018] [Accepted: 08/16/2018] [Indexed: 11/16/2022]
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21
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Franzin A, Panni P, Spatola G, Del Vecchio A, Gallotti AL, Gigliotti CR, Cavalli A, Donofrio CA, Mortini P. Results of volume-staged fractionated Gamma Knife radiosurgery for large complex arteriovenous malformations: obliteration rates and clinical outcomes of an evolving treatment paradigm. J Neurosurg 2018; 125:104-113. [PMID: 27903180 DOI: 10.3171/2016.7.gks161549] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There are few reported series regarding volume-staged Gamma Knife radiosurgery (GKRS) for the treatment of large, complex, cerebral arteriovenous malformations (AVMs). The object of this study was to report the results of using volume-staged Gamma Knife radiosurgery for patients affected by large and complex AVMs. METHODS Data from 20 patients with large AVMs were prospectively included in the authors' AVM database between 2004 and 2012. A staging strategy was used when treating lesion volumes larger than 10 cm3. Hemorrhage and seizures were the presenting clinical feature for 6 (30%) and 8 (40%) patients, respectively. The median AVM volume was 15.9 cm3 (range 10.1-34.3 cm3). The mean interval between stages (± standard deviation) was 15 months (± 9 months). The median margin dose for each stage was 20 Gy (range 18-25 Gy). RESULTS Obliteration was confirmed in 8 (42%) patients after a mean follow-up of 45 months (range 19-87 months). A significant reduction (> 75%) of the original nidal volume was achieved in 4 (20%) patients. Engel Class I-II seizure status was reported by 75% of patients presenting with seizures (50% Engel Class I and 25% Engel Class II) after radiosurgery. After radiosurgery, 71.5% (5/7) of patients who had presented with a worsening neurological deficit reported a complete resolution or amelioration. None of the patients who presented acutely because of hemorrhage experienced a new bleeding episode during follow-up. One (5%) patient developed radionecrosis that caused sensorimotor hemisyndrome. Two (10%) patients sustained a bleeding episode after GKRS, although only 1 (5%) was symptomatic. High nidal flow rate and a time interval between stages of less than 11.7 months were factors significantly associated with AVM obliteration (p = 0.021 and p = 0.041, respectively). Patient age younger than 44 years was significantly associated with a greater than 75% reduction in AVM volume but not with AVM obliteration (p = 0.024). CONCLUSIONS According to the results of this study, volume-staged GKRS is an effective and safe treatment strategy for large, complex, cerebral AVMs for which microsurgery or endovascular approaches could carry substantially higher risks to the patient. Radiation doses up to 20 Gy can be safely administered. The time interval between stages should be shorter than 11.7 months to increase the chance of obliteration. High nidal flow and a patient age younger than 44 years were factors associated with nidus obliteration and significant nidus reduction, respectively.
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Affiliation(s)
| | - Pietro Panni
- Departments of 1 Neurosurgery and Radiosurgery, and
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Onyx Embolization Before the Surgical Treatment of Grade III Spetzler-Martin Brain Arteriovenous Malformations: Single-Center Experience and Technical Nuances. World Neurosurg 2018; 116:e340-e353. [DOI: 10.1016/j.wneu.2018.04.203] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 04/26/2018] [Accepted: 04/27/2018] [Indexed: 11/15/2022]
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Modern radiosurgical and endovascular classification schemes for brain arteriovenous malformations. Neurosurg Rev 2018; 43:49-58. [PMID: 29728873 DOI: 10.1007/s10143-018-0983-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/22/2018] [Accepted: 04/25/2018] [Indexed: 10/17/2022]
Abstract
Stereotactic radiosurgery (SRS) and endovascular techniques are commonly used for treating brain arteriovenous malformations (bAVMs). They are usually used as ancillary techniques to microsurgery but may also be used as solitary treatment options. Careful patient selection requires a clear estimate of the treatment efficacy and complication rates for the individual patient. As such, classification schemes are an essential part of patient selection paradigm for each treatment modality. While the Spetzler-Martin grading system and its subsequent modifications are commonly used for microsurgical outcome prediction for bAVMs, the same system(s) may not be easily applicable to SRS and endovascular therapy. Several radiosurgical- and endovascular-based grading scales have been proposed for bAVMs. However, a comprehensive review of these systems including a discussion on their relative advantages and disadvantages is missing. This paper is dedicated to modern classification schemes designed for SRS and endovascular techniques.
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Orlov K, Panarin V, Krivoshapkin A, Kislitsin D, Berestov V, Shayakhmetov T, Gorbatykh A. Assessment of periprocedural hemodynamic changes in arteriovenous malformation vessels by endovascular dual-sensor guidewire. Interv Neuroradiol 2018; 21:101-7. [PMID: 25934783 DOI: 10.15274/inr-2014-10096] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Endovascular embolization is an important modality in the treatment of brain AVMs. Nowadays staged embolization is the method of choice for the prevention of perioperative hemorrhagic complications. Current theory suggests that simultaneous occlusion of more than 60% of AVM volume induces significant redistribution local blood flow. That, in turn, may lead to hemorrhage due to AVM rupture. Aside from angiographic findings, there is still no method that predicts the degree of safe partial embolization. Intraluminal measurement of flow velocity and pressure in the vicinity of the AVM nidus might allow detecting the changes in local hemodynamics. That can provide a valuable data and shed the light on the origin of vascular catastrophes. Ten patients underwent 12 embolization sessions with intraluminal flow velocity and pressure monitoring. The measurements were performed by dual-sensor guidewire. The "Combomap" (Volcano) system with Combowire microguidewires was chosen for measurements, as there is a documented experience of safe use of said guidewires in the cerebral vasculature. The findings observed during the study matched empirical data as well as the current physiological hypothesis of AVM hemorrhage. In conjunction with DSA runs, intraluminal flow velocity and pressure monitoring has the potential to become a valuable tool in AVM treatment.
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Affiliation(s)
- Kirill Orlov
- Department of Neurosurgery, Novosibirsk Research Institution of Circulation Pathology, Novosibirsk, Russia
| | - Vyacheslav Panarin
- Department of Neurosurgery, Novosibirsk Research Institution of Circulation Pathology, Novosibirsk, Russia
| | - Alexey Krivoshapkin
- Department of Neurosurgery, Novosibirsk Research Institution of Circulation Pathology, Novosibirsk, Russia
| | - Dmitry Kislitsin
- Department of Neurosurgery, Novosibirsk Research Institution of Circulation Pathology, Novosibirsk, Russia
| | - Vadim Berestov
- Department of Neurosurgery, Novosibirsk Research Institution of Circulation Pathology, Novosibirsk, Russia
| | - Timur Shayakhmetov
- Department of Neurosurgery, Novosibirsk Research Institution of Circulation Pathology, Novosibirsk, Russia
| | - Anton Gorbatykh
- Department of Neurosurgery, Novosibirsk Research Institution of Circulation Pathology, Novosibirsk, Russia
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Kocaman U, Dalbasti T, Yildirim UM, Yilmaz H. The 'radical combined approach' in cerebral arteriovenous malformation treatment: Technical note. Neurol Neurochir Pol 2017; 51:465-470. [PMID: 28830640 DOI: 10.1016/j.pjnns.2017.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 05/11/2017] [Accepted: 08/03/2017] [Indexed: 10/19/2022]
Abstract
AVMs are vessel anomalies where a connection between arterial and venous systems is present and the capillary bed is absent between the two. AVMs tend to present with seizures, headaches, focal neurological deficits and hemorrhage. Hemorrhage is the most common form of presentation. AVM's have a 2-4% annual risk of hemorrhage. Certain studies report this rate as 1%. The greatest discussion in AVM treatment is whether to use interventional treatment or monitor with medical treatment. There are 3 modalities that can be used for interventional treatment; microsurgical resection, endovascular embolization and stereotactic radiosurgery. Combined techniques are also possible. We defined the 'radical combined approach' combines embolization and microsurgery. We will discuss this procedure in this article as we believe it has several advantages.
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Affiliation(s)
- Umit Kocaman
- Izmir Cigli Education and Research Hospital, Department of Neurosurgery, Izmir, Turkey
| | - Tayfun Dalbasti
- Ege University Faculty of Medicine, Department of Neurosurgery, Izmir, Turkey
| | - Utku Mahir Yildirim
- University of Izmir of Medicine, Department of Interventional Radiology, Izmir, Turkey
| | - Hakan Yilmaz
- Usak State Hospital, Department of Neurosurgery, Usak, Turkey.
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Comparison of Grading Scales Regarding Perioperative Complications and Clinical Outcomes of Brain Arteriovenous Malformations After Endovascular Therapy-Multicenter Study. World Neurosurg 2017; 106:394-401. [PMID: 28712909 DOI: 10.1016/j.wneu.2017.07.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/04/2017] [Accepted: 07/06/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Several scales have been proposed for risk assessment and outcome determination in brain arteriovenous malformations treated by endovascular therapy. We aim to validate and compare the efficacy of these scales in predicting perioperative complications and clinical outcomes. METHODS We retrospectively reviewed brain arteriovenous malformations patients who underwent endovascular therapy at 4 centers in China from January 2012 to December 2015. The primary outcomes were complications, unfavorable outcome (mRS ≥ 3), and complete obliteration. Each patient was assessed using the Spetzler-Martin grading system (SM), Puerto Rico scale, Buffalo score, and arteriovenous malformation embocure score (AVMES). Correlation analysis was performed between primary outcomes incidence rate and the grades of each scale. The area under the receiver operating characteristic curve of these scales was calculated. Pairwise comparison of receiver operating characteristic curves was performed to compare the efficacy of the scales. RESULTS A total of 270 patients were included. Correlation analysis demonstrated that the complication rate increased with increasing grade in SM (P = 0.002), Puerto Rico scale (P = 0.014), and Buffalo score (P = 0.001); complete obliteration rate decreased with increasing grade in AVMES (P = 0.017); unfavorable outcome rate increased with increasing grade in the Puerto Rico scale (P = 0.005). The area under the receiver operating characteristic curve analysis showed statistical differences between the Puerto Rico score and SM (P = 0.047) in predicting complications and between the Puerto Rico score and SM (P = 0.008) in predicting unfavorable outcomes. The area under the curve of the AVMES in predicting complete obliteration was 0.757. CONCLUSIONS The Puerto Rico score predicts complications and unfavorable outcomes better than the SM. The AVMES scale has medium efficacy in predicting complete obliteration.
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Robert T, Blanc R, Sylvestre P, Ciccio G, Smajda S, Botta D, Redjem H, Fahed R, Piotin M. A proposed grading system to evaluate the endovascular curability of deep-seated arteriovenous malformations. J Neurol Sci 2017; 377:212-218. [PMID: 28477698 DOI: 10.1016/j.jns.2017.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 03/14/2017] [Accepted: 04/11/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Aggressive treatment of deep-seated AVMs is paramount because of their high tendency to bleed (or to re-bleed). In the literature concerning endovascular therapy, AVMs of the basal ganglia, the semi-ovale center and the midbrain are always considered as a single entity. In this study, the authors address the anatomical classification of these AVMs and propose a classification that considers factors influencing their endovascular curability. METHODS From 1995 to 2013, clinical and angiographic data of cerebral AVMs were prospectively collected. We reviewed data from patients treated for a deep-seated AVM with the goal to distinguish factors that influence the curability and the outcome of these AVMs. RESULTS 134 patients (mean age: 28years) were consecutively treated by endovascular techniques. We describe an anatomical classification concerning the exact location of the nidus and distinguish 5 different sub-types (anterior, lateral, medial, posterior and midbrain). Then, we propose a grading system based on statistical analysis of our series to evaluate the curability of a deep AVM. This comprehensive score is calculated with the Spetzler-Martin grade, the location of the nidus, its type, arterial feeders and venous drainage. CONCLUSIONS Deep-seated AVMs may be classified according to their exact location; we can distinguish 5 different sub-types (anterior, lateral, medial, posterior and midbrain). Each group presented different arterial supplies and venous drainage that influenced treatment possibilities. The comprehensive grading system that we propose in this study must be tested in another deep-seated AVMs population.
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Affiliation(s)
- Th Robert
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France.
| | - R Blanc
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - P Sylvestre
- University of Montreal, Montreal, Quebec, Canada
| | - G Ciccio
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - S Smajda
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - D Botta
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - H Redjem
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - R Fahed
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - M Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
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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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Target Embolization of Associated Aneurysms in Ruptured Arteriovenous Malformations. World Neurosurg 2017; 101:26-32. [PMID: 28153612 DOI: 10.1016/j.wneu.2017.01.081] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/17/2017] [Accepted: 01/19/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The purpose of this study was to examine the safety and efficacy of target embolization of aneurysms associated with ruptured brain arteriovenous malformations (BAVMs). METHODS Ruptured BAVM patients who underwent endovascular treatment at our institution from January 2011 to December 2015 were retrospectively reviewed. Patients were divided into aneurysm (AN) and nonaneurysm (non-AN) groups on the basis of the existence of BAVM-associated aneurysms or not. Demographics, angiographic characteristics, complications, and clinical outcomes were compared between 2 groups. Complication risk factors were analyzed for all objects. Patient outcomes were assessed with modified Rankin Scale (mRS). RESULTS A total of 129 (male = 53) patients were included. In 31 (24.0%) patients, 33 aneurysms were observed, including 16 intranidal and 17 flow-related aneurysms. Of the 166 sessions of embolization performed, there were 13 (10.1% of patients, 7.8% per session) complications in all, including 2 hemorrhagic, 8 transient ischemic, and 3 permanent ischemic types. There was no statistical difference in terms of complication incidence rate between groups. A total of 12 patients (9.3% of patients, 3.3% per person-year) experienced postoperative hemorrhage during follow-up (mean = 3.4 years). The yearly postoperative hemorrhage incidence rate was 3.4% in the non-AN group and 2.0% in AN group. Excellent or good outcomes (mRS ≤ 2) were observed in 103 (91.2%) patients. Unfavorable outcomes (mRS ≥ 3) as a direct result of embolization remained in no patients. CONCLUSIONS Target embolization of aneurysms associated with ruptured BAVMs could significantly decrease postoperative rehemorrhage without increasing complications.
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Primary Hemorrhagic Neurovascular Diseases in Tibetans: A Retrospective Observational Study. World Neurosurg 2016; 96:423-428. [DOI: 10.1016/j.wneu.2016.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/05/2016] [Accepted: 09/06/2016] [Indexed: 11/18/2022]
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Elkordy A, Endo H, Sato K, Matsumoto Y, Kondo R, Niizuma K, Endo T, Fujimura M, Tominaga T. Embolization of the choroidal artery in the treatment of cerebral arteriovenous malformations. J Neurosurg 2016; 126:1114-1122. [PMID: 27153173 DOI: 10.3171/2016.2.jns152370] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The anterior and posterior choroidal arteries are often recruited to supply arteriovenous malformations (AVMs) involving important paraventricular structures, such as the basal ganglia, internal capsule, optic radiation, lateral geniculate body, and medial temporal lobe. Endovascular embolization through these arteries is theoretically dangerous because they supply eloquent territories, are of small caliber, and lack collaterals. This study aimed to investigate the safety and efficacy of embolization through these arteries. METHODS This study retrospectively reviewed 13 patients with cerebral AVMs who underwent endovascular embolization through the choroidal arteries between 2006 and 2014. Embolization was performed as a palliative procedure before open surgery or Gamma Knife radiosurgery. Computed tomography and MRI were performed the day after embolization to assess any surgical complications. The incidence and type of complications and their association with clinical outcomes were analyzed. RESULTS Decreased blood flow was achieved in all patients after embolization. Postoperative CT detected no hemorrhagic complications. In contrast, postoperative MRI detected that 4 of the 13 patients (30.7%) developed infarctions: 3 patients after embolization through the anterior choroidal artery, and 1 patient after embolization through the lateral posterior choroidal artery. Two of the 4 patients in whom embolization was from the cisternal segment of the anterior choroidal artery (proximal to the plexal point) developed symptomatic infarction of the posterior limb of the internal capsule, 1 of whom developed morbidity (7.7%). The treatment-related mortality rate was 0%. Additional treatment was performed in 12 patients: open surgery in 9 and Gamma Knife radiosurgery in 3 patients. Complete obliteration was confirmed by angiography at the last follow-up in 10 patients. Recurrent bleeding from the AVMs did not occur in any of the cases during the follow-up period. CONCLUSIONS Ischemic complications are possible following the embolization of cerebral AVMs through the choroidal artery, even with modern neurointerventional devices and techniques. Although further study is needed, embolization through the choroidal artery may be an appropriate treatment option when the risk of surgery or radiosurgery is considered to outweigh the risk of embolization.
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Affiliation(s)
- Alaa Elkordy
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai;,Neuroendovascular Section, Department of Neurology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Kenichi Sato
- Neuroendovascular Therapy, Kohnan Hospital, Sendai
| | | | - Ryushi Kondo
- Department of Neurosurgery, Kitasato University School of Medicine, Sagamihara, Japan; and
| | - Kuniyasu Niizuma
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai
| | | | - Miki Fujimura
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai
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Oermann EK, Ding D, Yen CP, Starke RM, Bederson JB, Kondziolka D, Sheehan JP. Effect of Prior Embolization on Cerebral Arteriovenous Malformation Radiosurgery Outcomes: A Case-Control Study. Neurosurgery 2016; 77:406-17; discussion 417. [PMID: 25875580 DOI: 10.1227/neu.0000000000000772] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Embolization before stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations (AVM) has been shown to negatively affect obliteration rates, but its impact on the risks of radiosurgery-induced complications and latency period hemorrhage is poorly defined. OBJECTIVE To determine, in a case-control study, the effect of prior embolization on AVM SRS outcomes. METHODS We evaluated a database of AVM patients who underwent SRS. Propensity score analysis was used to match the case (embolized nidi) and control (nonembolized nidi) cohorts. AVM angioarchitectural complexity was defined as the sum of the number of major feeding arteries and draining veins to the nidus. Multivariate Cox proportional hazards regression analyses were performed on the overall study population to determine independent predictors of obliteration and radiation-induced changes. RESULTS The matching process yielded 242 patients in each cohort. The actuarial obliteration rates were significantly lower in the embolized (31%, 49% at 5, 10 years, respectively) compared with the nonembolized (48%, 64% at 5, 10 years, respectively) cohort (P = .003). In the multivariate analysis for obliteration, lower angioarchitectural complexity (P < .001) and radiologically evident radiation-induced changes (P = .016) were independent predictors, but embolization was not significant (P = .744). In the multivariate analysis for radiologic radiation-induced changes, lack of prior embolization (P = .009) and fewer draining veins (P = .011) were independent predictors. CONCLUSION The effect of prior embolization on AVM obliteration after SRS may be significantly confounded by nidus angioarchitectural complexity. Additionally, embolization could reduce the risk of radiation-induced changes. Thus, combined embolization and SRS may be warranted for appropriately selected nidi.
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Affiliation(s)
- Eric K Oermann
- *Mount Sinai Health System, Department of Neurosurgery, New York City, New York; ‡University of Virginia, Department of Neurosurgery, Charlottesville, Virginia; §New York University Langone Medical Center, Department of Neurosurgery, New York City, New York
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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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Abstract
In this case report, we discuss the microsurgical management of a Spetzler-Martin grade 5 arteriovenous malformation (AVM) in a young boy who presented with a hemorrhagic episode and had a high calculated risk of rebleeding. We also outline the rationale for choosing the management option.
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Affiliation(s)
- Sunil Munakomi
- College of Medical Sciences, Bharatpur, Chitwan, 44207, Nepal
| | - Binod Bhattarai
- College of Medical Sciences, Bharatpur, Chitwan, 44207, Nepal
| | - Iype Cherian
- College of Medical Sciences, Bharatpur, Chitwan, 44207, Nepal
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Lin N, Smith ER, Scott RM, Orbach DB. Safety of neuroangiography and embolization in children: complication analysis of 697 consecutive procedures in 394 patients. J Neurosurg Pediatr 2015; 16:432-8. [PMID: 26114994 DOI: 10.3171/2015.2.peds14431] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The safe treatment of children using catheter-based angiography and embolization poses unique challenges because of the technical factors regarding the size and fragility of access and target vessels, as well as unique pediatric cerebrovascular pathologies. The complication rates for neurointerventional procedures in children have not been established. METHODS The records of a consecutive cohort of pediatric patients who underwent neuroangiography and/or embolization between 2007 and 2013 were reviewed retrospectively to identify both intraprocedural and postprocedural complications. Demographic and clinical risk factors were analyzed with a multivariate logistic regression model. RESULTS The 697 consecutive procedures consisted of 429 diagnostic angiograms and 268 embolizations (mean age of patients 11.1 years; range 4 days to 18 years; 217 females). There were 130 intracranial, 122 extracranial, and 16 spinal embolizations. Pathologies included 28 intracranial arteriovenous malformations (AVMs), 12 spinal AVMs, 19 aneurysms, 29 vein of Galen malformations, 29 dural arteriovenous fistulas, 96 extracranial AVMs, 39 tumors, 3 strokes, and 13 others. Overall, 2 intraprocedural and 1 postprocedural complication (0.7%) occurred in the diagnostic group, all of which were nonneurological events. In the embolization group, 7 intraprocedural and 11 postprocedural complications (6.7%) were observed. Of these complications, 15 were nonneurological events (5.6%), 1 was a short-term neurological event (0.4%), and 2 were long-term neurological events (0.7%). CONCLUSIONS Neither the technical challenges posed by children's access and target vessels nor the unique neuro-vascular pathologies seen in children need result in an elevated morbidity rate related to neuroangiography and embolization. At a dedicated high-volume center, the complication rates may be lower than those for comparable procedures performed in adults.
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Affiliation(s)
- Ning Lin
- Department of Neurosurgery, Weill Cornell Medical Center, New York, New York; and.,Department of Neurosurgery and
| | | | | | - Darren B Orbach
- Division of Interventional and Neurointerventional Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Pines A, Aoun RJN, Halasa TK, Sattur M, Zammar SG, Bendok BR. Toward Individualized Neurosurgery: Quantifying Arteriovenous Malformation Embolization with Magnetic Resonance Angiography. World Neurosurg 2015; 84:1184-5. [PMID: 26375329 DOI: 10.1016/j.wneu.2015.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrew Pines
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Rami James N Aoun
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Tariq K Halasa
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Mithun Sattur
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Samer G Zammar
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
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Reynolds MR, Arias EJ, Chatterjee AR, Chicoine MR, Cross DT. Acute rupture of a feeding artery aneurysm after embolization of a brain arteriovenous malformation. Interv Neuroradiol 2015; 21:613-9. [PMID: 26126431 DOI: 10.1177/1591019915591740] [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] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Staged endovascular embolization of large arteriovenous malformations (AVMs) is frequently performed to gradually reduce flow and prevent abrupt hemodynamic changes. While feeding artery aneurysms have been associated with increased risk of hemorrhage in the setting of AVMs, decisions regarding if and when to treat these aneurysms vary. Acute, fatal rupture of a feeding artery aneurysm following embolization of a large, unruptured AVM has been infrequently reported in the literature. CASE DESCRIPTION A 69-year-old female presented with headache and mild left hemiparesis referable to a 5 cm right fronto-parieto-temporal AVM with surrounding vasogenic edema. The AVM was associated with numerous bilateral feeding artery aneurysms (the largest was a 2 cm right middle cerebral artery (MCA) bifurcation aneurysm). There was also a large, partially thrombosed venous varix. Staged embolization of the AVM was performed. Several hours after the third stage of her embolization, she became obtunded, with a fixed and dilated right pupil. Head computed tomography (CT) showed a large intraparenchymal hemorrhage with midline shift in the right sylvian fissure, remote from the AVM nidus. She was taken to surgery for a decompressive craniectomy and hematoma evacuation. The MCA aneurysm was confirmed to be the source of hemorrhage and it was clipped. Despite aggressive medical and surgical treatments, the patient died. CONCLUSIONS An increase in AVM feeding artery pressure following endovascular embolization may contribute to the rupture of a feeding artery aneurysm. For this reason, treatment of large arterial aneurysms on feeding pedicles should be considered prior to embolization of the AVM nidus.
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Affiliation(s)
- Matthew R Reynolds
- Department of Neurological Surgery, Washington University Medical School, USA
| | - Eric J Arias
- Department of Neurological Surgery, Washington University Medical School, USA
| | | | - Michael R Chicoine
- Department of Neurological Surgery, Washington University Medical School, USA
| | - Dewitte T Cross
- Department of Neurological Surgery, Washington University Medical School, USA Department of Radiology, Washington University Medical School, USA
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Bell DL, Leslie-Mazwi TM, Yoo AJ, Rabinov JD, Butler WE, Bell JE, Hirsch JA. Application of a Novel Brain Arteriovenous Malformation Endovascular Grading Scale for Transarterial Embolization. AJNR Am J Neuroradiol 2015; 36:1303-9. [PMID: 25857761 DOI: 10.3174/ajnr.a4286] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 01/02/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The advent of modern neuroendovascular techniques has highlighted the need for a simple, effective, and reliable brain arteriovenous malformation endovascular grading scale. A novel scale of this type has recently been described. It incorporates the number of feeding arteries, eloquence, and the presence of an arteriovenous fistula component. Our aim is to assess the validity of this grading scale. MATERIALS AND METHODS We retrospectively reviewed all suspected brain arteriovenous malformations at Massachusetts General Hospital from 2005 to 2013, identifying 126 patients who met the inclusion criteria. Spearman correlations between endovascular and Spetzler-Martin grading scales and long-term outcomes were performed. Median endovascular grades were compared between treatment modalities and endovascular outcomes. Binary regression analysis was performed with major endovascular complications as a dichotomized dependent variable. Intraclass correlation coefficients were calculated for interobserver reliability of the endovascular grading scale. RESULTS A significant Spearman correlation between the endovascular grade and the Spetzler-Martin grade was demonstrated (ρ = 0.5, P < .01). Differences in the median endovascular grades between the endovascular cure (median = 2) and endovascular complication groups (median = 4) (P < .05) and between the endovascular cure and successful multimodal treatment groups (median = 3) (P < .05) were demonstrated. The endovascular grade was the only independent predictor of complications (OR = 0.5, P < .01). The intraclass correlation coefficient of the endovascular grade was 0.71 (P < .01). CONCLUSIONS Validation of a brain arteriovenous malformation endovascular grading scale demonstrated that endovascular grades of ≤II were associated with endovascular cure, while endovascular grades of ≤III were associated with multimodal cure or significant lesion reduction and favorable outcome. The endovascular grade provides useful information to refine risk stratification for endovascular and multimodal treatment.
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Affiliation(s)
- D L Bell
- From the Department of Radiology, Neuroendovascular Program (D.L.B., A.J.Y., J.D.R., J.A.H.) Harvard Medical School (D.L.B., T.M.L.-M., J.D.R., W.E.B., J.A.H.), Boston, Massachusetts
| | - T M Leslie-Mazwi
- Department of Neurology and Radiology, Neurocritical Care and Neuroendovascular Program (T.M.L.-M.) Harvard Medical School (D.L.B., T.M.L.-M., J.D.R., W.E.B., J.A.H.), Boston, Massachusetts
| | - A J Yoo
- From the Department of Radiology, Neuroendovascular Program (D.L.B., A.J.Y., J.D.R., J.A.H.) Texas Stroke Institute (A.J.Y.), Plano, Texas
| | - J D Rabinov
- From the Department of Radiology, Neuroendovascular Program (D.L.B., A.J.Y., J.D.R., J.A.H.) Harvard Medical School (D.L.B., T.M.L.-M., J.D.R., W.E.B., J.A.H.), Boston, Massachusetts
| | - W E Butler
- Department of Neurosurgery, Vascular Center (W.E.B.), Massachusetts General Hospital, Boston, Massachusetts Harvard Medical School (D.L.B., T.M.L.-M., J.D.R., W.E.B., J.A.H.), Boston, Massachusetts
| | - J E Bell
- From the Department of Radiology, Neuroendovascular Program (D.L.B., A.J.Y., J.D.R., J.A.H.)
| | - J A Hirsch
- From the Department of Radiology, Neuroendovascular Program (D.L.B., A.J.Y., J.D.R., J.A.H.) Harvard Medical School (D.L.B., T.M.L.-M., J.D.R., W.E.B., J.A.H.), Boston, Massachusetts
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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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Iosif C, Mendes GAC, Saleme S, Ponomarjova S, Silveira EP, Caire F, Mounayer C. Endovascular transvenous cure for ruptured brain arteriovenous malformations in complex cases with high Spetzler-Martin grades. J Neurosurg 2015; 122:1229-38. [DOI: 10.3171/2014.9.jns141714] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Ruptured cerebral arteriovenous malformations (AVMs) with deep localization and high Spetzler-Martin grades are associated with considerable challenges regarding nidus eradication treatment. The authors report their experience with curative endovascular transvenous embolization in a series of patients harboring “untreatable” lesions.
METHODS
Between January 2008 and June 2013, a transvenous endovascular embolization protocol was implemented at the authors' institution for consecutive patients with ruptured brain AVMs that were considered incurable by classic endovascular and surgical techniques. Therapeutic decision making was based on Spetzler-Martin grades, AVM location, type of venous drainage, and angioarchitectural evaluation. Complete exclusion of the nidus was the objective of treatment.
RESULTS
Twenty patients (10 male and 10 female, mean age 36.7 ± 17.7 years) were included. Initial Spetzler-Martin grades were III–V for 90.0% of the patients. The lesions were deeply seated in 80% and in eloquent locations in 90% of cases. The preprocedural modified Rankin Scale score was 0–2 for 12 of the 20 patients (60.0%), 3 for 2 patients (10.0%), and 4 for 6 patients (30.0%). The postprocedural clinical status was unchanged for all patients. The procedure was technically feasible in all cases. Procedure-related mortality was 0%. Ninety percent of the patients were independent in their everyday lives (modified Rankin Scale Scores 0–2) at the 6-month follow-up. In all cases but one (95%) the embolization was curative, confirmed by selective DSA at 6 months and 18 months postintervention.
CONCLUSIONS
Single-session endovascular transvenous embolization seems to be a safe and effective curative treatment for patients harboring complex brain AVMs with high Spetzler-Martin grade.
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Affiliation(s)
| | | | | | | | | | - Francois Caire
- 2Neurosurgery, Dupuytren University Hospital, Limoges, France
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Soh HY, Muda AS, Jabar NA, Nordin R, Nabil S, Ramli R. Non-pulsatile traumatic pseudoaneurysm of the internal maxillary artery following trauma to mandible. Oral Maxillofac Surg 2015; 19:423-5. [PMID: 25903486 DOI: 10.1007/s10006-015-0497-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 04/14/2015] [Indexed: 11/25/2022]
Abstract
Traumatic pseudoaneurysm involving the maxillary artery is rare. Owing to its anatomic location, internal maxillary artery is usually protected by its surrounding structures. Formation of pseudoaneurysm usually takes place after several weeks to months of the initial injury. In this case, we reported a pseudoaneurysm arising from left internal maxillary artery following blunt injuries within 3 hours after a road accident and the treatment with endovascular embolization with titanium coils prior to open reduction and internal fixation of the fractured mandibles.
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Affiliation(s)
- Hui Yuh Soh
- Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Ahmad Sobri Muda
- Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Nazimi Abd Jabar
- Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Rifqah Nordin
- Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - S Nabil
- Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Roszalina Ramli
- Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia.
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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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A method for complete angiographic obliteration of a brain arteriovenous malformation in a single session through a single pedicle. J Clin Neurosci 2015; 22:391-5. [PMID: 25439751 DOI: 10.1016/j.jocn.2014.07.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/10/2014] [Accepted: 07/15/2014] [Indexed: 11/22/2022]
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Orlov K, Panarin V, Krivoshapkin A, Kislitsin D, Berestov V, Shayakhmetov T, Gorbatykh A. Assessment of periprocedural hemodynamic changes in arteriovenous malformation vessels by endovascular dual-sensor guidewire. Interv Neuroradiol 2015. [DOI: 10.1177/inr-2014-10096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Dumont TM, Kan P, Snyder KV, Hopkins LN, Siddiqui AH, Levy EI. A proposed grading system for endovascular treatment of cerebral arteriovenous malformations: Buffalo score. Surg Neurol Int 2015; 6:3. [PMID: 25657856 PMCID: PMC4310056 DOI: 10.4103/2152-7806.148847] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 09/05/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The Spetzler-Martin arteriovenous malformation (AVM) grading system has proven to be useful in guiding treatment of cerebral AVMs with craniotomy. It is based on anatomical characteristics each of which makes surgical resection of an AVM more difficult, namely, deep venous drainage, eloquence of surrounding tissue, and large nidus size. A higher score correlates with more complications after treatment. Although this grading system has proven reliable over time, it does not reflect the major determinants of risk associated with endovascular treatment. The authors developed a grading system unique to endovascular treatment of cerebral AVMs. METHODS The proposed grading system accounts for the principal AVM anatomical and physiological features that make endovascular embolization more difficult and, thus, the likelihood of complications greater. These include number of arterial pedicles, diameter of arterial pedicles, and eloquent location of AVM nidus. The proposed grading system was retrospectively applied to 50 patients undergoing endovascular AVM embolization, and its ability to predict complications was compared to the Spetzler-Martin grading system. RESULTS Perioperative complications among the 50 patients included 4 major and 9 minor complications. The proposed grading system was predictive of complication risk, with an increasing rate of perioperative complications associated with an increasing AVM grade. An improved correlation of perioperative complication incidence was noted with the proposed system (P = 0.002), when compared with the Spetzler-Martin grading system (P = 0.33). CONCLUSION This grading system for the endovascular treatment of AVMs is simple, easily reproduced, and clinically valuable.
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Affiliation(s)
- Travis M Dumont
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, State University of New York, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, New York, USA ; Division of Neurosurgery, Department of Surgery, The University of Arizona, Tucson, Arizona, USA
| | - Peter Kan
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, State University of New York, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, New York, USA ; Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, State University of New York, USA ; Department of Neurology, School of Medicine and Biomedical Sciences, State University of New York, USA ; Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA ; Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, New York, USA
| | - L Nelson Hopkins
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, State University of New York, USA ; Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA ; Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, New York, USA ; Jacobs Institute, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, State University of New York, USA ; Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA ; Jacobs Institute, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, State University of New York, USA ; Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, USA ; Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, USA ; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, New York, USA
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Elsenousi A, Aletich VA, Alaraj A. Neurological outcomes and cure rates of embolization of brain arteriovenous malformations with n-butyl cyanoacrylate or Onyx: a meta-analysis. J Neurointerv Surg 2014; 8:265-72. [PMID: 25540177 DOI: 10.1136/neurintsurg-2014-011427] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 12/01/2014] [Indexed: 12/29/2022]
Abstract
BackgroundIn the past decade, preoperative endovascular embolization of cerebral arteriovenous malformations (AVMs) became an essential tool in the treatment of these entities. With the current expansion of technology and wide incorporation of new devices, the indications for the use of endovascular embolization have expanded to include embolization for cure. This has been facilitated by the wide use of the new liquid embolic agents (ethylene-vinyl alcohol co-polymer (EVOH)) in addition to n-butyl cyanoacrylate (NBCA). The aim of this study was to review the current published literature for these two agents and report on permanent neurological injuries and cure rate.MethodsPublished literature citing embolization results for AVMs using liquid embolic agents was reviewed. Papers reporting on permanent complication rates and complete angiographic cure were reviewed. A meta-analysis was performed based on these two variables for the two embolic agents.Results103 studies met the selection criteria. Poor neurological outcomes for NBCA and EVOH were 5.2% and 6.8%, respectively (OR 1.4; p=0.56). AVM complete obliteration rate was seen in 13.7% in the NBCA group and in 24% in the EVOH group (OR 1.9). This OR decreased to 1.35 in the subgroup analysis for patients treated after the year 2000.ConclusionsNBCA continues to have a trend towards lower permanent complication rates, but EVOH had higher angiographic cure rates. The recent literature has demonstrated an increase in the cure rate of AVMs with endovascular embolization techniques yet with a possible increase in permanent neurological deficits and mortality.
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Affiliation(s)
- Abdussalam Elsenousi
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Victor A Aletich
- 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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Walcott BP, Hattangadi-Gluth JA, Stapleton CJ, Ogilvy CS, Chapman PH, Loeffler JS. Proton beam stereotactic radiosurgery for pediatric cerebral arteriovenous malformations. Neurosurgery 2014; 74:367-73; discussion 374. [PMID: 24448188 DOI: 10.1227/neu.0000000000000294] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND For cerebral arteriovenous malformations (AVMs) determined to be high risk for surgery or endovascular embolization, stereotactic radiosurgery (SRS) is considered the mainstay of treatment. OBJECTIVE To determine the outcomes of pediatric patients with AVMs treated with proton SRS. METHODS We reviewed the records of 44 consecutively treated pediatric patients (younger than 18 years of age) who underwent proton SRS at our institution from 1998 to 2010. The median target volume was 4.5 ± 5.9 mL (range, 0.3-29.0 mL) and the median maximal diameter was 3.6 ± 1.5 cm (range, 1-6 cm). Radiation was administered with a median prescription dose of 15.50 ± 1.87 CGE to the 90% isodose. RESULTS At a median follow-up of 52 ± 25 months, 2 patients (4.5%) had no response, 24 patients (59.1%) had a partial response, and 18 patients (40.9%) experienced obliteration of their AVM. The median time to obliteration was 49 ± 26 months, including 17 patients who underwent repeat proton radiosurgery. Four patients (9%) experienced hemorrhage after treatment at a median time of 45 ± 15 months. Univariate analysis identified modified AVM scale score (P = .045), single fraction treatment (0.04), larger prescription dose (0.01), larger maximum dose (<0.001), and larger minimum dose (0.01) to be associated with AVM obliteration. CONCLUSION High-risk AVMs can be safely treated with proton radiosurgery in the pediatric population. Because protons deposit energy more selectively than photons, there is the potential benefit of protons to lower the probability of damage to healthy tissue in the developing brain.
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Affiliation(s)
- Brian P Walcott
- Departments of *Neurosurgery and ‡Radiation Oncology, §Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; ¶Department of Radiation Oncology, University of California San Diego, San Diego, California; ‖Department of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Jordan J, Llibre JC, Vazquez F. Predictors of neurological deficit after endovascular treatment of cerebral arteriovenous malformations and functional repercussions in prospective follow-up. Neuroradiol J 2014; 27:718-24. [PMID: 25489896 DOI: 10.15274/nrj-2014-10095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 08/24/2014] [Indexed: 11/12/2022] Open
Abstract
Endovascular therapy is a well-established approach to the treatment of cerebral arteriovenous malformations (AVMs). The objective of this study was to determine the predictive factors of neurological deficit following endovascular procedures. Seventy-one patients with cerebral AVMs who underwent 147 embolization sessions from 2006 to 2011 were followed up prospectively (average 31.1 ± 17.5 months). Functional neurological condition was documented by means of the modified Rankin scale. Factors found to be predictors of neurological deficit were the partial obstruction of drainage veins (OR = 197.6; IC = 2.76 -1416.0; P = 0.015), a positive result in the Propofol test (OR = 50.2; IC = 6.18 - 566.5; P = 0.000), AVM diameter under 3 cm (OR = 21.3; IC: 1.71 - 265.6; P = 0.018), the presence of intranidal aneurysms (OR = 11.2; IC = 1.09 - 114.2; P = 0.042), the absence of post-procedure hypotension (OR = 10.2; IC = 1.35 - 77.7; P = 0.003), deep venous drainage (OR = 7.14; IC = 1.15 - 44.4; P = 0.035), and devascularization in excess of 40% per session (OR = 3.3; IC = 1.11 - 16.8; P = 0.056). Fifty-six patients (78.9%) did not experience changes in their neurological condition after the treatment and 13 patients (18.3%) showed a new neurological deficit related to the treatment; 95.8 % of the patients did not show significant long-term incapacity. Partial obstruction of drainage veins, small AVMs, intranidal aneurysms, faulty hemodynamic control and extensive devascularization were found to be predictors of neurological deficit. A significant number of patients with neurological deficit improved in the long term.
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Affiliation(s)
- Jose Jordan
- Interventional Neuroradiology Unit, CIMEQ, Institute of Neurology and Neurosurgery; La Habana, Cuba -
| | - Juan Carlos Llibre
- Interventional Neuroradiology Unit, CIMEQ, Institute of Neurology and Neurosurgery; La Habana, Cuba
| | - Frank Vazquez
- Interventional Neuroradiology Unit, CIMEQ, Institute of Neurology and Neurosurgery; La Habana, Cuba
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Cerebral arteriovenous malformations: evaluation and management. ScientificWorldJournal 2014; 2014:649036. [PMID: 25386610 PMCID: PMC4216697 DOI: 10.1155/2014/649036] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 09/11/2014] [Indexed: 11/17/2022] Open
Abstract
There has been increased detection of incidental AVMs as result of the frequent use of advanced imaging techniques. The natural history of AVM is poorly understood and its management is controversial. This review provides an overview of the epidemiology, pathophysiology, natural history, clinical presentation, diagnosis, and management of AVMs. The authors discussed the imaging techniques available for detecting AVMs with regard to the advantages and disadvantages of each imaging modality. Furthermore, this review paper discusses the factors that must be considered for the most appropriate management strategy (based on the current evidence in the literature) and the risks and benefits of each management option.
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Bruno CA, Meyers PM. Endovascular management of arteriovenous malformations of the brain. INTERVENTIONAL NEUROLOGY 2014; 1:109-23. [PMID: 25187772 DOI: 10.1159/000346927] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Arteriovenous malformations (AVMs) of the brain are rare, complex, vascular lesions that can result in significant morbidity and mortality. Modern treatment of brain AVMs is a multimodality endeavor, requiring a multidisciplinary team with expertise in cerebrovascular neurosurgery, endovascular intervention, and radiation therapy in order to provide all therapeutic options and determine the most appropriate treatment regimen depending on patient characteristics and AVM morphology. Current therapeutic options include microsurgical resection, radiosurgery (focused radiation), and endovascular embolization. Endovascular embolization is primarily used as a preoperative adjuvant before microsurgery or radiosurgery. Palliative embolization has been used successfully to reduce the risk of hemorrhage, alleviate clinical symptoms, and preserve or improve neurological function in inoperable or nonradiosurgical AVMs. Less frequently, embolization is used as 'primary therapy' particularly for smaller, surgically difficult lesions. Current embolic agents used to treat brain AVMs include both solid and liquid agents. Liquid agents including N-butyl cyanoacrylate and Onyx are the most commonly used agents. As newer embolic agents become available and as microcatheter technology improves, the role of endovascular treatment for brain AVMs will likely expand.
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Affiliation(s)
- Charles A Bruno
- Departments of Radiology and Neurosurgery, Columbia University/New York Presbyterian Hospital, New York, N.Y., USA
| | - Philip M Meyers
- Neuroendovascular Services, Columbia University/New York Presbyterian Hospital, New York, N.Y., USA
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