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Kumari K, Arsal SA, Devi A. Letter to the editor: Clinical analysis of surgical outcome of 89 patients having large cerebral arteriovenous malformations. Neurosurg Rev 2024; 47:277. [PMID: 38884809 DOI: 10.1007/s10143-024-02507-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 06/02/2024] [Accepted: 06/08/2024] [Indexed: 06/18/2024]
Affiliation(s)
- Kalpana Kumari
- Dow medical college, Mission road, new labour colony Nanakwara, Karachi city, Sindh, 74200, Pakistan.
| | - Syed Ali Arsal
- Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara Karachi, Karachi, 75100, Pakistan
| | - Anusha Devi
- Dow medical college, Mission road, new labour colony Nanakwara, Karachi city, Sindh, 74200, Pakistan
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Dabhi N, Sokolowski J, Zanaty M, Kellogg RT, Park MS, Mastorakos P. Primary Embolization of Cerebral Arteriovenous Malformations With Intention to Cure: A Systematic Review of Literature and Meta-Analysis. Neurosurgery 2024:00006123-990000000-01190. [PMID: 38842298 DOI: 10.1227/neu.0000000000003001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 03/28/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The treatment of brain arteriovenous malformations (AVMs) involves multiple approaches, including embolization, microsurgical resection, and radiosurgery. With the advent of new embolisates, dual-lumen balloon catheters, detachable tip microcatheters, and transvenous embolization, endovascular AVM obliteration has become more effective. Although adjuvant embolization and embolization are commonly used, the safety and effectiveness of curative embolization remain unclear. METHODS We conducted a systematic literature review using PubMed, Ovid Medline, and Web of Science to identify studies reporting outcomes in patients with AVMs who underwent primary embolization with the intention to cure. We collected data on patient characteristics, AVM features, complications, and radiographic and clinical outcomes for meta-analysis. RESULTS We identified 25 studies with a total of 1425 patients with 1427 AVMs who underwent curative embolization. Of these patients, 70% were low grade (pooled = 61% [39-82]), 67% were <3 cm (pooled = 78% [60-92]), and 75% were in superficial locations (pooled = 80% [72-86]). At last radiographic follow-up (mean, 16.7 ± 10.9 months), the full obliteration rate was 52% (pooled = 61% [43-77]) and retreatment rate was 25% (pooled = 17% [8.3-27]). At last clinical follow-up (mean, 24.2 ± 13.3 months), the poor clinical outcome rate was 7.9% (pooled = 4.4% [1.3-8.7]) and symptomatic complication rate was 13% (pooled = 13% [8-19]). There was no significant difference in the rate of radiographic cure, need for retreatment, and poor outcomes between ruptured and unruptured AVMs. Symptomatic complications were more common in the treatment of unruptured AVMs. The primary outcomes showed high heterogeneity (I2 = 72%-94%). CONCLUSION Curative embolization of AVM is primarily reserved for small and low-grade AVMs, with highly variable outcomes. Our findings suggest poor radiographic outcomes and increased risk of complications. Outcomes are highly dependent on patient selection and technique used. Large multicenter prospective studies are required to further guide patient selection, categorize clinical and radiographic outcomes, and identify subgroup of patients that may benefit from curative embolization.
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Affiliation(s)
- Nisha Dabhi
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jennifer Sokolowski
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa, USA
| | - Ryan T Kellogg
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
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Rodríguez RG, Agyemang K, Arias SAM, Cearns MD, Chaddad-Neto F. Importance of Arachnoid Dissection in Arteriovenous Malformation Microsurgery: A Technical Note. World Neurosurg 2023; 173:12. [PMID: 36775233 DOI: 10.1016/j.wneu.2023.02.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 02/12/2023]
Abstract
Intracranial arteriovenous malformations (AVMs) are congenital anomalies where arteries and veins connect without a capillary bed. AVMs are the leading cause of nontraumatic intracerebral hemorrhages in people younger than 35 years old.1 The leptomeninges (arachnoid and pia) form from the meninx primitiva.2,3 Endothelial channels produce a vascular plexus in the meninx connected by primitive arachnoid. Remodeling of the plexus in response to changing metabolic demands results in a recognizable pattern of arteries and veins.2,3 Defects at the level of capillaries during arteriovenous specification are most likely responsible for arteriovenous fistula formation.4-6 Interplay between the congenital dysfunction and flow-related maturation in adulthood, when vasculogenesis has stopped, produces the AVM.6,7 The relationship between the primitive arachnoid and aberrant AVM vessels is preserved and forms the basis of microsurgical disconnection discussed in Video 1. Several authors have described dissecting these natural planes to delineate the abnormal AVM vessels, relax the brain, and avoid morbidity during AVM surgery.8-10 We recommend sharp arachnoid dissection with a scalpel or microscissors, occasionally helped by blunt dissection with patties or bipolar forceps. We present a 2-dimensional video of the microsurgical resection of a right parietal AVM. The patient, a healthy 30-year-old female, presented with intermittent headaches and mild impairment of arithmetic and visuospatial ability. Magnetic resonance imaging and digital subtraction angiography showed a compact 3.5-cm supramarginal gyrus AVM supplied by the middle cerebral artery, with superficial drainage. Complete microsurgical resection was performed without morbidity. We demonstrate the principles of arachnoid dissection requisite to disentanglement of the nidus and safe resection of the AVM.
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Affiliation(s)
- Rony Gómez Rodríguez
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo-SP, Brazil
| | - Kevin Agyemang
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo-SP, Brazil; School of Medicine, University of Glasgow, Glasgow, United Kingdom
| | | | - Michael D Cearns
- Hospital Beneficência Portuguesa de São Paulo, São Paulo-SP, Brazil
| | - Feres Chaddad-Neto
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo-SP, Brazil; Hospital Beneficência Portuguesa de São Paulo, São Paulo-SP, Brazil.
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Rodriguez-Calienes A, Vivanco-Suarez J, Costa M, Echevarria-Quispe JY, Rodríguez-Varela R, Ortega-Gutierrez S, Saal-Zapata G. Embolization as stand-alone strategy for pediatric low-grade brain arteriovenous malformations. J Stroke Cerebrovasc Dis 2023; 32:107137. [PMID: 37068327 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107137] [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: 01/25/2023] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 04/19/2023] Open
Abstract
OBJECTIVES We evaluated the safety and efficacy of endovascular embolization as first-line stand-alone strategy for the treatment of low-grade brain arteriovenous malformations (bAVMs) (Spetzler Martin [SM] grade I and II) in pediatric patients. In addition, we assessed the predictors of procedure-related complications and radiographic complete obliteration in a single session. MATERIAL AND METHODS We conducted a single center retrospective cohort study of all pediatric (≤18 years) patients who underwent embolization as a stand-alone strategy for low-grade bAVMs between 2010 and 2022. Safety was measured by procedure-related complications and mortality. Efficacy was defined as complete angiographic obliteration after the last embolization session. RESULTS Sixty-eight patients (41 females; median age 14 years) underwent a total of 102 embolization sessions. There were 24 (35%) SM grade I lesions and 44 (65%) grade II. Six procedure-related complications (5.8% of procedures) were observed and no deaths were reported. All the complications were intraoperative nidus ruptures. A single draining vein was the only significant predictor of procedure-related complications (OR=0.10; 95% CI 0.01 - 0.72; p=0.048). Complete angiographic obliteration was achieved in 44 patients (65%). In 35 patients (51%) the bAVM was completely occluded in one session. The bAVM nidal size was a predictor of complete obliteration in one session (OR=0.44; 95% CI, 0.21-0.80; p=0.017). CONCLUSION Endovascular treatment as a stand-alone strategy for pediatric low-grade bAVMs is an adequate first-line approach in high volume centers with endovascular expertise. Nidal size evaluation is relevant in order to optimize patient selection for embolization as a stand-alone treatment modality.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, 339 Teeters Ct, Iowa City, IA 52246, USA; Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru.
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, 339 Teeters Ct, Iowa City, IA 52246, USA
| | - Matias Costa
- Cerebrovascular Neurosurgery Department, Swedish Neuroscience Institute, Seattle, WA, USA
| | | | - Rodolfo Rodríguez-Varela
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, Lima, Peru; Departament of Neurosurgery, Clinica Angloamericana, Lima, Peru
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Hospitals and Clinics, 339 Teeters Ct, Iowa City, IA 52246, USA; Department of Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, Lima, Peru; Departament of Neurosurgery, Clinica Angloamericana, Lima, Peru
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Sattari SA, Shahbandi A, Yang W, Feghali J, Xu R, Huang J. Microsurgery versus Microsurgery With Preoperative Embolization for Brain Arteriovenous Malformation Treatment: A Systematic Review and Meta-analysis. Neurosurgery 2023; 92:27-41. [PMID: 36519858 DOI: 10.1227/neu.0000000000002171] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/29/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Preoperative embolization has traditionally been regarded as a safe and effective adjunct to microsurgical treatment of brain arteriovenous malformations (bAVM). However, there is currently no high-level evidence to ascertain this presumption. OBJECTIVE To compare the outcomes of microsurgery (MS) vs microsurgery with preoperative embolization (E + MS) in patients with bAVM through systematic review. METHODS We searched MEDLINE, PubMed, and Embase. The primary outcome was bAVM obliteration. Secondary outcomes were intraoperative bleeding (mL), complications, worsened modified Rankin Scale (mRS), and mortality. The pooled proportions of outcomes were calculated through the logit transformation method. The odds ratio (OR) of categorical data and mean difference of continuous data were estimated through the Mantel-Haenszel and the inverse variance methods, respectively. RESULTS Thirty-two studies met the eligibility criteria. One thousand eight hundred twenty-eight patients were treated by microsurgery alone, and 1088 were treated by microsurgery with preoperative embolization, respectively. The meta-analysis revealed no significant difference in AVM obliteration (94.1% vs 95.6%, OR = 1.15 [0.63-2.11], P = .65), mortality (1.7% vs 2%, OR = 0.88 [0.30-2.58], P = .82), procedural complications (18.2% vs 27.2%, OR = 0.47 [0.19-1.17], P = .10), worsened mRS (21.2% vs 18.5%, OR = 1.08 [0.33-3.54], P = .9), and intraoperative blood loss (mean difference = 182.89 [-87.76, 453.55], P = .19). CONCLUSION The meta-analysis showed no significant difference in AVM obliteration, mortality, complications, worse mRS, and intraoperative blood loss between MS and E + MS groups. For AVMs where MS alone has acceptable results, it is reasonable to bypass unnecessary preoperative embolization given higher postoperative complication risk.
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Affiliation(s)
- Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ataollah Shahbandi
- Tehran School of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Raj Sharma M, Sedain G, Kafle P, Rajbhandari B, Bahadur Pradhanang A, Kumar Shrestha D, Singh Karki A, Chiluwal A. Clinical characteristics and outcome of patients with brain arteriovenous malformations from a university hospital in nepal. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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7
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Abbas R, Al-Saiegh F, Atallah E, Naamani KE, Tjoumakaris S, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH. Treatment of Intracerebral Vascular Malformations: When to Intervene. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00739-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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8
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Moufarrij N, Schmidt A. Durability of excellent outcome for 15 years after resection of a ruptured grade 5 arteriovenous malformation. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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9
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Lauzier DC, Vellimana AK, Chatterjee AR, Osbun JW, Moran CJ, Zipfel GJ, Kansagra AP. Return of the lesion: a meta-analysis of 1134 angiographically cured pediatric arteriovenous malformations. J Neurosurg Pediatr 2021:1-8. [PMID: 34507285 DOI: 10.3171/2021.6.peds21227] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain arteriovenous malformations (AVMs) carry a risk of rupture and subsequent morbidity or mortality unless fully treated. AVMs in pediatric patients are known to occasionally recur after obliteration. The objective of this study was to characterize the risk of AVM recurrence following angiographically confirmed obliteration in children. METHODS Consecutive pediatric AVMs treated at a single center were identified from a prospective database. Patients with angiographically confirmed AVM obliteration following treatment were included in this study. Associations between AVM recurrence and patient or procedural factors were characterized using the two-tailed Fisher exact test or Mann-Whitney U-test. A literature search was conducted using PubMed, Scopus, Embase, and the Clarivate Web of Science with defined search criteria, and eligible studies were included alongside this study cohort in a meta-analysis. Rates of AVM recurrence following obliteration were pooled across studies with a random-effects model and reported with 95% confidence intervals (CIs). RESULTS Recurrence after angiographic confirmation of AVM obliteration was observed in 10.4% (7/67) of pediatric AVMs treated at the authors' center. Patients with recurrent AVMs were significantly younger than those without recurrence (p = 0.002). In the meta-analysis, which included 1134 patients across 24 studies, the rate of recurrence was 4.8% (95% CI 3.0%-6.7%). The rate of AVM recurrence following radiosurgery was 0.7% (95% CI 0%-1.6%), which was significantly lower than the 8.5% rate (95% CI 5.0%-12.0%) following microsurgery. CONCLUSIONS Recurrence of obliterated brain AVMs is common in children. Recurrence is more common in young children and following microsurgery.
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Affiliation(s)
| | | | - Arindam R Chatterjee
- 1Mallinckrodt Institute of Radiology.,2Department of Neurological Surgery, and.,3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua W Osbun
- 1Mallinckrodt Institute of Radiology.,2Department of Neurological Surgery, and.,3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher J Moran
- 1Mallinckrodt Institute of Radiology.,2Department of Neurological Surgery, and
| | - Gregory J Zipfel
- 2Department of Neurological Surgery, and.,3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Akash P Kansagra
- 1Mallinckrodt Institute of Radiology.,2Department of Neurological Surgery, and.,3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
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10
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Lee JE, Kan P. Commentary: Hemorrhage Following Complete Arteriovenous Malformation Resection With No Detectable Recurrence: Insights From a Twenty-Seven-Year Registry. Neurosurgery 2021; 89:E107-E108. [PMID: 33913489 DOI: 10.1093/neuros/nyab161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/06/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jae Eun Lee
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
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11
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Does Endovascular Treatment with Curative Intention Have Benefits for Treating High-Grade Arteriovenous Malformation versus Radiosurgery? Efficacy, Safety, and Cost-Effectiveness Analysis. World Neurosurg 2021; 149:e178-e187. [PMID: 33618042 DOI: 10.1016/j.wneu.2021.02.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The treatment of high-grade arteriovenous malformations (AVMs) remains challenging. Microsurgery provides a rapid and complete occlusion compared with other options but is associated with undesirable morbidity and mortality. The aim of this study was to compare the occlusion rates, incidence of unfavorable outcomes, and cost-effectiveness of embolization and stereotactic radiosurgery (SRS) as a curative treatment for high-grade AVMs. METHODS A retrospective series of 57 consecutive patients with high-grade AVM treated with embolization or SRS, with the aim of achieving complete occlusion, was analyzed. Demographic, clinical, and angioarchitectonic variables were collected. Both treatments were compared for the occlusion rate and procedure-related complications. In addition, a cost-effectiveness analysis was performed. RESULTS Thirty patients (52.6%) were men and 27 (47.4%) were women (mean age, 39 years). AVMs were unruptured in 43 patients (75.4%), and ruptured in 14 patients (24.6%). The presence of deep venous drainage, nidus volume, perforated arterial supply, and eloquent localization was more frequent in the SRS group. Complications such as hemorrhage or worsening of previous seizures were more frequent in the embolization group. No significant differences were observed in the occlusion rates or in the time necessary to achieve occlusion between the groups. The incremental cost-effectiveness ratio for endovascular treatment versus SRS was $53.279. CONCLUSIONS Both techniques achieved similar occlusion rates, but SRS carried a lower risk of complications. Staged embolization may be associated with a greater risk of hemorrhage, whereas SRS was shown to have a better cost-effectiveness ratio. These results support SRS as a better treatment option for high-grade AVMs.
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12
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Wang A, Mandigo GK, Feldstein NA, Sisti MB, Connolly ES, Solomon RA, Lavine SD, Meyers PM. Curative treatment for low-grade arteriovenous malformations. J Neurointerv Surg 2019; 12:48-54. [DOI: 10.1136/neurintsurg-2019-015115] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/12/2019] [Accepted: 06/16/2019] [Indexed: 11/03/2022]
Abstract
BackgroundSpetzler-Martin (SM) grade I-II (low-grade) arteriovenous malformations (AVMs) are often considered safe for microsurgery or radiosurgery. The adjunctive use of preoperative embolization to reduce surgical risk in these AVMs remains controversial.ObjectiveTo assess the safety of combined treatment of grade I-II AVMs with preoperative embolization followed by surgical resection or radiosurgery, and determine the long-term functional outcomes.MethodsWith institutional review board approval, a retrospective analysis was carried out on patients with ruptured and unruptured SM I-II AVMs between 2002 and 2017. Details of the endovascular procedures, including number of arteries supplying the AVM, number of branches embolized, embolic agent(s) used, and complications were studied. Baseline clinical and imaging characteristics were compared. Functional status using the modified Rankin Scale (mRS) before and after endovascular and microsurgical treatments was compared.Results258 SM I-II AVMs (36% SM I, 64% SM II) were identified in patients with a mean age of 38 ± 17 years. 48% presented with hemorrhage, 21% with seizure, 16% with headache, 10% with no symptoms, and 5% with clinical deficits. 90 patients (68%) in the unruptured group and 74 patients (59%) in the ruptured group underwent presurgical embolization (p = 0.0013). The mean number of arteries supplying the AVM was 1.44 and 1.41 in the unruptured and ruptured groups, respectively (p = 0.75). The mean number of arteries embolized was 2.51 in the unruptured group and 1.82 in the ruptured group (p = 0.003). n-Butyl cyanoacrylate and Onyx were the two most commonly used embolic agents. Four complications were seen in four patients (4/164 patients embolized): two peri-/postprocedural hemorrhage, one dissection, and one infarct. All patients undergoing surgery had a complete cure on postoperative angiography. Patients were followed up for a mean of 55 months. Good long-term outcomes (mRS score ≤ 2) were seen in 92.5% of patients with unruptured AVMs and 88.0% of those with ruptured AVMs. Permanent neurological morbidity occurred in 1.2%.ConclusionsCurative treatment of SM I-II AVMs can be performed using endovascular embolization with microsurgical resection or radiosurgery in selected cases, with very low morbidity and high cure rates. Compared with other published series, these outcomes suggest that preoperative embolization is a safe and effective adjunct to definitive surgical treatment. Long-term follow-up showed that patients with low-grade AVMs undergoing surgical resection or radiosurgery have good functional outcomes.
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13
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Nisson PL, Fard SA, Walter CM, Johnstone CM, Mooney MA, Tayebi Meybodi A, Lang M, Kim H, Jahnke H, Roe DJ, Dumont TM, Lemole GM, Spetzler RF, Lawton MT. A novel proposed grading system for cerebellar arteriovenous malformations. J Neurosurg 2019; 132:1105-1115. [PMID: 30849761 DOI: 10.3171/2018.12.jns181677] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 12/03/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the existing Spetzler-Martin (SM), Spetzler-Ponce (SP), and Lawton-Young (LY) grading systems for cerebellar arteriovenous malformations (AVMs) and to propose a new grading system to estimate the risks associated with these lesions. METHODS Data for patients with cerebellar AVMs treated microsurgically in two tertiary medical centers were retrospectively reviewed. Data from patients at institution 1 were collected from September 1999 to February 2013, and at institution 2 from October 2008 to October 2015. Patient outcomes were classified as favorable (modified Rankin Scale [mRS] score 0-2) or poor (mRS score 3-6) at the time of discharge. Using chi-square and logistic regression analysis, variables associated with poor outcomes were assigned risk points to design the proposed grading system. The proposed system included neurological status prior to treatment (poor, +2 points), emergency surgery (+1 point), age > 60 years (+1 point), and deep venous drainage (deep, +1 point). Risk point totals of 0-1 comprised grade 1, 2-3 grade 2, and 4-5 grade 3. RESULTS A total of 125 cerebellar AVMs of 1328 brain AVMs were reviewed in 125 patients, 120 of which were treated microsurgically and included in the study. With our proposed grading system, we found poor outcomes differed significantly between each grade (p < 0.001), while with the SM, SP, and LY grading systems they did not (p = 0.22, p = 0.25, and p = 1, respectively). Logistic regression revealed grade 2 had 3.3 times the risk of experiencing a poor outcome (p = 0.008), while grade 3 had 9.9 times the risk (p < 0.001). The proposed grading system demonstrated a superior level of predictive accuracy (area under the receiver operating characteristic curve [AUROC] of 0.72) compared with the SM, SP, and LY grading systems (AUROC of 0.61, 0.57, and 0.51, respectively). CONCLUSIONS The authors propose a novel grading system for cerebellar AVMs based on emergency surgery, venous drainage, preoperative neurological status, and age that provides a superior prognostication power than the formerly proposed SM, SP, and LY grading systems. This grading system is clinically predictive of patient outcomes and can be used to better guide vascular neurosurgeons in clinical decision-making.
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Affiliation(s)
- Peyton L Nisson
- 1College of Medicine, University of Arizona, Tucson, Arizona.,2Department of Neurosurgery, University of California, San Francisco, California
| | - Salman A Fard
- 1College of Medicine, University of Arizona, Tucson, Arizona
| | - Christina M Walter
- 3Division of Neurosurgery, Banner-University Medical Center, Tucson, Arizona
| | - Cameron M Johnstone
- 3Division of Neurosurgery, Banner-University Medical Center, Tucson, Arizona
| | - Michael A Mooney
- 4Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Ali Tayebi Meybodi
- 4Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Michael Lang
- 4Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Helen Kim
- 2Department of Neurosurgery, University of California, San Francisco, California
| | - Heidi Jahnke
- 4Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Denise J Roe
- 5Epidemiology and Biostatistics, College of Public Health, University of Arizona, Tucson, Arizona
| | - Travis M Dumont
- 3Division of Neurosurgery, Banner-University Medical Center, Tucson, Arizona
| | - G Michael Lemole
- 3Division of Neurosurgery, Banner-University Medical Center, Tucson, Arizona
| | - Robert F Spetzler
- 4Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Michael T Lawton
- 2Department of Neurosurgery, University of California, San Francisco, California.,4Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
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14
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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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15
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Delayed hemorrhagic complication after complete embolization of a brain arteriovenous malformation. Neurochirurgie 2018; 64:316-320. [PMID: 29908698 DOI: 10.1016/j.neuchi.2018.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 02/20/2018] [Accepted: 04/13/2018] [Indexed: 11/20/2022]
Abstract
Endovascular embolization is an essential therapeutic approach in the multidisciplinary management of cerebral arteriovenous malformations (AVM). However, it rarely occludes the AVM in its entirety. It is often combined with surgery or stereotactic radiosurgery. The aim of embolization is to reduce the size of the nidus and the intra-nidal flow in order to facilitate the microsurgical or the radiosurgical procedure. We report the case of a 61-year-old patient with a right frontal hemorrhagic AVM treated with complete embolization in a single session. Initially, a surgical procedure for excision of the AVM was scheduled 24hours post-embolization. This surgery was canceled due to a good angiographic result of the embolization. Eight days post-embolization, there was a massive re-bleed of the AVM which justified emergency surgical management. This case illustrates a delayed post-embolization hemorrhagic complication of an occluded AVM and prompts a review of the therapeutic strategy of the cerebral AVM to select the most effective and least morbid procedure or combination of procedures.
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Pohjola A, Lehto H, Hafez A, Oulasvirta E, Koroknay-Pál P, Laakso A. Arteriovenous Malformations of the Posterior Fossa: Focus on Surgically Treated Patients Presenting with Hemorrhage. World Neurosurg 2018; 116:e934-e943. [PMID: 29857215 DOI: 10.1016/j.wneu.2018.05.138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 05/18/2018] [Accepted: 05/19/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Arteriovenous malformations (AVMs) of the posterior fossa are demanding lesions that often present with rupture. Studies including outcome analyses in surgically operated patients with ruptured infratentorial AVMs are scarce. Certain anatomic and demographic features have shown associations with postoperative outcomes. METHODS Eighty-six patients with infratentorial AVM were collected from our AVM database. Fifty-four patients were admitted from 1990 onward, and their demographic, lesion, and treatment characteristics were analyzed. The cohort was further refined to 38 consecutive patients with surgically treated ruptured infratentorial AVM admitted to our center between 1990 and 2014, and statistical analyses of factors influencing outcomes were conducted. RESULTS Twenty-seven patients (69%) had a favorable outcome at early follow-up and 24 (67%) had a favorable outcome at final follow-up. Factors associated with poor outcome in early recovery on univariate analyses were deep venous drainage of the lesion (odds ratio [OR], 5.3; P = 0.037) and high Hunt & Hess score (P = 0.003). In the multivariate model, independent predictors for poor outcome were deep venous drainage (OR, 14.5; P = 0.010) and older age at admission (OR, 1.06; P = 0.028). The sole independent predictor for poor outcome at last follow-up was deep venous drainage (OR, 5.00; P = 0.046). The total follow-up time was 370 person-years. CONCLUSIONS AVMs of the posterior fossa usually present with rupture and thus require prompt clinical treatment. The majority of surgically treated patients recover favorably. Our data show that venous drainage patterns have the greatest influence on the patient's postoperative condition. Other influencing factors include the severity of hemorrhage and patient age at admission.
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Affiliation(s)
- Anni Pohjola
- Department of Neurosurgery, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Hanna Lehto
- Department of Neurosurgery, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Ahmad Hafez
- Department of Neurosurgery, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Elias Oulasvirta
- Department of Neurosurgery, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Päivi Koroknay-Pál
- Department of Neurosurgery, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Aki Laakso
- Department of Neurosurgery, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland.
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Ye Z, Ai X, Hu X, Fang F, You C. Clinical features and prognostic factors in patients with intraventricular hemorrhage caused by ruptured arteriovenous malformations. Medicine (Baltimore) 2017; 96:e8544. [PMID: 29137064 PMCID: PMC5690757 DOI: 10.1097/md.0000000000008544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Intraventricular hemorrhage (IVH) was associated with poor outcomes in patients with intracerebral hemorrhage. IVH had a high incidence in patients with ruptured arteriovenous malformations (AVMs). In this study, we aimed to discuss the clinical features and prognostic factors of outcomes in the patients with AVM-related IVH.From January 2010 to January 2016, we collected the data of the patients with AVM-related IVH retrospectively. The data, including clinical and radiological parameters, were collected to evaluate the clinical features. Univariate and multivariate logistic regression analyses were used to identify the prognostic factors for clinical outcomes (hydrocephalus, 6-month outcomes measured by the modified Rankin scale) in our cohort.A total of 67 eligible patients were included and 19 patients (28%) only presented with IVH. Thirty-three patients (49%) presented hydrocephalus, and 12 patients (18%) presented brain ischemia. Nineteen patients (28%) had a poor outcome after 6 months. In multivariate logistic regression, subarachnoid hemorrhage (SAH) (P = .028) was associated with hydrocephalus and higher Graeb score (P = .080) tended to increase the risk of hydrocephalus. The high Glasgow coma scale (P = .010), large hematoma volume of parenchyma (P = .006), and high supplemented Spetzler-Martin (sup-SM) score (P = .041) were independent factors of the poor outcome.IVH was common in ruptured AVMs and increased the poor outcomes in patients with the ruptured AVMs. The AVM-related IVH patients had a high incidence of hydrocephalus, which was associated with brain ischemia and SAH. Patients with lower Glasgow coma scale, lower sup-SM score, and smaller parenchymal hematoma had better long-term outcomes.
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