1
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Davison M, McCune M, Thiyagarajah N, Kashkoush A, Achey R, Shost M, Toth G, Bain M, Moore N. The incidence of infratentorial arteriovenous malformation-associated aneurysms: an institutional case series and systematic literature review. J Neurointerv Surg 2024:jnis-2024-022003. [PMID: 38937081 DOI: 10.1136/jnis-2024-022003] [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: 05/16/2024] [Accepted: 06/13/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Arteriovenous malformation (AVM)-associated aneurysms represent a high-risk feature predisposing them to rupture. Infratentorial AVMs have been shown to have a greater incidence of associated aneurysms, however the existing data is outdated and biased. The aim of our research was to compare the incidence of supratentorial vs infratentorial AVM-associated aneurysms. METHODS Patients were identified from our institutional AVM registry, which includes all patients with an intracranial AVM diagnosis since 2000, regardless of treatment. Records were reviewed for clinical details, AVM characteristics, nidus location (supratentorial or infratentorial), and presence of associated aneurysms. Statistical comparisons were made using Fisher's exact or Wilcoxon rank sum tests as appropriate. Multivariable logistic regression analysis determined independent predictors of AVM-associated aneurysms. As a secondary analysis, a systematic literature review was performed, where studies documenting the incidence of AVM-associated aneurysms stratified by location were of interest. RESULTS From 2000-2024, 706 patients with 720 AVMs were identified, of which 152 (21.1%) were infratentorial. Intracranial hemorrhage was the most common AVM presentation (42.1%). The incidence of associated aneurysms was greater in infratentorial AVMs compared with supratentorial cases (45.4% vs 20.1%; P<0.0001). Multivariable logistic regression demonstrated that infratentorial nidus location was the singular predictor of an associated aneurysm, odds ratio: 2.9 (P<0.0001). Systematic literature review identified eight studies satisfying inclusion criteria. Aggregate analysis indicated infratentorial AVMs were more likely to harbor an associated aneurysm (OR 1.7) and present as ruptured (OR 3.9), P<0.0001. CONCLUSIONS In this modern consecutive patient series, infratentorial nidus location was a significant predictor of an associated aneurysm and hemorrhagic presentation.
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Affiliation(s)
- Mark Davison
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Maximos McCune
- Cerebrovascular Center, CCF, Cleveland Heights, Ohio, USA
| | | | - Ahmed Kashkoush
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rebecca Achey
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Michael Shost
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Gabor Toth
- Cerebrovascular Center, CCF, Cleveland Heights, Ohio, USA
| | - Mark Bain
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Cerebrovascular Center, CCF, Cleveland Heights, Ohio, USA
| | - Nina Moore
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Cerebrovascular Center, CCF, Cleveland Heights, Ohio, USA
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland, OH, USA
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2
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Miron I, Prună VM, Visarion DM, Petrescu GED, Gorgan RM. Natural History and Predictors for Hemorrhage in Supratentorial Brain Arteriovenous Malformations. J Clin Med 2024; 13:3760. [PMID: 38999325 PMCID: PMC11242268 DOI: 10.3390/jcm13133760] [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: 05/21/2024] [Revised: 06/21/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: Approximately half of the patients harboring supratentorial brain arterio-venous malformations (stAVMs) present with hemorrhage, and another considerable proportion suffer from epileptic seizures. An important milestone in the management of this vascular pathology is acknowledging their natural history, especially across long periods of time. The aim of this study was to assess the predictive factors for hemorrhage and for epileptic seizures as presenting symptoms in stAVMs. Methods: We retrospectively analyzed patients with stAVMs admitted to our institution between 2012 and 2022 and evaluated predictive factors for hemorrhage and the risk factors associated with epileptic seizures. Results: The cohort included 169 patients, 78 of them (46.2%) presenting with intracerebral hemorrhage (ICH). Seventy-seven (45.5%) patients suffered from epileptic seizures. The annual hemorrhagic rate was 1.28%/year. Unruptured lesions (p = 0.001, OR 3.1, 95% CI 1.6-6.2), superficial venous drainage (p = 0.007, OR 2.7, 95% CI 1.3-5.7) and large nidus size (p = 0.025, OR 4, 95% CI 1.2-13.5) were independently associated with seizures. Among unruptured lesions, superficial venous drainage (OR 2.6, p = 0.036, 95% CI 1.06-6.3) and frontal/temporal/parietal location (OR 2.7, p = 0.040, 95 CI% 1.04-6.9) significantly increased the risk of seizures as a presenting symptom in multivariate analysis. Patients younger than 18 (p = 0.003, OR 4.5, 95% CI 1.6-12.2), those with AVMs < 3 cm (p = 0.03, OR 2, 95% CI 1.07-3.9) or those with deep located AVMs (p = 0.035, OR 2.3, 95% CI 1.06-5.1) presented statistically more often with ICH in multivariate regression. Small size (HR 1.8, 95% CI 1.09-3, p = 0.022) and exclusively deep venous drainage (HR 2.2, 95% CI 1.2-4, p = 0.009) were independent predictors for ICH, in time-dependent birth-to-diagnosis analysis. After shifting the birth-to-diagnosis curve by 10 years, unique arterial feeder demonstrated a positive correlation with ICH presentation as well. Conclusions: Small AVMs, those with exclusively deep venous drainage, unique arterial feeder or deep location may pose higher hemorrhagic risks for the patient, and therapeutic strategies should be tailored accordingly. When managing unruptured brain AVMs, it is important to consider the risk of developing seizures, in addition to the lifelong risk of hemorrhage, in determining the optimal treatment approach for each patient.
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Affiliation(s)
- Ioana Miron
- Department of Neurosurgery, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Neurosurgery, "Bagdasar-Arseni" Clinical Emergency Hospital, 041915 Bucharest, Romania
| | - Viorel M Prună
- Department of Neurosurgery, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Neurosurgery, "Bagdasar-Arseni" Clinical Emergency Hospital, 041915 Bucharest, Romania
| | - Dan M Visarion
- Department of Neurosurgery, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Neurosurgery, "Bagdasar-Arseni" Clinical Emergency Hospital, 041915 Bucharest, Romania
| | - George E D Petrescu
- Department of Neurosurgery, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Neurosurgery, "Bagdasar-Arseni" Clinical Emergency Hospital, 041915 Bucharest, Romania
| | - Radu M Gorgan
- Department of Neurosurgery, "Carol Davila" University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Neurosurgery, "Bagdasar-Arseni" Clinical Emergency Hospital, 041915 Bucharest, Romania
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Miron I, Prună VM, Visarion D, Giovani A, Sandu AM, Brehar FM, Petrescu GED, Gorgan RM. Clinical outcomes of posterior fossa arteriovenous malformations: a single center experience. Acta Neurochir (Wien) 2024; 166:215. [PMID: 38744729 PMCID: PMC11093870 DOI: 10.1007/s00701-024-06116-9] [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: 01/10/2024] [Accepted: 05/05/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Posterior fossa arterio-venous malformations (pfAVMs) are challenging lesions due to the anatomical particularities of the posterior fossa, and the high incidence of hemorrhagic presentation. The two most important goals when treating AVMs are preserving neurological function and preventing rupture, or a second hemorrhage. The aim of this study was to analyze the clinical and imaging features of pfAVMs to identify the factors that influence the prognosis of these patients. METHODS We conducted a single-center retrospective observational study that included patients treated at our institution with pfAVMs between January 1997 and December 2021. RESULTS A total of 48 patients were included. A good modified Rankin score (mRS) was observed in 33 cases (69%) at presentation. Thirty-four patients (71%) presented with a ruptured AVM. Out of these, 19 patients (40%) had intraventricular hemorrhage. Microsurgical resection was performed in 33 cases (69%), while in the other cases, the patients opted for conservative management (7 cases, 15%), stereotactic radiosurgery (SRS) (6 cases, 12%), or endovascular treatment (2 cases, 4%). Patients ≤ 30 years old were more prone to hemorrhagic presentation (OR: 5.23; 95% CI: 1.42-17.19; p = 0.024) and this remained an independent risk factor for rupture after multivariate analysis as well (OR: 4.81; 95% CI: 1.07-21.53; p = 0.040). Following multivariate analysis, the only factor independently associated with poor prognosis in the surgically treated subgroup was a poor clinical status (mRS 3-5) at admission (OR: 96.14; 95% CI: 5.15-1793.9; p = 0.002). CONCLUSIONS Management of posterior fossa AVMs is challenging, and patients who present with ruptured AVMs often have a poor clinical status at admission leading to a poor prognosis. Therefore, proper and timely management of these patients is essential.
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Affiliation(s)
- Ioana Miron
- Department of Neurosurgery, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of Neurosurgery, Bagdasar-Arseni Clinical Emergency Hospital, Bucharest, Romania
| | - Viorel M Prună
- Department of Neurosurgery, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of Neurosurgery, Bagdasar-Arseni Clinical Emergency Hospital, Bucharest, Romania
| | - Dan Visarion
- Department of Neurosurgery, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of Neurosurgery, Bagdasar-Arseni Clinical Emergency Hospital, Bucharest, Romania
| | - Andrei Giovani
- Department of Neurosurgery, Bagdasar-Arseni Clinical Emergency Hospital, Bucharest, Romania
| | - Aurelia M Sandu
- Department of Neurosurgery, Bagdasar-Arseni Clinical Emergency Hospital, Bucharest, Romania
| | - Felix M Brehar
- Department of Neurosurgery, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of Neurosurgery, Bagdasar-Arseni Clinical Emergency Hospital, Bucharest, Romania
| | - George E D Petrescu
- Department of Neurosurgery, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
- Department of Neurosurgery, Bagdasar-Arseni Clinical Emergency Hospital, Bucharest, Romania.
| | - Radu M Gorgan
- Department of Neurosurgery, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of Neurosurgery, Bagdasar-Arseni Clinical Emergency Hospital, Bucharest, Romania
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Calafiore R, Burke RM, Becerril-Gaitan A, Chen CJ, Oravec CS, Belanger K, Ding D, Yang HC, Kondziolka D, Mathieu D, Iorio-Morin C, Grills IS, Feliciano C, Barnett G, Starke RM, Lunsford LD, Sheehan JP. Characterization of Pediatric Infratentorial Arteriovenous Malformations: A Retrospective, Multicenter Cohort Study. Neurosurgery 2024:00006123-990000000-01158. [PMID: 38700839 DOI: 10.1227/neu.0000000000002977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/11/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Infratentorial arteriovenous malformations (AVMs) harbor different characteristics compared with supratentorial AVMs. This study aims to explore the unique characteristics of pediatric infratentorial AVMs and their response to single session stereotactic radiosurgery (SRS). METHODS The International Radiosurgery Research Foundation database of pediatric patients with AVM (age <18 years) who underwent SRS was retrospectively reviewed. Baseline demographics, AVM characteristics, outcomes, and complications post-SRS were compared between infratentorial and supratentorial pediatric AVMs. Unfavorable outcome was defined as the absence of AVM obliteration, post-SRS hemorrhage, or permanent radiation-induced changes at last follow-up. RESULTS A total of 535 pediatric AVMs managed with SRS with a median follow-up of 67 months (IQR 29.0-130.6) were included, with 69 being infratentorial and 466 supratentorial. The infratentorial group had a higher proportion of deep location (58.4% vs 30.3%, P = <.001), deep venous drainage (79.8% vs 61.8%, P = .004), and prior embolization (26.1% vs 15.7%, P = .032). There was a higher proportion of hemorrhagic presentation in the infratentorial group (79.7% vs 71.3%, P = .146). There was no statistically significant difference in the odds of an unfavorable outcome (odds ratio [OR] = 1.36 [0.82-2.28]), AVM obliteration (OR = 0.85 [0.5-1.43]), post-SRS hemorrhage (OR = 0.83 [0.31-2.18]), or radiologic radiation-induced changes (OR = 1.08 [0.63-1.84]) between both cohorts. No statistically significant difference on the rates of outcomes of interest and complications were found in the adjusted model. CONCLUSION Despite baseline differences between infratentorial and supratentorial pediatric AVMs, SRS outcomes, including AVM obliteration and post-SRS hemorrhage rates, were comparable amongst both groups. SRS appears to have a similar risk profile and therapeutic benefit to infratentorial pediatric AVMs as it does for those with a supratentorial location.
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Affiliation(s)
- Rebecca Calafiore
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem , North Carolina , USA
| | - Rebecca M Burke
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem , North Carolina , USA
| | - Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston , Texas , USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston , Texas , USA
| | - Chesney S Oravec
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem , North Carolina , USA
| | - Katherine Belanger
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem , North Carolina , USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville , Kentucky , USA
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei , Taiwan
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York , New York , USA
| | - David Mathieu
- Division of Neurosurgery, Centre de recherche du CHUS, University of Sherbrooke, Sherbrooke , Quebec , Canada
| | - Christian Iorio-Morin
- Division of Neurosurgery, Centre de recherche du CHUS, University of Sherbrooke, Sherbrooke , Quebec , Canada
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak , Michigan , USA
| | - Caleb Feliciano
- Section of Neurological Surgery, University of Puerto Rico, San Juan , Puerto Rico , USA
| | - Gene Barnett
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland , Ohio , USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami, Miami , Florida , USA
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville , Virginia , USA
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Winkler EA, Scherschinski L, Catapano JS, DiDomenico JD, Hanalioglu S, Lawton MT. Posterior Interhemispheric-Transtentorial Approach for Resection of an Arteriovenous Malformation of the Superior Medullary Velum and Fourth Ventricle: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01139. [PMID: 38683955 DOI: 10.1227/ons.0000000000001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/05/2024] [Indexed: 05/02/2024] Open
Abstract
Brain arteriovenous malformations (AVMs) of the fourth ventricle represent a rare subtype associated with an aggressive natural course.1,2 In this case, a woman in her early 50s presented with dizziness. An AVM was diagnosed in the left superior cerebellar peduncle extending into the fourth ventricle. The AVM was supplied by superior cerebellar artery branches and classified as a Spetzler-Martin grade III and a Lawton-Young grade III, with a supplemented grade of 6.3,4 Being a single case report, institutional review board approval was not needed. Patient consent was obtained. The lesion was accessed through a torcular craniotomy and posterior interhemispheric-transtentorial approach, employing gravity to naturally retract the parietooccipital lobe.5-7 Dissection continued into the quadrigeminal and ambient cisterns, where the tentorium was incised parallelling the straight sinus to reach the superior vermis. Partial resection of the lingual and central lobules of the vermis facilitated access to the superior medullary velum. The superior cerebellar artery feeders were divided and followed to the superior cerebellar peduncle and through the superior medullary vellum. A vertical incision in the superior medullary velum facilitated entry into the fourth ventricle, where the AVM nidus was dissected circumferentially and resected en bloc. Intraoperative indocyanine green videoangiography and postoperative digital subtraction angiography confirmed complete obliteration of the AVM. After surgery, the patient experienced mild ataxia, but motor symptoms greatly improved during 3-month follow-up. This video illustrates resection of a complex fourth ventricular AVM through a posterior interhemispheric-transtentorial approach, highlighting pivotal considerations of patient positioning and approach selection to optimize treatment outcome for complex posterior fossa AVM resection.
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Affiliation(s)
- Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Maalim AA, Zhu M, Shu K, Wu Y, Zhang S, Ye F, Zeng Y, Huang Y, Lei T. Microsurgical Treatment of Arteriovenous Malformations: A Single-Center Study Experience. Brain Sci 2023; 13:1183. [PMID: 37626539 PMCID: PMC10452609 DOI: 10.3390/brainsci13081183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVE The purpose of the study was to assess the functional outcomes after microsurgical resection of arteriovenous malformations (AVMs) and to compare the results between patients eligible for A Randomized Trial of Unruptured Brain Arteriovenous Malformations in this surgical series to the results reported and the ARUBA study. METHODS We reviewed the records of 169 patients who underwent microsurgical treatment of arteriovenous malformation (AVMs) in our institution between January 2016 and December 2021. These patients' functional status was assessed using modified Rankin Scale (mRS) scores at the last follow-up and before treatment. The mRS scores at the latest follow-up were classified into good outcomes (mRS < 3) and poor outcomes (mRS ≥ 3). Clinical presentation, patients' demographics, AVM characteristics, follow-up time, and obliteration rate were analyzed. Subgroup analyses were performed on the whole cohort, comparing Spetzler-Martin Grade I and Grade II, and ARUBA-eligible AVMs. RESULTS The initial hemorrhagic presentation occurred in 71 (42%) out of 169 patients. The majority of the patients presented with headaches (73%). The AVMs were completely obliterated in 166 (98.2%) patients. The series included 65 Spetzler-Martin Grade I (38.5%), 46 Grade II (27.2%), 32 Grade III (18.9%), 22 Grade IV (13%), and 4 Grade V (2.4%) AVMs. There were 98 unruptured and 79 ARUBA-eligible cases. Also, optimal functional outcome was achieved in 145 (85.8%) patients. The overall mortality rate was 5.3% (9/169). The multivariate analysis illustrated that a poor outcome was significantly associated with presurgical mRS ≥3 (p < 0.013; OR, 0.206; 95% CI 0.059-0.713), increasing age (p < 0.045; odds ratio [OR], 1.022; 95% CI 1.000-0.045), and female gender (p < 0.009; OR, 2.991; 95% CI 1.309-6.832). CONCLUSIONS Our study suggests that better outcomes can be obtained using microsurgical resection in the majority of patients with AVMs. Independent predictors of poor outcomes after surgical resection of AVMs include increasing age at the time of surgery, poor presurgical functional status, and female gender. Supposing that patients are more suitable for microsurgery after presurgical examination, outcomes are normally better in that case than those achieved by multimodal interventions (such as conservative treatment or ARUBA treatment arm). Therefore, we recommend early surgical removal on all surgically accessible AVMs to prevent successive hemorrhages and the consequences of poor neurological outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ting Lei
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China; (A.A.M.); (M.Z.); (K.S.); (Y.W.); (S.Z.); (F.Y.); (Y.Z.); (Y.H.)
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7
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Long-term follow-up in patients with brain arteriovenous malformation based on the Quality of Life Scale and socioeconomic status. Neurosurg Rev 2022; 45:3281-3290. [PMID: 36083567 DOI: 10.1007/s10143-022-01847-8] [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: 02/13/2022] [Revised: 07/19/2022] [Accepted: 07/28/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Intracranial haemorrhage (ICH) is associated with permanent neurological disability resulting in deterioration of the quality of life (QoL). Our study assesses QoL in patients with ruptured arteriovenous malformation (AVM) in long-term follow-up at least five years after ICH and compares their QoL with the QoL of patient with non-ruptured AVM. METHODS Using the Quality of Life Scale (QOLS), the Patient Health Questionnaire (PHQ-9) for depressive symptoms, and the socioeconomic status (SES), a prospective assessment was performed. The modified Rankin Scale (mRS) was assessed for outcome. RESULTS Of 73 patients, 42 (57.5%) had ruptured (group 1) and 31 (42.5%) a non-ruptured AVM (group 2). Mean follow-up time was 8.6 ± 3.9 years (8.5 ± 4.2 years in group 1 and 8.9 ± 3.7 years in group 2). Favourable outcome (mRS 0-1) was assessed in 60 (83.3%) and unfavourable in 12 (16.7%) patients. Thirty-one of 42 patients (73.8%) in group 1 and 29 of 30 patients in group 2 (96.7%) had favourable outcomes. Mean QOLS was 85.6 ± 14.1 (group 1 86.1 ± 15.9, group 2 84.9 ± 11.4). Patients in group 1 did not show a significant difference in QoL compared to patients in group 2 (p = 0.23). Additional analyses in group 2 (rho = - 0.73; p < 0.01) and in untreated AVM patients (rho = - 0.81; p < 0.01) showed a strong correlation between QOLS and PHQ-9. CONCLUSION Long-term follow-up showed no difference in the QoL between patients with and without ICH caused by brain AVM. Outcome- and QoL-scores were high in both groups. Further studies are necessary to evaluate depression and anxiety symptoms in patients with AVM.
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Peto I, Krafft PR, Vakharia KV. Commentary: Precuneal Interhemispheric, Transtentorial Approach to a Dorsal Pontine Cavernous Malformation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e174-e175. [PMID: 35972101 DOI: 10.1227/ons.0000000000000311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Ivo Peto
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
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Mooney J, Salehani A, Erickson N, Thomas E, Ilyas A, Rahm S, Eustace N, Maleknia P, Yousuf O, Bredel M, Fiveash J, Dobelbower C, Fisher W. Stereotactic radiosurgery for ruptured versus unruptured intracranial arteriovenous malformations. Surg Neurol Int 2022; 13:194. [PMID: 35673645 PMCID: PMC9168326 DOI: 10.25259/sni_86_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/22/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
There are a limited data examining the effects of prior hemorrhage on outcomes after stereotactic radiosurgery (SRS). The goal of this study was to identify risk factors for arteriovenous malformation (AVM) rupture and compare outcomes, including post-SRS hemorrhage, between patients presenting with ruptured and unruptured AVMs.
Methods:
A retrospective review of consecutive patients undergoing SRS for intracranial AVMs between 2009 and 2019 at our institution was conducted. Chi-square and multivariable logistic regression analyses were utilized to identify patient and AVM factors associated with AVM rupture at presentation and outcomes after SRS including the development of recurrent hemorrhage in both ruptured and unruptured groups.
Results:
Of 210 consecutive patients with intracranial AVMs treated with SRS, 73 patients (34.8%) presented with AVM rupture. Factors associated with AVM rupture included smaller AVM diameter, deep venous drainage, cerebellar location, and the presence of intranidal aneurysms (P < 0.05). In 188 patients with adequate follow-up time (mean 42.7 months), the overall post-SRS hemorrhage rate was 8.5% and was not significantly different between ruptured and unruptured groups (10.3 vs. 7.5%, P = 0.51). There were no significant differences in obliteration rate, time to obliteration, or adverse effects requiring surgery or steroids between unruptured and ruptured groups.
Conclusion:
Smaller AVM size, deep venous drainage, and associated intranidal aneurysms were associated with rupture at presentation. AVM rupture at presentation was not associated with an increased risk of recurrent hemorrhage or other complication after SRS when compared to unruptured AVM presentation. Obliteration rates were similar between ruptured and unruptured groups.
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Affiliation(s)
- James Mooney
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Arsalaan Salehani
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Nicholas Erickson
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Evan Thomas
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Sage Rahm
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Nicholas Eustace
- Department of School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Pedram Maleknia
- Department of School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Omer Yousuf
- Department of School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Markus Bredel
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - John Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Chris Dobelbower
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Winfield Fisher
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States,
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García-Pérez D, Panero I, Munarriz PM, Jimenez-Roldán L, Lagares A, Alén JA. Hemodynamic alterations following a cerebellar arteriovenous malformation resection: Case report and densitometric quantitative analysis from CT imaging. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:141-148. [PMID: 35526945 DOI: 10.1016/j.neucie.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/23/2020] [Indexed: 06/14/2023]
Abstract
BACKGROUND Cerebellar arteriovenous malformations (cAVMs) are rare and challenging lesions with an aggressive natural history. The mechanisms whereby a patient can worsen clinically after a supratentorial AVM resection include an acute alteration in cerebral hemodynamics, which is a known cause of postoperative hyperemia, edema and/or hemorrhage. These phenomena has not been described for cAVMS. Moreover, the underlying pathophysiology of edema and hemorrhage after AVM resection still remains controversial. METHODS We report a patient that presented an abrupt neurological deterioration after cAVM surgical resection. Emergent external ventricular drainage to treat incipient hydrocephalus only partially reverted the patient's deterioration. Consecutive post-surgery CT images revealed fourth ventricle compression secondary to cerebellar swelling that concurred with a new neurological deterioration. Densitometric analysis was performed in these CT images to reveal the nature of these changes as well as their evolution over time. RESULTS Importantly, we demonstrated a dynamic increase in the cerebellum mean density at the interval of Hounsfield values which correspond to hyperemia values. These changes were dynamic, and when hyperemia resolved and cerebellar density returned to basal levels, the fourth ventricle re-expanded and the patient neurologically recovered. CONCLUSIONS This study demonstrated the utility of quantitative CT image analysis in the context of hemodynamic alterations following cAVM resection. Densitometric CT analysis demonstrated that hyperemic changes, but not ischemic ones, were time-dependent and were responsible for swelling and hemorrhage that conditioned neurological status and patient's evolution.
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Affiliation(s)
- Daniel García-Pérez
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, Madrid 28041, Spain.
| | - Irene Panero
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, Madrid 28041, Spain
| | - Pablo M Munarriz
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, Madrid 28041, Spain
| | - Luis Jimenez-Roldán
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, Madrid 28041, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, Madrid 28041, Spain
| | - José A Alén
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, Madrid 28041, Spain
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11
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Almefty R, Essayed WI, Al-Mefty O. Multimodality resection of Oliveira Type IIIC* cerebellar AVM: A distinct entity. Surg Neurol Int 2022; 13:163. [PMID: 35509557 PMCID: PMC9062940 DOI: 10.25259/sni_217_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/01/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Posterior fossa AVMs constitute about 10% of AVMs and are associated with a higher rate of hemorrhage and increased morbidity and mortality rates necessitating treatment with rare exception. Cerebellar AVMs differ markedly from their supratentorial counterparts in that there are no perforating vessels involvement, drainage into the deep cerebral venous system, or presence of eloquent functional area except for the dentate nucleus. While Yaşargil has classified cerebellar AVMs into seven subtypes according to their location, de Oliveira et al. have classified them using a more impactful grading system based on the size, location, and involvement of the dentate nucleus with the highest risk being III (size over 4 cm) C (mixed superficial and deep location) * (dentate involvement). In this extensive AVM with multiple arterial feeders from the SCA, AICA, and PICAs, preoperative embolization facilitates the safe surgical removal.
Case Description:
We present the case of resection of de Oliveira et al. IIIC* cerebellar AVM highlighting the tenets of preoperative embolization, wide surgical exposure with an extended retrosigmoid approach, arachnoidal dissection of the SAC, AICA, and PICA feeders, parenchymal dissection with preservation of the dentate nucleus, and preservation of venous drainage until complete disconnection. The patient consented to surgery after presenting with hemorrhage and developed hydrocephalus and CSF leak, managed successfully.
Conclusion:
de Oliveira et al. classification is highly impactful in grading posterior fossa AVMs.
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Affiliation(s)
- Rami Almefty
- Department of Neurosurgery, Lewis Katz School of Medicine, Temple University, Philadelphia, United States,
| | - Walid Ibn Essayed
- Department of Neurosurgery, Harvard Medical School, Brigham and Women’s Hospital, Boston, United States
| | - Ossama Al-Mefty
- Department of Neurosurgery, Harvard Medical School, Brigham and Women’s Hospital, Boston, United States
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12
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Vignesh S, Prasad SN, Singh V, Neyaz Z, Phadke RV, Mehrotra A, Mishra P. Angiographic analysis on posterior fossa hemorrhages and vascular malformations beyond aneurysms by CT angiography and digital subtraction angiography. EGYPTIAN JOURNAL OF NEUROSURGERY 2022. [DOI: 10.1186/s41984-022-00152-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Posterior fossa malformations are less common than supratentorial malformations, but hemorrhages in posterior fossa are more serious due to presence of vital structures within this region. Most common cause of bleed in posterior fossa apart from hypertension is aneurysms but other vascular malformations are also there which cause hemorrhage. Here we discuss other causes of posterior fossa bleed beyond aneurysms.
Results
A total of 80 patients were evaluated: 47 (58.8%) had aneurysms, 29 (36.3%) had arteriovenous malformations, one each had developmental venous anomaly and brainstem cavernoma. Thirty vascular malformations were detected, of which 18 (62.1%) were pial arteriovenous malformations (AVMs), 11 (37.9%) were dural arteriovenous fistulas (dAVF), and one had developmental venous anomaly (DVA). Six patients of AVM underwent both DSA and CTA, and CTA could correctly diagnose only 2 of 4 pial AVMs detected by DSA. Among two dAVFs detected by DSA, CTA could demonstrate dAVF only in one patient.
Conclusion
CTA could be used as alternative to DSA in diagnosis and characterizing aneurysms in posterior fossa but for AVMs, 3D-CTA cannot replace DSA; however potential of time-resolved CTA (TR-CTA) appears promising.
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13
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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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14
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Budohoski KP, Mohan M, Millar Z, Tajsic T, Barone DG, Cao JJL, Mediratta S, Phelps E, Sukthankar T, Kirollos RW, Helmy AE, Guilfoyle MR, Trivedi RA. Longitudinal Changes in Size of Conservatively Managed Flow-Related Aneurysms Associated with Brain Arteriovenous Malformations. World Neurosurg 2021; 154:e754-e761. [PMID: 34358686 DOI: 10.1016/j.wneu.2021.07.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Flow aneurysms (FAs) associated with brain arteriovenous malformations (AVMs) are thought to arise from increased hemodynamic stress due to high-flow shunting. This study aims to describe the changes in conservatively managed FAs after successful AVM treatment. METHODS Patients with symptomatic AVMs and associated FAs who underwent successful treatment of the AVM between 2008 and 2017 were included. FA dimensions were measured on surveillance angiography to assess longitudinal changes. RESULTS Thirty-two patients were identified with 48 FAs. Sixteen (33%) FAs were treated endovascularly; 18 (38%) FAs were treated surgically; and 14 (29%) FAs (11 patients) were monitored. FAs demonstrated a decrease in size from 5.0 mm to 3.8 mm (24%; P = 0.016) and 4.9 mm to 3.6 mm (27%; P = 0.013) in height and width, respectively, over a median 35 months. However, on subgroup analysis, only class IIb aneurysms demonstrated a significant decrease in size (51% reduction in largest diameter, P = 0.046) and only 3 FAs (21%) resolved. There were no hemorrhages observed during follow-up. CONCLUSIONS While conservatively managed FAs demonstrated a reduction in size after the culprit AVM was treated, this was only significant in FAs located close to an AVM nidus (class IIb). There were no hemorrhages during the median 35 months' follow-up; however, long-term data are lacking. Our data support close observation of all conservatively managed aneurysms and a tailored approach based on the proximity to the nidus and observed changes in size.
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Affiliation(s)
- Karol P Budohoski
- Department of Neurosurgery, Cambridge University Hospitals, University of Cambridge, Cambridge, United Kingdom.
| | - Midhun Mohan
- Department of Neurosurgery, Cambridge University Hospitals, University of Cambridge, Cambridge, United Kingdom
| | - Zack Millar
- Department of Neurosurgery, Cambridge University Hospitals, University of Cambridge, Cambridge, United Kingdom
| | - Tamara Tajsic
- Department of Neurosurgery, Cambridge University Hospitals, University of Cambridge, Cambridge, United Kingdom
| | - Damiano G Barone
- Department of Neurosurgery, Cambridge University Hospitals, University of Cambridge, Cambridge, United Kingdom
| | - Jennifer J L Cao
- Department of Neurosurgery, Cambridge University Hospitals, University of Cambridge, Cambridge, United Kingdom
| | - Saniya Mediratta
- Department of Neurosurgery, Cambridge University Hospitals, University of Cambridge, Cambridge, United Kingdom
| | - Ellie Phelps
- Department of Neurosurgery, Cambridge University Hospitals, University of Cambridge, Cambridge, United Kingdom
| | - Tanmay Sukthankar
- Department of Neurosurgery, Cambridge University Hospitals, University of Cambridge, Cambridge, United Kingdom
| | - Ramez W Kirollos
- Department of Neurosurgery, National Neurosciences Institute, Singapore, Singapore
| | - Adel E Helmy
- Department of Neurosurgery, Cambridge University Hospitals, University of Cambridge, Cambridge, United Kingdom; Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospitals, University of Cambridge, Cambridge, United Kingdom
| | - Mathew R Guilfoyle
- Department of Neurosurgery, Cambridge University Hospitals, University of Cambridge, Cambridge, United Kingdom
| | - Rikin A Trivedi
- Department of Neurosurgery, Cambridge University Hospitals, University of Cambridge, Cambridge, United Kingdom
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15
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Current concepts and perspectives on brain arteriovenous malformations: A review of pathogenesis and multidisciplinary treatment. World Neurosurg 2021; 159:314-326. [PMID: 34339893 DOI: 10.1016/j.wneu.2021.07.106] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 11/23/2022]
Abstract
Brain arteriovenous malformations (bAVMs) are unusual vascular pathologies characterized by the abnormal aggregation of dilated arteries and veins in the brain parenchyma and for which the absence of a normal vascular structure and capillary bed leads to direct connections between arteries and veins. Although bAVMs have long been believed to be congenital anomalies that develop during the prenatal period, current studies show that inflammation is associated with AVM genesis, growth, and rupture. Interventional treatment options include microsurgery, stereotactic radiosurgery, and endovascular embolization, and management often comprises a multidisciplinary combination of these modalities. The appropriate selection of patients with brain arteriovenous malformations for interventional treatment requires balancing the risk of treatment complications against the risk of hemorrhaging during the natural course of the pathology; however, no definitive guidelines have been established for the management of brain arteriovenous malformations. In this paper, we comprehensively review the current basic and clinical studies on bAVMs and discuss the contemporary status of multidisciplinary management of bAVMs.
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16
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Steczek P, Tazarourte K, Benhamed A. Rupture de malformation artérioveineuse cérébelleuse secondaire à un traumatisme crânien léger. ANNALES FRANCAISES DE MEDECINE D URGENCE 2021. [DOI: 10.3166/afmu-2021-0327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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17
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D'Andrea M, Mongardi L, Fuschillo D, Musio A, Commodaro C, Quilis-Quesada V, Tosatto L. Vermian subtentorial arteriovenous malformation supplied by the artery of Wollschlaeger and Wollschlaeger. Clin Neurol Neurosurg 2021; 206:106670. [PMID: 34015698 DOI: 10.1016/j.clineuro.2021.106670] [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: 11/07/2020] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The artery of Wollschlaeger and Wollschlaeger is a tentorial branch of the superior cerebellar artery: due to its small diameter, it is not usually seen in normal angiograms except when enlarged in the setting of a dural AVF or tentorial meningioma. Its presence has been rarely described in the Literature. CASE REPORT herein we describe the first ever reported case of a vermian subtentorial arteriovenous malformation supplied by the artery of Wollschlaeger and Wollschlaeger in 70 year old female patient. CONCLUSION vermian subtentorial AVMs supplied by the artery of Wollschlaeger and Wollschlaeger are extremely rare vascular malformations. The presence of the artery of Wollschlaeger and Wollschlaeger must be carefully evaluated during preoperative surgical planning due to its key role in the supply of vascular malformation and to decrease the risk of intra operative bleeding during surgery.
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Affiliation(s)
- M D'Andrea
- Neurosurgery Division, M. Bufalini Hospital, Viale Ghirotti 286, 47521 Cesena, Italy
| | - L Mongardi
- Neurosurgery, Sant'Anna University Hospital Ferrara, Via Aldo Moro 8, 44124, Cona (Ferrara), Italy.
| | - D Fuschillo
- Neurosurgery Division, M. Bufalini Hospital, Viale Ghirotti 286, 47521 Cesena, Italy
| | - A Musio
- Neurosurgery, Sant'Anna University Hospital Ferrara, Via Aldo Moro 8, 44124, Cona (Ferrara), Italy
| | - C Commodaro
- Neuroradiology Division, M. Bufalini Hospital, Viale Ghirotti 286, 47521 Cesena, Italy
| | | | - L Tosatto
- Neurosurgery Division, M. Bufalini Hospital, Viale Ghirotti 286, 47521 Cesena, Italy
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18
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García-Pérez D, Panero I, Munarriz PM, Jimenez-Roldán L, Lagares A, Alén JA. Hemodynamic alterations following a cerebellar arteriovenous malformation resection: Case report and densitometric quantitative analysis from CT imaging. Neurocirugia (Astur) 2021; 33:S1130-1473(21)00008-7. [PMID: 33716014 DOI: 10.1016/j.neucir.2020.12.006] [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: 11/01/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Cerebellar arteriovenous malformations (cAVMs) are rare and challenging lesions with an aggressive natural history. The mechanisms whereby a patient can worsen clinically after a supratentorial AVM resection include an acute alteration in cerebral hemodynamics, which is a known cause of postoperative hyperemia, edema and/or hemorrhage. These phenomena has not been described for cAVMS. Moreover, the underlying pathophysiology of edema and hemorrhage after AVM resection still remains controversial. METHODS We report a patient that presented an abrupt neurological deterioration after cAVM surgical resection. Emergent external ventricular drainage to treat incipient hydrocephalus only partially reverted the patient's deterioration. Consecutive post-surgery CT images revealed fourth ventricle compression secondary to cerebellar swelling that concurred with a new neurological deterioration. Densitometric analysis was performed in these CT images to reveal the nature of these changes as well as their evolution over time. RESULTS Importantly, we demonstrated a dynamic increase in the cerebellum mean density at the interval of Hounsfield values which correspond to hyperemia values. These changes were dynamic, and when hyperemia resolved and cerebellar density returned to basal levels, the fourth ventricle re-expanded and the patient neurologically recovered. CONCLUSIONS This study demonstrated the utility of quantitative CT image analysis in the context of hemodynamic alterations following cAVM resection. Densitometric CT analysis demonstrated that hyperemic changes, but not ischemic ones, were time-dependent and were responsible for swelling and hemorrhage that conditioned neurological status and patient's evolution.
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Affiliation(s)
- Daniel García-Pérez
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, Madrid 28041, Spain.
| | - Irene Panero
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, Madrid 28041, Spain
| | - Pablo M Munarriz
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, Madrid 28041, Spain
| | - Luis Jimenez-Roldán
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, Madrid 28041, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, Madrid 28041, Spain
| | - José A Alén
- Department of Neurosurgery, University Hospital 12 de Octubre, Avda de Córdoba s/n, Madrid 28041, Spain
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19
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Hendricks BK, Cohen-Gadol AA. Giant diffuse cerebellar AVM: managing ultimate intraoperative challenges. NEUROSURGICAL FOCUS: VIDEO 2021; 4:V12. [PMID: 36284614 PMCID: PMC9542586 DOI: 10.3171/2020.10.focvid2093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/16/2020] [Indexed: 06/16/2023]
Abstract
Surgery within the posterior cranial fossa uniquely requires excellence in microsurgical technique, given the complexity of the neurovascular structures housed within this region. Arteriovenous malformations (AVMs) within this region represent the greatest surgical challenge because of the difficulty in resecting an AVM completely while preserving the highly eloquent surrounding structures. The AVM in this video exemplifies a surgeon's "most challenging case," a surgery that spanned two stages, including 14 hours of resection, but concluded with complete resection despite the complexity of deep arterial and dural feeders. The video can be found here: https://youtu.be/WNBuwFHSrQ0.
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Affiliation(s)
| | - Aaron A. Cohen-Gadol
- The Neurosurgical Atlas, Carmel; and
- Department of Neurological Surgery, Indiana University, Indianapolis, Indiana
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20
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Rodriguez-Calienes A, Saal-Zapata G, De la Cruz J. Endovascular Treatment of an Arteriovenous Malformation Associated with a Double Origin of the Posterior Inferior Cerebellar Artery. Pediatr Neurosurg 2021; 56:492-496. [PMID: 34237747 DOI: 10.1159/000517248] [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: 12/16/2020] [Accepted: 05/14/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION A double origin of the posterior inferior cerebellar artery (DOPICA) is a rare anatomical variant. Posterior fossa arteriovenous malformations (AVMs), especially cerebellar AVMs, are also not common. Consequently, the association of a DOPICA with a cerebellar AVM is even rare. CASE PRESENTATION We present a rare case of a pediatric cerebellar AVM supplied by a branch of a DOPICA which was treated endovascularly with NBCA. Total obliteration was achieved in the immediate controls and at 1-year follow-up. CONCLUSION Navigation through tortuous and long branches from a DOPICA is technically feasible. Although NBCA cure rates are relatively low, when the microcatheter can no longer navigate through the feeding artery, a correct dilution of NBCA with lipiodol can provide adequate penetration of this embolic agent, to obliterate the AVM nidus completely.
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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
| | - Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Joselyn De la Cruz
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru
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21
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Marani W, Montemurro N, Tsuji S, Perrini P, Noda K, Ota N, Kinoshita Y, Kamiyama H, Tanikawa R. Microsurgical resection of unruptured cerebellar arteriovenous malformation presenting with trigeminal neuralgia. NEUROSURGICAL FOCUS: VIDEO 2021; 4:V13. [PMID: 36284621 PMCID: PMC9542384 DOI: 10.3171/2020.10.focvid2071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/15/2020] [Indexed: 11/28/2022]
Abstract
Cerebellar arteriovenous malformations (AVMs) represent 10%–15% of all intracranial AVMs and are associated with a greater risk for hemorrhagic presentation compared with supratentorial AVMs. When they reach the cerebellopontine angle cistern, neurovascular compression syndromes, including trigeminal neuralgia and hemifacial spasm, can occur. Due to the aggressive natural history of cerebellar AVM, an effective treatment strategy is required. In this video, the authors demonstrate the technical nuances of microsurgical resection of an unruptured cerebellar AVM in a 24-year-old female presenting with trigeminal neuralgia. The patient underwent right retrosigmoid craniotomy and complete resection of the AVM with resolution of trigeminal neuralgia. The video can be found here: https://youtu.be/6GmNjgFQwx8
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Affiliation(s)
- Walter Marani
- Far East Neurosurgical Institute, Sapporo Teishinkai Hospital, Sapporo, Japan
- Department of Neurosurgery, Azienda Ospedaliera Universitaria Pisana (AOUP), Pisa; and
| | - Nicola Montemurro
- Department of Neurosurgery, Azienda Ospedaliera Universitaria Pisana (AOUP), Pisa; and
- Department of Translational Research on New Surgical and Medical Technologies, University of Pisa, Italy
| | - Shoichiro Tsuji
- Far East Neurosurgical Institute, Sapporo Teishinkai Hospital, Sapporo, Japan
| | - Paolo Perrini
- Department of Neurosurgery, Azienda Ospedaliera Universitaria Pisana (AOUP), Pisa; and
- Department of Translational Research on New Surgical and Medical Technologies, University of Pisa, Italy
| | - Kosumo Noda
- Far East Neurosurgical Institute, Sapporo Teishinkai Hospital, Sapporo, Japan
| | - Nakao Ota
- Far East Neurosurgical Institute, Sapporo Teishinkai Hospital, Sapporo, Japan
| | - Yu Kinoshita
- Far East Neurosurgical Institute, Sapporo Teishinkai Hospital, Sapporo, Japan
| | - Hiroyasu Kamiyama
- Far East Neurosurgical Institute, Sapporo Teishinkai Hospital, Sapporo, Japan
| | - Rokuya Tanikawa
- Far East Neurosurgical Institute, Sapporo Teishinkai Hospital, Sapporo, Japan
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22
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Demartini Z, Ceccato GHW, da Trindade ÉSGG, Borba LAB. Multimodal treatment of a pediatric posterior fossa arteriovenous malformation employing endovascular and microsurgical techniques. NEUROSURGICAL FOCUS: VIDEO 2021; 4:V17. [PMID: 36284618 PMCID: PMC9542227 DOI: 10.3171/2020.10.focvid2064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 10/21/2020] [Indexed: 11/18/2022]
Abstract
Intracranial hemorrhage is the most common presentation of posterior fossa arteriovenous malformations (AVMs) and may have serious consequences. The authors present a case of a 7-year-old girl with headache, vomiting, dysmetria, and ataxia due to a ruptured cerebellar grade III AVM. After two sessions of embolization, the patient underwent total microsurgical resection through a suboccipital craniotomy. There were no additional postoperative deficits, and the patient improved progressively during 6 months of rehabilitation. These challenging lesions should be removed after rupture, especially in children with long-term cumulative risk of rebleeding. Multimodal treatment reduces the perioperative bleeding, allowing better outcomes for pediatric AVM. The video can be found here: https://youtu.be/HQWnjD8ENZQ
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Phuyal S, Agrawal P, Dawadi K, Paudel R, Lamsal R. The First Successful Endovascular Management of Posterior Fossa Arteriovenous Malformations in Nepal: Case Series. ACTA ACUST UNITED AC 2020; 58:1089-1092. [PMID: 34506400 PMCID: PMC8028537 DOI: 10.31729/jnma.4933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 12/29/2020] [Indexed: 12/03/2022]
Abstract
Posterior fossa arteriovenous malformations represent 7-15% of all intracranial AVMs. They carry a higher risk of rupture than supratentorial AVMs and are associated with considerable rates of morbidity and mortality. Available treatment options include conservative management, microsurgical resection, radiosurgery, endovascular embolization, or combinations of these modalities. Recent advances in endovascular techniques have revolutionized their management with better clinical outcomes. We illustrate two cases of posterior fossa AVMs treated by endovascular techniques with good clinical outcomes. The first patient also had associated flow-related aneurysms. One of these aneurysms had already ruptured, so it was coiled first followed by AVM nidus embolization using the same microcatheter. The second patient had a diffuse type of posterior fossa AVM for which staged-embolization was planned and the first-stage partial embolization was successfully performed.
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Affiliation(s)
- Subash Phuyal
- Department of Neuroimaging and Intervention Neuroradiology, Grande International Hospital, Dhapasi, Kathmandu, Nepal
| | - Pooja Agrawal
- Department of Radiology, Norvic International Hospital, Thapathali, Kathmandu, Nepal
| | - Kapil Dawadi
- Department of Neuroimaging and Intervention Neuroradiology, Grande International Hospital, Dhapasi, Kathmandu, Nepal
| | - Raju Paudel
- Department of Neurology, Grande International Hospital, Dhapasi, Kathmandu, Nepal
| | - Ritesh Lamsal
- Department of Anaesthesiology, Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal
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Healy V, O'Halloran PJ, Husien MB, Bolger C, Farrell M. Intermixed arteriovenous malformation and hemangioblastoma: case report and literature review. CNS Oncol 2020; 9:CNS66. [PMID: 33244995 PMCID: PMC7737198 DOI: 10.2217/cns-2020-0021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 10/27/2020] [Indexed: 12/14/2022] Open
Abstract
We report the third presentation of an intermixed arteriovenous malformation and hemangioblastoma. The rare occurrence of the diagnostic histologic features of both a neoplasm and vascular malformation in a single lesion is more common in gliomas, as angioglioma, and is termed an 'intermixed' lesion. We review the literature concerning the developmental biology of each lesion, and potential interplay in the formation of an intermixed vascular neoplasm and vascular malformation. The roles of cellular origin, genetic susceptibility, favourable microenvironment, altered local gene expression and key regulatory pathways are reviewed. Our review supports angiography and genetic profiling in intermixed lesions to inform management strategies. Consideration should be given to multimodality therapeutic interventions as required, including microsurgical resection, stereotactic radiosurgery and further research to exploit emerging molecular targets.
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Affiliation(s)
- Vincent Healy
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
- Department of Neuroscience, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Philip J O'Halloran
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
- Department of Neuroscience, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Ciaran Bolger
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
- Department of Neuroscience, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Michael Farrell
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
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Tjahjadi M, Wijaya V, Serrone J, Caropeboka MS. Trigeminal Neuralgia Secondary to Cerebellar Arteriovenous Malformation: A Report of Two Cases. Asian J Neurosurg 2020; 15:745-749. [PMID: 33145245 PMCID: PMC7591222 DOI: 10.4103/ajns.ajns_229_20] [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: 05/11/2020] [Revised: 06/14/2020] [Accepted: 07/04/2020] [Indexed: 11/28/2022] Open
Abstract
Trigeminal neuralgia (TN) secondary to cerebellar arteriovenous malformation (cAVM) is a rare condition with only few reports existing in the literatures. Given to its rarity, the treatment armamentarium is still controversial. We reported our experiences treated two cases of TN secondary to cAVM using different strategies. The first case was successfully treated by a combination of gamma knife radiosurgery and microvascular decompression (MVD) of the trigeminal nerve. The second case was successfully treated by one-step microsurgical AVM resection and MVD of the trigeminal nerve. Postoperative immediate pain relief was achieved in both patients. Microsurgical procedure is still playing an important role in treating TN secondary to cAVM.
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Affiliation(s)
- Mardjono Tjahjadi
- Department of Surgery, Universitas Pembangunan Nasional Veteran Jakarta/Pasar Minggu Regional Hospital, Jakarta, Indonesia.,Department of Surgery, Universitas Katolik Indonesia Atmajaya, Jakarta, Indonesia
| | - Vincent Wijaya
- Department of Surgery, Universitas Katolik Indonesia Atmajaya, Jakarta, Indonesia
| | - Joseph Serrone
- Department of Neurosurgery, Loyola University Medical Center, Chicago, Illinois, USA
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Guerrero WR, Dandapat S, Ortega-Gutierrez S. Hemorrhagic Cerebrovascular Pathology in the Pediatric Population. Front Neurol 2020; 11:1055. [PMID: 33041990 PMCID: PMC7527474 DOI: 10.3389/fneur.2020.01055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/11/2020] [Indexed: 01/10/2023] Open
Abstract
Hemorrhagic cerebrovascular disease in the pediatric population can have devastating and long-term effects. Progress in the fields of genetics, neuroimaging, pharmacology, and surgical techniques has led to improved diagnosis and management of pediatric cerebrovascular diseases. In this review we discuss the current etiologies and medical and surgical treatments of hemorrhagic cerebrovascular pathology affecting infants and children. A special emphasis is placed on neuroendovascular treatment options. Increased knowledge about this unique pathology and the medical and therapeutic options will empower practitioners to more quickly and accurately identify and accurately treat hemorrhagic diseases in the pediatric population.
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Affiliation(s)
- Waldo R Guerrero
- Department of Neurosurgery, University of South Florida Morsani College of Medicine, Tampa, FL, United States
| | - Sudeepta Dandapat
- Department of Neurology, Radiology, and Neurosurgery, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, IA, United States
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Radiology, and Neurosurgery, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, IA, United States
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Magro E, Darsaut TE, Mezui EDO, Bojanowski MW, Ziegler D, Gentric JC, Roy D, Raymond J. Arteriovenous malformations of the posterior fossa: a systematic review. Acta Neurochir (Wien) 2020; 162:905-910. [PMID: 32067118 DOI: 10.1007/s00701-020-04260-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/10/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Posterior fossa arteriovenous malformations (pfAVMs) can be challenging lesions to manage. AVMs in this location may have distinct features compared with supratentorial AVMs. Our aim was to systematically review the literature on the presenting characteristics of pfAVMs and compare clinical and angiographic outcomes after the various types of treatment employed. METHODS The review was conducted according to the Cochrane Collaboration guidelines. Electronic databases from 1900 to March 2018 were searched and complemented by hand-searching and cross-referencing. Articles were categorized into (i) AVM studies that included those in the posterior fossa, (ii) those that focused exclusively on pfAVM, and (iii) those that further specified a cerebellar or brainstem location of the AVM. RESULTS Seventy-seven articles with 4512 pfAVM patients were retained for analyses. Compared with historical supratentorial controls, pfAVMs were reported to more frequently present with rupture, to more commonly have associated arterial aneurysms, and to more frequently lead to poor clinical and angiographic outcomes. The quality of the literature and lack of standardization of outcome reporting precluded performing a meta-analysis on the results of the various different treatment modalities. CONCLUSIONS Posterior fossa AVMs may have some distinct features compared with supratentorial AVMs. The available reports on pfAVMs are not sufficiently standardized to provide reliable guidance for patient management decisions. This goal will require future studies to be multicentric and to focus on standardized, repeatable clinical and angiographic outcomes.
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Sato K, Matsumoto Y, Tominaga T, Satow T, Iihara K, Sakai N. Complications of Endovascular Treatments for Brain Arteriovenous Malformations: A Nationwide Surveillance. AJNR Am J Neuroradiol 2020; 41:669-675. [PMID: 32193193 PMCID: PMC7144660 DOI: 10.3174/ajnr.a6470] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/10/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Embolization is widely performed to treat brain arteriovenous malformations, but little has been reported on factors contributing to complications. We retrospectively reviewed a nationwide surveillance to identify risk factors contributing to complications and short-term clinical outcomes in the endovascular treatment of brain arteriovenous malformations. MATERIALS AND METHODS Data for endovascular treatment of brain arteriovenous malformations were extracted from the Japanese nationwide surveillance. Patient characteristics, brain arteriovenous malformation features, procedures, angiographic results, complications, and clinical outcomes at 30 days postprocedure were analyzed. RESULTS A total of 1042 endovascular procedures (788 patients; mean, 1.43 ± 0.85 procedures per patient) performed in 111 institutions from 2010 to 2014 were reviewed. Liquid materials were used in 976 procedures (93.7%): to perform presurgical embolization in 638 procedures (61.2%), preradiosurgical embolization in 160 (15.4%), and as sole endovascular treatment in 231 (22.2%). Complete or near-complete obliteration of brain arteriovenous malformations was obtained in 386 procedures (37.0%). Procedure-related complications occurred in 136 procedures (13.1%), including hemorrhagic complications in 59 (5.7%) and ischemic complications in 57 (5.5%). Univariate analysis identified deep venous drainage, associated aneurysms, infratentorial location, and preradiosurgical embolization as statistically significant risk factors for complications. Multivariate analysis showed that embolization of brain arteriovenous malformations in the infratentorial location was significantly associated with complications. Patients with complications due to endovascular procedures had worse clinical outcomes 30 days after the procedures than those without complications. CONCLUSIONS Complications arising after endovascular treatment of brain arteriovenous malformations are not negligible even though they may play a role in adjunctive therapy, especially in the management of infratentorial brain arteriovenous malformations.
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Affiliation(s)
- K Sato
- From the Department of Neuroendovascular Therapy (K.S., Y.M.), Kohnan Hospital, Sendai, Japan
| | - Y Matsumoto
- From the Department of Neuroendovascular Therapy (K.S., Y.M.), Kohnan Hospital, Sendai, Japan
| | - T Tominaga
- Department of Neurosurgery (T.T.), Tohoku Graduate School of Medicine, Sendai, Japan
| | - T Satow
- Department of Neurosurgery (T.S.), National Cerebral and Cardiovascular Center, Suita, Japan
| | - K Iihara
- Department of Neurosurgery (K.I.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - N Sakai
- Department of Neurosurgery (N.S.), Kobe City Medical Center General Hospital, Kobe, Japan
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Saal-Zapata G, Valer D, Rodriguez R. Single-session Curative Embolization of Unruptured Cerebellar Arteriovenous Malformation with Precipitating Hydrophobic Injectable Liquid. INDIAN JOURNAL OF NEUROSURGERY 2020. [DOI: 10.1055/s-0039-3403457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
AbstractMicrosurgery is the treatment of choice for cerebellar arteriovenous malformations (AVMs). Nevertheless, endovascular therapy aims to be an effective treatment since the introduction of new embolic agents. Cerebellar AVMs represent a subgroup of vascular lesions with a high rate of hemorrhagic presentation compared with their cerebral counterpart. Moreover, they have a higher incidence of flow-related aneurysms when diagnosed. With this in mind, prompt treatment must be performed to avoid rebleeding with devastating consequences. Herein, we present the case of an unruptured cerebellar AVM treated with precipitating hydrophobic injectable liquid (PHIL) with complete obliteration.
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Affiliation(s)
- Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen - EsSalud, La Victoria, Lima, Perú
| | - Dante Valer
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen - EsSalud, La Victoria, Lima, Perú
| | - Rodolfo Rodriguez
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen - EsSalud, La Victoria, Lima, Perú
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Lefevre E, Robert T, Escalard S, Fahed R, Smajda S, Ciccio G, Desilles JP, Mazighi M, Blanc R, Piotin M. Presence of direct vertebrobasilar perforator feeders in posterior fossa arteriovenous malformations and association with poor outcomes after endovascular treatment. J Neurosurg 2019; 133:1802-1810. [PMID: 31703199 DOI: 10.3171/2019.8.jns191971] [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: 07/20/2019] [Accepted: 08/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Treatment of posterior fossa arteriovenous malformations (PFAVMs) remains controversial as it is always challenging and may lead to major complications. Nonetheless, these lesions are more likely to bleed and generate poorer outcomes than other brain AVMs. The aim of this study was to evaluate the effect of endovascular treatment on long-term outcomes and identify the patient subgroups that might benefit from endovascular treatment. METHODS The authors performed a retrospective analysis of all consecutive cases of PFAVM managed at the Fondation Rothschild Hospital between 1995 and 2018. Clinical, imaging, and treatment data were prospectively gathered; these data were analyzed with respect to long-term outcomes. RESULTS Among the 1311 patients with brain AVMs, 114 (8.7%) had a PFAVM, and 88 (77.2%) of these patients had a history of bleeding. Of the 114 PFAVMs, 101 (88.6%) were treated (83 ruptured and 18 unruptured). The mean duration of follow-up was 47.6 months (range 0-240 months). Good neurological outcome at last follow-up was achieved in 79 cases (78.2%). Follow-up angiography showed obliteration of the PFAVM in 68.3% of treated cases. The presence of direct vertebrobasilar perforator feeders was associated with neurological deterioration (OR 5.63, 95% CI 11.15-30.76) and a lower obliteration rate (OR 15.69, 95% CI 2.52-304.03) after endovascular treatment. Other predictors of neurological deterioration and obliteration rate were consistent with the Spetzler-Martin grading system. CONCLUSIONS Advances in endovascular techniques have enabled higher obliteration rates in the treatment of PFAVMs, but complication rates are still high. Subgroups of patients who might benefit from treatment must be carefully selected and the presence of direct vertebrobasilar perforator feeders must call into question the indication for endovascular treatment.
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Affiliation(s)
- Etienne Lefevre
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Thomas Robert
- 2Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Ticino, Switzerland
| | - Simon Escalard
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Robert Fahed
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Stanislas Smajda
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Gabriele Ciccio
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Jean-Philippe Desilles
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Mikael Mazighi
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Raphaël Blanc
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Michel Piotin
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
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van Rooij SBT, Bechan RS, van Rooij WJ, Sprengers ME. Current Hospital Demographics of Subarachnoid Hemorrhage Based on CT Angiography and 3D Rotational Angiography in a Neurosurgical Center. AJNR Am J Neuroradiol 2019; 40:1013-1017. [PMID: 31072975 DOI: 10.3174/ajnr.a6060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 04/04/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Aneurysmal subarachnoid hemorrhage is an important cause of mortality and morbidity. Modern hospital demographics are scarce. We evaluated the diagnosis and treatment of patients with SAH in a neurosurgical referral center. MATERIALS AND METHODS Between March 2013 and April 2015, two hundred eighty-four patients with SAH diagnosed on CT or lumbar puncture were admitted. All patients underwent 64- to 128-detector row CT angiography. Additional imaging was with 3D rotational angiography of all vessels. In patients with aneurysms, characteristics and mode of treatment were recorded. RESULTS In 197 of 220 patients with an aneurysmal bleeding pattern, we found a cause of the bleeding: One hundred ninety-five patients had a ruptured aneurysm (98%); 1 patient, a micro-AVM; and 1 patient, reversible vasoconstriction syndrome. Of 195 ruptured aneurysms, 6 were dissecting aneurysms and 3 were AVM-associated flow aneurysms. In 23 of 204 patients (11%) with an aneurysmal bleeding pattern and 3D rotational angiography performed, no cause was found. In 8 of 9 patients (89%) with lumbar puncture positive for SAH but CT negative for it, no cause was found. Of 180 patients with a ruptured aneurysm eligible for treatment, 147 (82%) were treated endovascularly and 30 aneurysms (17%) were clipped. Of 204 patients with an aneurysmal bleeding pattern and 3D rotational angiography, 72 (35%) had multiple aneurysms. These 72 patients had, altogether, 117 additional aneurysms, of which 24 (21%) were treated by either coiling or clipping. CONCLUSIONS This study provides robust data on hospital demographics of SAH in a neurosurgical referral center, based on CTA and 3D rotational angiography of all vessels.
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Affiliation(s)
- S B T van Rooij
- From the Department of Radiology (S.B.T.v.R.), Noordwest ZIekenhuisgroep Alkmaar, the Netherlands
| | - R S Bechan
- Universitair Medisch Centrum Amsterdam (R.S.B.), Vrije Universiteit, Amsterdam, the Netherlands
| | - W J van Rooij
- Algemeen Ziekenhuis Turnhout (W.J.v.R.), Turnhout, Belgium
| | - M E Sprengers
- Universitair Medisch Centrum Amsterdam (M.E.S.), Academisch Medisch Centrum, Amsterdam, the Netherlands
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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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Dinc N, Won SY, Quick-Weller J, Berkefeld J, Seifert V, Marquardt G. Prognostic variables and outcome in relation to different bleeding patterns in arteriovenous malformations. Neurosurg Rev 2019; 42:731-736. [DOI: 10.1007/s10143-019-01091-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/12/2019] [Accepted: 02/25/2019] [Indexed: 12/27/2022]
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34
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Nisson PL, Fard SA, Meybodi AT, Mooney MA, Kim H, Jahnke H, Walter CM, Dumont TM, Lemole GM, Lawton MT, Spetzler RF. The Unique Features and Outcomes of Microsurgically Resected Cerebellar Arteriovenous Malformations. World Neurosurg 2018; 120:e940-e949. [DOI: 10.1016/j.wneu.2018.08.194] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 08/23/2018] [Accepted: 08/24/2018] [Indexed: 11/16/2022]
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35
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Cerebellar arteriovenous malformation presenting with recurrent positional vertigo. J Neurol 2018; 266:247-249. [PMID: 30377820 DOI: 10.1007/s00415-018-9103-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/20/2018] [Accepted: 10/21/2018] [Indexed: 10/28/2022]
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36
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Endovascular Therapy for Brainstem Arteriovenous Malformations. World Neurosurg 2018; 125:481-488. [PMID: 30149173 DOI: 10.1016/j.wneu.2018.08.099] [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] [Received: 06/24/2018] [Revised: 08/11/2018] [Accepted: 08/13/2018] [Indexed: 11/21/2022]
Abstract
Brainstem arteriovenous malformations (AVMs) represent ∼5% of all intracranial AVMs and carry a higher risk of hemorrhage than their supratentorial counterparts. There is a high and near-uniform mortality with initial and recurrent episodes of hemorrhage. Brainstem AVMs may also present symptomatically with focal neurologic deficits or hydrocephalus. Treatment is indicated for ruptured and symptomatic brainstem AVMs, as well as those possessing high-risk angioarchitectural features. Microsurgical resection and stereotactic radiosurgery are ideal therapeutic options when feasible. Embolization is most commonly used as adjunctive treatment before surgery or stereotactic radiosurgical irradiation. Preoperative embolization facilitates microsurgical resection and reduces intraoperative and postoperative hemorrhage rates. Use of embolization preradiosurgically helps to reduce nidal size, transforming a large lesion to a size amenable to radiosurgical intervention, increasing the probability of obliteration, decreasing procedural hemorrhage risk, stabilizing the lesion until radiotherapeutic effect achieves obliteration, and providing interval symptomatic resolution. Embolization may also be used effectively as stand-alone monotherapy for small lesions with 1 or 2 arterial feeders not supplying eloquent parenchyma. Although an extensive evidence base exists for clinical usefulness of stereotactic radiosurgery as monotherapy or in combination with other therapeutic modalities, only a few studies have reported specifically on obliteration and complication rates with monotherapeutic embolization in the treatment of brainstem AVMs. The potential role of embolization as monotherapy for brainstem AVMs is reviewed and discussed.
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Dinc N, Platz J, Tritt S, Quick-Weller J, Eibach M, Wolff R, Berkefeld J, Seifert V, Marquardt G. Posterior fossa AVMs: Increased risk of bleeding and worse outcome compared to supratentorial AVMs. J Clin Neurosci 2018; 53:171-176. [DOI: 10.1016/j.jocn.2018.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 02/07/2018] [Accepted: 04/08/2018] [Indexed: 10/14/2022]
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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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Elewa MK. Cerebral arteriovenous malformations in the era of embolization for angiographic cure: a single-center experience in Egypt. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2018; 54:12. [PMID: 29780232 PMCID: PMC5954783 DOI: 10.1186/s41983-018-0003-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 03/23/2018] [Indexed: 11/10/2022] Open
Abstract
Background Embolization for cerebral arteriovenous malformations (AVMs) has evolved in the last decade with evolution in both equipment and material. Embolization targets have expanded to include angiographic cure. Methods To discuss the technical and management outcomes of our first cerebral AVM case series treated with embolization. The clinical, angiographic, treatment, and outcome variables of consecutive cerebral arteriovenous malformation cases, treated with curative embolization, between January 2011 and June 2017 in one regional center, were retrospectively analyzed. Results In 21 patients, 21 AVMs were identified, and 13 patients (61.9%) were males. The mean of the age was 34.24 ± 12.99. Fifteen patients (71.4%) had a history of intracranial hemorrhage, and 10 (47.6%) patients had seizures. Sixteen patients (76.2%) were at grade 1 of modified Rankin Scale (mRS) at admission. The median for modal Spetzler-Martin grade was 2. The average number of arterial feeders was 3. Direct arteriovenous fistulas were found in 4 cases (19.0%). Venous aneurysms were found in 4 cases (19.0%). Seventeen AVMs (80.9%) were considered high bleeding risk lesions. Forty-three embolization sessions were done. Early hemorrhage occurred in 3 sessions (7.0%). Vessel perforation occurred 1 session (2.3%). Poor outcome occurred in 1 patient that was discharged at grade 3 mRS. Angiographic cure was achieved in 9 patients (42.9%). The average size reduction was 65%. Conclusions Onyx embolization could serve as a curative option for AVM treatment with accepted morbidity and mortality.
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Affiliation(s)
- Mohamed K Elewa
- Neurology Department, Ain Shams University, 38 El-Abbasia, Cairo, 11566 Egypt
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Al Safatli D, Guenther A, McLean AL, Waschke A, Kalff R, Ewald C. Prediction of 30-day mortality in spontaneous cerebellar hemorrhage. Surg Neurol Int 2017; 8:282. [PMID: 29279799 PMCID: PMC5705929 DOI: 10.4103/sni.sni_479_16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 05/30/2017] [Indexed: 11/05/2022] Open
Abstract
Background: Cerebellar hemorrhage is a potentially life-threatening condition and an understanding of the factors influencing outcome is essential for sound clinical decision-making. Methods: We retrospectively evaluated data from 50 consecutive patients who suffered a first spontaneous cerebellar hemorrhage (SCH) from 2005 to 2014, analysing their short-term outcomes and identifying possible clinical, radiological and therapeutic risk factors for poor prognosis and death within 30 days. Results: Among 50 patients with first SCH, the mean age was 72 ± 10 years. Median Glasgow Coma Scale (GCS) score on admission was 11 [interquartile range (IQR) = 7–11]. Among 50 patients, 19 patients (38%) underwent surgical hemorrhage evacuation with placement of an external ventricular drain (EVD), 12 patients (24%) received an EVD only and 19 patients (38%) were treated conservatively. The 30-day mortality rate was 36%. In multivariate analysis only the GCS score on admission was a significant predictor of 30-day mortality [odds ratio (OR) = 0.598; 95% confidence interval (CI) = 0.406–0.879; P = 0.009]. For prediction of 30-day mortality, receiver operating characteristic curve analysis confirmed that the best cut-off point was a GCS score of 10 on admission [area under the curve: 0.882, 95% CI = 0.717–1, P < 0.001]. Conclusion: Lower GCS score on admission was associated with increased 30-day mortality and poorer short-term outcome in patients with SCH. For patients with a GCS score <10 on admission, it is important to balance the possibility of survival afforded by further therapy against the formidable risk of significant functional disability and poor quality of life.
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Affiliation(s)
- Diaa Al Safatli
- Department of Neurosurgery, Jena University Hospital, Friedrich Schiller University Jena, Germany
| | - Albrecht Guenther
- Department of Neurology, Jena University Hospital, Friedrich Schiller University Jena, Germany
| | - Aaron Lawson McLean
- Department of Neurosurgery, Jena University Hospital, Friedrich Schiller University Jena, Germany
| | - Albrecht Waschke
- Department of Neurosurgery, Jena University Hospital, Friedrich Schiller University Jena, Germany
| | - Rolf Kalff
- Department of Neurosurgery, Jena University Hospital, Friedrich Schiller University Jena, Germany
| | - Christian Ewald
- Department of Neurosurgery, Jena University Hospital, Friedrich Schiller University Jena, Germany
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Cohen-Inbar O, Starke RM, Kano H, Bowden G, Huang P, Rodriguez-Mercado R, Almodovar L, Grills IS, Mathieu D, Silva D, Abbassy M, Missios S, Lee JYK, Barnett GH, Kondziolka D, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for cerebellar arteriovenous malformations: an international multicenter study. J Neurosurg 2017; 127:512-521. [DOI: 10.3171/2016.7.jns161208] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVECerebellar arteriovenous malformations (AVMs) represent the majority of infratentorial AVMs and frequently have a hemorrhagic presentation. In this multicenter study, the authors review outcomes of cerebellar AVMs after stereotactic radiosurgery (SRS).METHODSEight medical centers contributed data from 162 patients with cerebellar AVMs managed with SRS. Of these patients, 65% presented with hemorrhage. The median maximal nidus diameter was 2 cm. Favorable outcome was defined as AVM obliteration and no posttreatment hemorrhage or permanent radiation-induced complications (RICs). Patients were followed clinically and radiographically, with a median follow-up of 60 months (range 7–325 months).RESULTSThe overall actuarial rates of obliteration at 3, 5, 7, and 10 years were 38.3%, 74.2%, 81.4%, and 86.1%, respectively, after single-session SRS. Obliteration and a favorable outcome were more likely to be achieved in patients treated with a margin dose greater than 18 Gy (p < 0.001 for both), demonstrating significantly better rates (83.3% and 79%, respectively). The rate of latency preobliteration hemorrhage was 0.85%/year. Symptomatic post-SRS RICs developed in 4.5% of patients (n = 7). Predictors of a favorable outcome were a smaller nidus (p = 0.0001), no pre-SRS embolization (p = 0.003), no prior hemorrhage (p = 0.0001), a higher margin dose (p = 0.0001), and a higher maximal dose (p = 0.009). The Spetzler-Martin grade was not found to be predictive of outcome. The Virginia Radiosurgery AVM Scale score (p = 0.0001) and the Radiosurgery-Based AVM Scale score (p = 0.0001) were predictive of a favorable outcome.CONCLUSIONSSRS results in successful obliteration and a favorable outcome in the majority of patients with cerebellar AVMs. Most patients will require a nidus dose of higher than 18 Gy to achieve these goals. Radiosurgical and not microsurgical scales were predictive of clinical outcome after SRS.
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Affiliation(s)
- Or Cohen-Inbar
- 1Department of Neurosurgery and Gamma-Knife Center, University of Virginia Health System, Charlottesville, Virginia
| | - Robert M. Starke
- 1Department of Neurosurgery and Gamma-Knife Center, University of Virginia Health System, Charlottesville, Virginia
- 9Department of Neurological Surgery and Radiology, University of Miami, Florida
| | - Hideyuki Kano
- 2Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Gregory Bowden
- 2Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Paul Huang
- 3Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | | | - Luis Almodovar
- 4Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | - Inga S. Grills
- 5Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - David Mathieu
- 6Department of Neurosurgery, University of Sherbrooke, Centre de Recherche Clinique Étienne-LeBel, Sherbrooke, Quebec, Canada
| | - Danilo Silva
- 7Rose-Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Mahmoud Abbassy
- 7Rose-Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Symeon Missios
- 7Rose-Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - John Y. K. Lee
- 8Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Gene H. Barnett
- 7Rose-Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio
| | - Douglas Kondziolka
- 3Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - L. Dade Lunsford
- 2Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Jason P. Sheehan
- 1Department of Neurosurgery and Gamma-Knife Center, University of Virginia Health System, Charlottesville, Virginia
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Charalambous LT, Penumaka A, Komisarow JM, Hemmerich AC, Cummings TJ, Codd PJ, Friedman AH. Masson's tumor of the pineal region: case report. J Neurosurg 2017; 128:1725-1730. [PMID: 28777021 DOI: 10.3171/2017.2.jns162350] [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] [Indexed: 11/06/2022]
Abstract
Intracranial intravascular papillary endothelial hyperplasia (IPEH), also referred to as Masson's tumor, is a condition that rarely occurs in the nervous system. IPEH most frequently occurs extracranially in the skin of the face, skull, neck, and trunk and can easily be mistaken clinically, radiologically, and histologically for angiosarcoma, organizing hematoma, or other vascular malformations. IPEH accounts for roughly 2% of all vascular tumors and is extremely rare intracranially, with only 23 reported cases compared with more than 300 cases of IPEH occurring in the skin and subcutaneous tissue. To date, it has never been reported to occur in the pineal region. The authors report the case of a patient with an IPEH in the pineal region who underwent complex resection and experienced reversal of neurological symptoms.
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Khayat HA, Alshareef F, Alshamy A, Algain A, Alhejaili E, Alnabihi O, Alzahrani S, Stendel R. Pure Endovascular Management of an Arteriovenous Malformation and an Aneurysm Both Supplied by Anterio-Inferior Cerebellar Artery: A Case Report and a Review of Literature. Front Neurol 2017; 8:382. [PMID: 28824538 PMCID: PMC5539170 DOI: 10.3389/fneur.2017.00382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 07/18/2017] [Indexed: 11/21/2022] Open
Abstract
Background and importance The tendency of posterior fossa arteriovenous malformations (pfAVM) to develop associated aneurysms (AA) is a well-known phenomenon with an increased total risk of rupture. Most pfAVM and AA develop in the territory of the posterior inferior cerebellar artery while the involvement of the anterior inferior cerebellar artery (AICA) is extremely rare. We describe an unusual case of an arteriovenous malformation (AVM) supplied by the AICA with a “proximal” AA. This unique combination of vascular lesions has been reported in only four cases so far, limiting the available experience that can safely guide the therapeutic intervention. Clinical presentation This study describes a 59-year-old female presented with a subarachnoid hemorrhage, Hunt and Hess grade 4. Angiography demonstrated an AVM fed mainly by the right AICA and draining superficially into the transverse sinus (Spetzler–Martin grade II). In addition, there was a ruptured proximal AICA aneurysm. An endovascular approach was chosen to coil the aneurysm and obliterate the AVM using ONYX in a multi-staged process. The patient recovered well without residual deficit at 6-month follow-up. Conclusion To the best of our knowledge, this is the first report describing a proximal AICA aneurysm and AVM treated by endovascular means. The outcome was very good, considering the technically demanding location. All previously reported cases with exactly similar lesions were managed surgically, with inconclusive outcomes. The data presented in this study are meant to help in decision-making process for similar cases till more data are available.
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Affiliation(s)
- Hassan A Khayat
- King Abdullah International Medical Research Center (KAIMRC)/Department of Neurosurgery-King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs (MNG-HA), Jeddah, Saudi Arabia
| | - Fawaz Alshareef
- King Abdullah International Medical Research Center/Department of interventional radiology-King Abdulaziz medical city (KAMC), Ministry of National Guard Health Affairs (MNG-HA), Jeddah, Saudi Arabia
| | - Abdulrahman Alshamy
- King Abdullah International Medical Research Center/Department of interventional radiology-King Abdulaziz medical city (KAMC), Ministry of National Guard Health Affairs (MNG-HA), Jeddah, Saudi Arabia
| | - Abdulrahman Algain
- King Abdullah International Medical Research Center/Department of interventional radiology-King Abdulaziz medical city (KAMC), Ministry of National Guard Health Affairs (MNG-HA), Jeddah, Saudi Arabia
| | - Essam Alhejaili
- King Abdullah International Medical Research Center/College of Medicine - King Saud bin Abdulaziz University for Health Sciences (KSAUHS), Ministry of National Guard Health Affairs (MNG-HA), Jeddah, Saudi Arabia
| | - Omar Alnabihi
- King Abdullah International Medical Research Center/College of Medicine - King Saud bin Abdulaziz University for Health Sciences (KSAUHS), Ministry of National Guard Health Affairs (MNG-HA), Jeddah, Saudi Arabia
| | - Saeed Alzahrani
- King Abdullah International Medical Research Center/College of Medicine - King Saud bin Abdulaziz University for Health Sciences (KSAUHS), Ministry of National Guard Health Affairs (MNG-HA), Jeddah, Saudi Arabia
| | - Ruediger Stendel
- King Abdullah International Medical Research Center (KAIMRC)/Department of Neurosurgery-King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs (MNG-HA), Jeddah, Saudi Arabia
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Hung AL, Yang W, Braileanu M, Garzon-Muvdi T, Caplan JM, Colby GP, Coon AL, Tamargo RJ, Huang J. Risk Assessment of Hemorrhage of Posterior Inferior Cerebellar Artery Aneurysms in Posterior Fossa Arteriovenous Malformations. Oper Neurosurg (Hagerstown) 2017; 14:359-366. [DOI: 10.1093/ons/opx120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/18/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Posterior fossa arteriovenous malformations (AVMs) are associated with increased risk of rupture and severe consequences from such rupture. The hemorrhagic risk of prenidal aneurysms (anr) on the posterior inferior cerebellar artery (PICA) may exceed that of the AVM in posterior fossa AVMs fed by PICA (PICA-AVM).
OBJECTIVE
To characterize the relative risks of aneurysm and AVM hemorrhage in patients with posterior fossa AVMs.
METHODS
We retrospectively reviewed patients diagnosed with AVM. Patients with posterior fossa AVMs were divided into 3 groups: PICA-AVM with prenidal aneurysm (PICA-AVM-anr group), PICA-AVM without prenidal aneurysm (PICA-AVM group), and AVMs without PICA feeder with/without aneurysm (AVM-only group). Patient and lesion characteristics and treatment outcomes were compared. ANOVA and chi squared tests were used for statistical analyses.
RESULTS
Our cohort included 85 patients. Mean age was 45.3 ± 18.1 yr, with 43(50.6%) female patients. Fifty-one patients (60.0%) had hemorrhagic presentation, and 27 (31.8%) experienced acute hydrocephalus. Patients in the PICA-AVM-anr group (n = 11) were more likely to present with aneurysmal subarachnoid hemorrhage (SAH; P = .005) and less likely to have AVM rupture (P < .001). Ten (90.9%) patients presented with hemorrhage, 6 (60.0%) of which resulted from aneurysm rupture. Of these 6, 5 (83.3%) had acute hydrocephalus. No patients with AVM rupture had hydrocephalus. Eight (72.7%) received aneurysm treatment prior to AVM treatment. There were no significant differences in post-treatment outcomes dependent on treatment order.
CONCLUSION
In addition to relatively higher risk of AVM rupture from infratentorial location and prenidal aneurysm, a higher risk of aneurysm rupture rather than AVM rupture was observed in patients with PICA-AVM-anr complex.
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Affiliation(s)
- Alice L Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Maria Braileanu
- Department of Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Tomas Garzon-Muvdi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Geoffrey P Colby
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Takayama M, Kashiwagi M, Hara K, Matsusue A, Waters B, Ikematsu N, Kubo SI. Basal subarachnoid hemorrhage by rupture of arteriovenous malformation at the cerebellopontine angle. Neuropathology 2017; 37:441-445. [PMID: 28397378 DOI: 10.1111/neup.12383] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 11/30/2022]
Abstract
A man in his late forties had lived as a recluse for more than ten years. He was found dead in his room. At autopsy, subarachnoid hemorrhage (SAH) was detected at the base of the brain, which weighed 1333 g. The cerebellar tonsil was swollen. The cerebral ventricle was enlarged and filled with blood. A hematoma was observed in the upper part of the left side of the cerebellar hemisphere. The location and size of SAH in this case indicated that the rupture of a cerebral aneurysm (CA) had occurred; however, CA was not detected. A mass of blood vessels buried in the hematoma was observed at the left cerebellopontine angle (CPA). The vascular lesion showed round-shaped blood vessels as well as flat-shaped vessels with the appearance of veins, but with elastic fibers indicative of arteries. The lesion was considered to be the nidus and was 5-8 mm in size. Feeding arteries appeared to be from the anterior inferior cerebellar artery (AICA). However, the draining vein and anastomotic parts of the artery and vein were not confirmed. Based on these histopathological features, this vascular lesion was diagnosed as arteriovenous malformation (AVM). A differential diagnosis between AVM at CPA and CA is needed in order to identify the source of non-traumatic SAH.
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Affiliation(s)
- Mio Takayama
- Department of Forensic Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Masayuki Kashiwagi
- Department of Forensic Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kenji Hara
- Department of Forensic Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Aya Matsusue
- Department of Forensic Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Brian Waters
- Department of Forensic Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Natsuki Ikematsu
- Department of Forensic Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Shin-Ichi Kubo
- Department of Forensic Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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Long-Term Outcomes of Single-Session Stereotactic Radiosurgery for Cerebellar Arteriovenous Malformation, with a Median Follow-Up of 10 Years. World Neurosurg 2017; 98:314-322. [DOI: 10.1016/j.wneu.2016.10.137] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/27/2016] [Accepted: 10/28/2016] [Indexed: 11/20/2022]
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Yang W, Porras JL, Garzon-Muvdi T, Xu R, Caplan JM, Hung AL, Braileanu M, Rong X, Colby GP, Coon AL, Tamargo RJ, Huang J. Management Outcome of Brainstem Arteriovenous Malformations: The Role of Radiosurgery. World Neurosurg 2016; 94:64-72. [DOI: 10.1016/j.wneu.2016.06.082] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/17/2016] [Accepted: 06/20/2016] [Indexed: 11/29/2022]
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El-Ghanem M, Kass-Hout T, Kass-Hout O, Alderazi YJ, Amuluru K, Al-Mufti F, Prestigiacomo CJ, Gandhi CD. Arteriovenous Malformations in the Pediatric Population: Review of the Existing Literature. INTERVENTIONAL NEUROLOGY 2016; 5:218-225. [PMID: 27781052 DOI: 10.1159/000447605] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Arteriovenous malformations (AVMs) in the pediatric population are relatively rare but reportedly carry a higher rate of rupture than in adults. This could be due to the fact that most pediatric AVMs are only detected after rupture. We aimed to review the current literature regarding the natural history and the clinical outcome after multimodality AVM treatment in the pediatric population, as optimal management for pediatric AVMs remains controversial. A multidisciplinary approach using multimodality therapy if needed has been proved to be beneficial in approaching these lesions in all age groups. Microsurgical resection remains the gold standard for the treatment of all accessible pediatric AVMs. Embolization and radiosurgery should be considered as an adjunctive therapy. Embolization provides a useful adjunct therapy to microsurgery by preventing significant blood loss and to radiosurgery by decreasing the volume of the AVM. Radiosurgery has been described to provide an alternative treatment approach in certain circumstances either as a primary or adjuvant therapy.
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Affiliation(s)
- Mohammad El-Ghanem
- Department of Neurology, Pennsylvania State University, Hershey, Pa, N.Y., USA
| | - Tareq Kass-Hout
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA; Division of Neuro-Endovascular Surgery, Department of Surgery, Rochester Regional Health System, Rochester, N.Y., USA
| | - Omar Kass-Hout
- Department of Neurology, Emory University School of Medicine, Atlanta, Va, N.Y., USA
| | - Yazan J Alderazi
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
| | - Krishna Amuluru
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
| | - Charles J Prestigiacomo
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
| | - Chirag D Gandhi
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
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Tong X, Wu J, Lin F, Cao Y, Zhao Y, Wang S, Zhao J. Microsurgical Outcome of Cerebellar Arteriovenous Malformations: Single-Center Experience. World Neurosurg 2016; 95:469-479. [PMID: 27567580 DOI: 10.1016/j.wneu.2016.08.059] [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] [Received: 06/18/2016] [Revised: 08/12/2016] [Accepted: 08/13/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We aimed to describe our single-center experience in treating cerebellar arteriovenous malformations (AVMs) with microsurgical resection. METHODS During a 16-year period, 181 patients with cerebellar AVMs were surgically treated at the Department of Neurosurgery in Beijing Tiantan Hospital. Patient functional status was evaluated using modified Rankin Scale (mRS) scores both before treatment and at the last follow-up. The mRS scores at the last follow-up were dichotomized as good outcome (mRS <3) and poor outcome (mRS ≥3). The treatment modalities, post-treatment complications, obliteration rate, and follow-up outcomes were analyzed. RESULTS Of the 181 patients, 172 (95%) patients presented with initial hemorrhage and 62 (34%) patients experienced rehemorrhage before microsurgical treatment. Complete obliteration of the AVMs was achieved in 177 (97.8%) patients. Good functional outcome was achieved in 144 (80%) of the patients. The surgical mortality rate was 4.4% (8/181), and overall mortality rate was 6.6% (12/181). Poor outcome was significantly associated with increasing age (P = 0.035; odds ratio [OR], 1.030; 95% CI 1.002-1.060), presurgical mRS ≥3 (P = 0.029; OR, 2.563; 95% CI 1.101-5.968), eloquent AVM location (P = 0.015; OR, 3.058; 95% CI 1.244-7.516), and presurgical rehemorrhage (P = 0.008; OR, 3.266; 95% CI 1.358-7.858). CONCLUSION Good outcome can be achieved by microsurgical resection in most patients with cerebellar AVMs. Increasing age at surgery, poor presurgical functional status, eloquent AVM location, and presurgical rehemorrhage are independent predictors of poor outcomes after AVM resection. We recommend early surgical resection for all surgically accessible cerebellar AVMs to prevent subsequent hemorrhage and resultant poor neurologic outcomes.
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Affiliation(s)
- Xianzeng Tong
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Fuxin Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China.
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China.
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
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Tong X, Wu J, Lin F, Cao Y, Zhao Y, Wang S, Zhao J. Risk Factors for Subsequent Hemorrhage in Patients with Cerebellar Arteriovenous Malformations. World Neurosurg 2016; 92:47-57. [DOI: 10.1016/j.wneu.2016.04.082] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 04/20/2016] [Accepted: 04/22/2016] [Indexed: 11/28/2022]
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