Transdural arterial recruitment to brain arteriovenous malformation: clinical and management implications in a prospective cohort series

An Uncommon Case of Moyamoya Syndrome Is Accompanied by an Arteriovenous Malformation with the Involvement of Dural Arteries

(1) Background: This report describes the surgical management of a case of concurrent AVM with the involvement of dural arteries and moyamoya syndrome. Given the infrequency of this combination, there is currently no established management strategy available. (2) Case Description: A 49-year-old male patient with multiple symptoms including headaches, tinnitus, and visual impairment diagnosed with the coexistence of an arteriovenous malformation with the involvement of dural arteries and moyamoya syndrome was admitted to the national tertiary hospital. The patient underwent surgical management through embolization of the AVM from the afferents of the dural arteries, which has resulted in positive clinical outcomes. However, this approach may not be suitable for all cases, and a multidisciplinary team approach may be required to develop an individualized treatment strategy. (3) Conclusion: The contradictory nature of the treatment approaches in cases of combined AVM with the involvement of dural arteries and MMD highlights the complex nature of this condition and the need for further research to identify the most effective treatment strategies.

Comparing health-related quality of life in modified Rankin Scale grades: 15D results from 323 patients with brain arteriovenous malformation and population controls

Background

We wanted to understand how patients with different modified Rankin Scale (mRS) grades differ regarding their health-related quality of life (HRQoL) and how this affects the interpretation and dichotomization of the grade.

Methods

In 2016, all adult patients in our brain arteriovenous malformation (AVM) database (n = 432) were asked to fill in mailed letters including a questionnaire about self-sufficiency and lifestyle and the 15D HRQoL questionnaire. The follow-up mRS was defined in 2016 using the electronic patient registry and the questionnaire data. The 15D profiles of each mRS grade were compared to those of the general population and to each other, using ANCOVA with age and sex standardization.

Results

Patients in mRS 0 (mean 15D score = 0.954 ± 0.060) had significantly better HRQoL than the general population (mean = 0.927 ± 0.028), p < 0.0001, whereas patients in mRS 1–4 had worse HRQoL than the general population, p < 0.0001. Patients in mRS 1 (mean = 0.844 ± 0.100) and mRS 2 (mean = 0.838 ± 0.107) had a similar HRQoL. In the recently published AVM research, the most commonly used cut points for mRS dichotomization were between mRS 1 and 2 and between mRS 2 and 3.

Conclusions

Using 15D, we were able to find significant differences in the HRQoL between mRS 0 and mRS 1 AVM patients, against the recent findings on stroke patients using EQ-5D in their analyses. Although the dichotomization cut point is commonly set between mRS 1 and 2, patients in these grades had a similar HRQoL and a decreased ability to continue their premorbid lifestyle, in contrast to patients in mRS 0.

Characteristics of pial brain arteriovenous malformations with transdural arterial supply

PURPOSE

Transdural blood supply (TDBS) to pial brain arteriovenous malformations (BAVM) is uncommon and believed to be related to vascular endothelial growth factor - induced angiogenesis. The aim of this study was to define the BAVM characteristics in relation to presence and volume of TDBS.

METHODS

BAVMs managed at our institution between January 2006 and December 2016 who subsequently underwent complete digital subtraction angiography (DSA) were included. They were classified based on presence of TDBS as well as volume of TDBS.

RESULTS

Of the 641 BAVM patients managed during the recruitment period, 387 (391 BAVMs) had complete pretreatment DSAs. Forty-three (11.0 %, 10 ruptured) BAVMs exhibited TDBS. With TDBS group had a significantly greater proportion of large nidus (> 3.1 cm) than the Without TDBS group (85.1 % vs 19.5 %, p < 0.01) and were more frequently temporal (32.6 % vs 14.7 %, p < 0.01) and occipital (25.6 % vs 13.5 %, p < 0.05) in location. In unruptured BAVMs, the presence of headaches was significantly more prevalent when the malformation harboured TDBS compared to not (57.6 vs 34.8 %, p < 0.05). The annual rupture rate among unruptured BAVMs treated by conservative management was 4.7 % in the With TDBS (n = 12) group and 0% (n = 21) in BAVMs with TDBS that underwent treatment including surgery, endovascular therapy, or radiosurgery.

CONCLUSION

BAVMs with TDBS are more likely to be associated with a large nidus and located in the temporal and occipital lobes. Headache is more frequently associated with the presence of TDBS. Rupture rate of unruptured BAVMS with TDBS can be effectively reduced following treatment.

Angiographic Evaluation and Endovascular Treatment Considerations of Brain Arteriovenous Malformations With a Transdural Blood Supply: A Single-Center Experience

Background: In rare circumstances, brain arteriovenous malformations (BAVMs) can recruit a transdural blood supply (TBS). The clinical and radiologic characteristics of BAVMs with a TBS are poorly understood.

Methods: A retrospective review of the medical records was conducted for adult patients who were admitted for BAVMs from Jan 2013 to Dec 2019. TBSs for BAVMs were divided into 3 types: (1) unilateral TBSs from the external carotid artery (ECA) and/or meningeal branch of the vertebral artery (VA); (2) bilateral TBSs from the ECA and/or meningeal branch of the VA; and (3) meningohypophyseal trunk TBSs of the internal carotid artery.

Results: Four hundred and twenty-eight patients were diagnosed with BAVMs during the study period, of whom 30 (7.0%, 30/428) were identified as having a TBS. Type 1, type 2, and type 3 TBSs were identified in 21 (70%, 21/30), 7 (23.3%, 7/30), and 2 (6.7%, 2/30) patients, respectively. Six (20%, 6/30) patients were conservatively managed. Twelve (40%, 12/30) patients underwent endovascular treatment (EVT) of the BAVM through non-TBS feeders. Eight (26.8%, 8/30) patients underwent EVT of the BAVM both through the TBS and non-TBS feeders. The modified Rankin Scale scores at the 3-month follow-up were 0, 1, 2, 4, and 5 in 24 (80%, 24/30), 2 (6.7%, 2/30), 2 (6.7%, 2/30), 1 (3.3%, 1/30), and 1 (3.3%, 1/30) patients, respectively. Good short-term recovery was achieved in 86.7% (26/30) of the patients. The size of the BAVMs with a TBS was larger than that of BAVMs without a TBS. Patients with higher Spetzler-Martin grades tended to have a TBS. No statistical difference was noted between the patients with and without a TBS with regard to age, sex, location, or concurrent aneurysms.

Conclusions: This study showed that a TBS was likely to develop in patients with larger BAVMs and that a TBS was likely to be located in the temporal lobe in patients BAVMs with higher SM grades. Weak structures were the primary targets of management. In addition, a BAVM could be embolized via the TBS.

Microsurgical treatment of a posterior fossa arteriovenous malformation initially mistaken for a dural arteriovenous fistula: avoidance of near disaster

Many brain arteriovenous malformations (AVMs) derive dural blood supply, while 10%–15% of dural arteriovenous fistulas (dAVFs) have pial arterial input. To differentiate between the two is critical, as treatment of these entities is diametrically opposed. To treat dAVFs, the draining vein(s) is disconnected from feeding arteries, which portends hemorrhagic complications for AVMs. The authors present an operative video of a subtle cerebellar AVM initially treated as a dAVF by attempted embolization through dural vessels. The lesion was subsequently microsurgically extirpated. The authors show a comparison case of an AVM mistaken for a dAVF and transvenous embolization that resulted in a fatal hemorrhage.

The video can be found here: https://youtu.be/eDeiMrGoE0Q

Microsurgical Anatomy of the Meningeal Branch of the Dorsolateral Medullary Plexus

BACKGROUND

Meningeal branches originating from intradural arteries may be involved in several diseases such as meningeal tumors and arteriovenous lesions. These "pial-dural" arterial connections have been described for anterior cerebral, posterior cerebral, and cerebellar arteries. However, to the best of our knowledge, meningeal supply originating from the arterial plexus over the dorsolateral aspect of the medulla oblongata (dorsolateral medullary plexus [DLMP]) has not been described.

OBJECTIVE

To define the microsurgical anatomy of the meningeal branch of DLMP.

METHODS

A total of 20 cadaver heads (40 sides) underwent far-lateral craniotomy and the cerebellomedullary cisterns were explored to find the DLMP and any meningeal branches. Additionally, de-identified intraoperative images of 85 patients with vertebral artery (VA)/posterior inferior cerebellar artery aneurysms who had undergone far-lateral craniotomy were studied to find any meningeal branches of DLMP.

RESULTS

The meningeal branches of DLMP were identified in 4 cadavers/sides. These branches reached the region of jugular tubercle (JT) after crossing the accessory nerve. In 3 specimens, these branches were joined by a small twig from V4-VA before penetrating the dura. DLMP meningeal branches were found in 12 patients of the studied cohort (14%) with similar anatomical features as those found in the cadaveric study.

CONCLUSION

DLMP may give rise to meningeal branches to the adjacent dura of JT. The actual prevalence of this anatomic variation is difficult to estimate using our data. However, when present, these branches may have important clinical implications, ie, diseases such as dural arteriovenous fistulas, pial arteriovenous malformations (AVMs), and meningeal-based tumors.

Brain arteriovenous malformation with transdural blood supply: Current status

Arterial blood supply to a brain arteriovenous malformation (BAVM) is mainly derived from the internal carotid artery (ICA) and vertebral basilar artery (VBA) system. However, in certain cases, arteries supplying the meninges may also contribute to the blood supply of the BAVM, resulting in the formation of a BAVM with transdural blood supply (TBS). To review the current status of BAVM with TBS, a literature search was performed in the PubMed database. Articles were screened for relevance and suitability of data. According to recent studies, the mechanisms by which TBS to a BAVM forms are mainly classified into the congenital and acquired type. BAVM with TBS is common in elderly patients and is characterized by intracranial hemorrhage, epilepsy, chronic headache and increased intracranial pressure. Digital subtraction angiography is the gold standard for diagnosing BAVM with TBS. Superselective angiography is also important. Treatments for BAVM with TBS include surgical resection, endovascular treatment (EVT), stereotactic radiosurgery and combined treatment. Surgical resection is difficult to perform. EVT has become the major therapy for treating BAVM with TBS due to its low procedural invasiveness. Combination of surgical resection and EVT may be a good option. In addition, stereotactic radiosurgery is frequently used as a complementary treatment to surgical and endovascular interventions. The prognosis of BAVM with TBS is not favorable, as the defect involves a complex arterial supply system.

Clinical importance of the occipital artery in vascular lesions: A review of the literature

The occipital artery (OA) is a critical artery in vascular lesions. However, a comprehensive review of the importance of the OA is currently lacking. In this study, we used the PubMed database to perform a review of the literature on the OA to increase our understanding of its role in vascular lesions. We also provided our typical cases to illustrate the importance of the OA. The OA has several variations. For example, it may arise from the internal carotid artery or anastomose with the vertebral artery. Therefore, the OA may provide a crucial collateral vascular supply source and should be preserved in these cases. The OA is a good donor artery. Consequently, it is used in extra- to intracranial bypasses for moyamoya disease (MMD) or aneurysms. The OA can be involved in dural arteriovenous fistula (DAVF) and is a feasible artery for the embolisation of DAVF. True aneurysms and pseudoaneurysms can occur in the OA; surgical resection and embolisation are the effective treatment approaches. Direct high-flow AVF can occur in the OA; embolisation treatment is a good option in such cases. The OA can also be involved in MMD and brain arteriovenous malformation (AVM) by forming transdural collaterals. For a patient in the prone position, if occipital and suboccipital craniotomies are performed, the OA can also be used for intraoperative angiography. In brief, the OA is a very important artery in vascular lesions.

Transdural Blood Supply in Cerebral Arteriovenous Malformations: A Systematic Evaluation of Angioarchitecture

BACKGROUND AND PURPOSE

Arterial transdural blood supply is a rare angiographic phenomenon in cerebral AVMs. This study aimed to evaluate angiographic transdural blood supply characteristics and to describe the clinical peculiarities of these lesions.

MATERIALS AND METHODS

A prospective AVM data base of 535 patients, enrolled from 1990 to 2016, was analyzed retrospectively. Clinical information was reviewed through patients' medical charts and radiologic studies. Patients with previous AVM treatment were excluded (n = 28).

RESULTS

Patients with (n = 32, male/female ratio = 10:22; mean age, 46 ± 15 years; range, 13-75 years) and without transdural blood supply (n = 475, male/female ratio = 260:215; mean age, 40 ± 18 years; range, 2-87 years) did not show significant differences in clinical presentation (age, hemorrhage, seizures, chronic headache). The predominant nidus size in patients with transdural blood supply was ≥30 mm, with significantly more patients with large AVMs (>60 mm, P = .001). To describe the transdural blood supply, we used 3 grades based on the angiographic transdural blood supply proportion and intensity of AVM nidus perfusion (I-III). Fifty-seven percent of patients with chronic headache had a strong and substantial transdural nidus perfusion (III) and a high-flow transdural blood supply.

CONCLUSIONS

Cerebral AVMs with transdural blood supply represent a rare and heterogeneous subgroup. Lesions can be graded by quantifying the transdural blood supply of the nidus and by capturing hemodynamic characteristics. The broad spread of angiographic features and comparable clinical patterns of patients with or without transdural blood supply raises questions about the relevance of the transdural blood supply to the natural history risk of an AVM and the intention for treatment.

Posterior Fossa Arteriovenous Malformation with Multiple Pedicle Aneurysms and Recruitment of Meningeal Supply

Cerebral aneurysms arising on the peripheral posterior inferior cerebellar artery (PICA) are rare. Here, we present a unique case of arteriovenous malformation (AVM) with pedicle aneurysms arising on the peripheral PICA and recruited by meningeal supply. A 67-year-old woman presented with subarachnoid hemorrhage. Cerebral angiography revealed two saccular aneurysms on the peripheral PICA, which formed an abnormal arteriovenous shunt adjacent to the transverse sinus. The shunt was also fed by the ipsilateral superior cerebellar and contralateral posterior meningeal arteries. The proximal aneurysm was larger and deep seated while the distal aneurysm was smaller and located superficially. The patient underwent coil embolization of the proximal aneurysm followed by microsurgical trap of the distal aneurysm and resection of the arteriovenous shunt lying superficially in the cerebellar hemisphere. The shunt was histologically verified as AVM. Staged approach with coil embolization and open microsurgery can be a treatment option for multiple PICA aneurysms associated with an AVM.