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Gopalakrishnan R, Cunningham DA, Hogue O, Schroedel M, Campbell BA, Baker KB, Machado AG. Electrophysiological Correlates of Dentate Nucleus Deep Brain Stimulation for Poststroke Motor Recovery. J Neurosci 2024; 44:e2149232024. [PMID: 38724284 PMCID: PMC11223455 DOI: 10.1523/jneurosci.2149-23.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 07/05/2024] Open
Abstract
While ipsilesional cortical electroencephalography has been associated with poststroke recovery mechanisms and outcomes, the role of the cerebellum and its interaction with the ipsilesional cortex is still largely unknown. We have previously shown that poststroke motor control relies on increased corticocerebellar coherence (CCC) in the low beta band to maintain motor task accuracy and to compensate for decreased excitability of the ipsilesional cortex. We now extend our work to investigate corticocerebellar network changes associated with chronic stimulation of the dentato-thalamo-cortical pathway aimed at promoting poststroke motor rehabilitation. We investigated the excitability of the ipsilesional cortex, the dentate (DN), and their interaction as a function of treatment outcome measures. Relative to baseline, 10 human participants (two women) at the end of 4-8 months of DN deep brain stimulation (DBS) showed (1) significantly improved motor control indexed by computerized motor tasks; (2) significant increase in ipsilesional premotor cortex event-related desynchronization that correlated with improvements in motor function; and (3) significant decrease in CCC, including causal interactions between the DN and ipsilesional cortex, which also correlated with motor function improvements. Furthermore, we show that the functional state of the DN in the poststroke state and its connectivity with the ipsilesional cortex were predictive of motor outcomes associated with DN-DBS. The findings suggest that as participants recovered, the ipsilesional cortex became more involved in motor control, with less demand on the cerebellum to support task planning and execution. Our data provide unique mechanistic insights into the functional state of corticocerebellar-cortical network after stroke and its modulation by DN-DBS.
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Affiliation(s)
- Raghavan Gopalakrishnan
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195
- Cleveland FES Center, Cleveland, Ohio 44106
| | - David A Cunningham
- Cleveland FES Center, Cleveland, Ohio 44106
- Physical Medicine and Rehabilitation, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106
- Center for Rehabilitation Research, MetroHealth Systems, Cleveland, Ohio 44109
| | - Olivia Hogue
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195
| | - Madeleine Schroedel
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195
| | - Brett A Campbell
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195
| | - Kenneth B Baker
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195
| | - Andre G Machado
- Center for Neurological Restoration, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195
- Department of Neurosciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio 44195
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio 44195
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Ivanov K, Atsev S, Petrov PP, Ilyov I, Penchev P. Partial Endovascular Embolization of a Cerebral Arteriovenous Malformation in a Patient With Seizures Caused by a Steal Phenomenon: A Case Analysis. Cureus 2024; 16:e60499. [PMID: 38883140 PMCID: PMC11180516 DOI: 10.7759/cureus.60499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 06/18/2024] Open
Abstract
Cerebral arteriovenous malformations (cAVMs) are developmental pathologic lesions of the blood vessels of the brain in which multiple arteries shunt blood directly into the venous drainage network. They are lesions with an unclear etiology and, if left untreated, can bear significant risks of complications such as migraines, seizures, neurological deficits, and intracranial hemorrhages. The diagnosis is based on several imaging methods, with angiography being the primary method. Treatment modalities include microsurgery, radiosurgery, embolization with the intent of obliteration, and various multidisciplinary approaches. We aim to introduce the case of an adult female patient with symptomatic cAVM who underwent partial endovascular embolization of the lesion and evaluate her recovery and the overall reliability of her treatment modality. A 22-year-old female patient has presented to the Neurosurgery Clinic with clinical manifestations with photosensitive seizures, migraines, and a history of sleep disturbances persisting for a period of one year. An appointed MRI and angiography revealed the presence of a glomerular cAVM of the anterior parietal branch of the middle cerebral artery located within the intraparietal sulcus of the left cerebral hemisphere (Spetzler-Martin grade 2). The venous drainage of the malformation led to a loss of nutrients in the surrounding brain parenchyma (a steal phenomenon), causing the seizures. The patient successfully underwent transarterial endovascular embolization with Onyx, which proved to be partial on a postoperative angiography, and refused further embolization procedures. There were no postoperative complications to be mentioned. The patient reported no seizures or sleep disturbances at the 12-month follow-up, with sporadic weak headaches remaining. cAVMs remain a pathology with significant morbidity and mortality when undiagnosed. Symptomatic cAVMs leading to a steal phenomenon and seizures can be reliably managed via endovascular embolization alone when the malformation has an appropriate angioarchitecture, location, size, and a low Spetzler-Martin score. However, further inquiry is required into the use of partial embolization in cases where further multiple-stage embolization procedures are declined and/or complete occlusion of the lesion is unfeasible. This case report emphasizes that partial endovascular embolization can be successfully utilized as a treatment modality for the symptoms caused by a steal phenomenon of the venous drainage of a cAVM, such as seizure disorders and migraines, in the rare instance when multiple-stage embolization is declined by the patient and occlusion of the lesion remains subtotal.
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Affiliation(s)
- Kiril Ivanov
- Faculty of Medicine, Medical University of Plovdiv, Plovdiv, BGR
| | | | - Petar-Preslav Petrov
- Department of Anatomy, Histology and Embryology, Medical University of Plovdiv, Plovdiv, BGR
| | - Ilko Ilyov
- Faculty of Medicine, Medical University of Plovdiv, Plovdiv, BGR
| | - Plamen Penchev
- Faculty of Medicine, Medical University of Plovdiv, Plovdiv, BGR
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Puthuran M, Gravino G, Babatola F, Pullicino R, Masri S, Biswas S, Chapot R, Chandran A. Primary endovascular embolisation of intracranial arteriovenous malformations (AVM)-UK single centre experience. Neuroradiology 2024; 66:227-236. [PMID: 37999787 DOI: 10.1007/s00234-023-03258-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/19/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE Intracranial arteriovenous malformations (AVMs) treated at our institution with modern techniques of endovascular intervention were analysed for the rate of complete occlusion, associated morbidity, and mortality. To our knowledge, this is the first series from the UK evaluating the effectiveness of endovascular embolisation as a primary treatment for selected cases. METHODS All newly referred AVMs between January 2017 and June 2022 were reviewed and those treated with primary endovascular intervention were identified. Details of the endovascular procedures were retrospectively reviewed. RESULTS In 5½ years, 41.1% of AVMs referred to our institution have been triaged for primary endovascular intervention. Sixty-eight AVMs were embolised and followed-up: 44 ruptured and 24 unruptured. Spetzler-Martin grading varied from I to III, and a single AVM was grade IV. The approach was arterial in 73.5%, solely venous in 7.4%, and combined in 19.1%. The mean follow-up was 18 months for imaging and 26 months for clinical assessment. Complete obliteration was achieved in 95.6%. Ruptured AVM cohort: The rate of functional deterioration was 13.6%. Unruptured AVM cohort: The rate of functional deterioration secondary to complications from embolisation was 4.2%. CONCLUSIONS Endovascular embolisation may be a favourable option for primary AVM treatment in carefully selected patients. However, selection criteria need to be better delineated for more specialists to consider this as a primary therapy.
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Affiliation(s)
- Mani Puthuran
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Gilbert Gravino
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK.
| | - Feyi Babatola
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | | | - Souhyb Masri
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | | | | | - Arun Chandran
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
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Zhu D, Wang C, Ma P, Qi D, Cao W, Li S, Du M, He J, Ye S, Song T, Hu R, Li P, Zheng T, Liu J, Fang Y. Arm-only combined transarterial and transvenous access for neurointerventional procedures: a double-center retrospective study. Br J Radiol 2023; 96:20230465. [PMID: 37750839 PMCID: PMC10646665 DOI: 10.1259/bjr.20230465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023] Open
Abstract
OBJECTIVE This study aims to share our experience with the arm-only combined transarterial and transvenous access approach for neurointerventional procedures and evaluate its efficacy and safety. METHODS The arm-only combined transarterial and transvenous access approach was performed using the right/bilateral proximal radial arteries and the right forearm superficial vein system, guided by ultrasonic guidance. Arterial access closure was achieved using a transradial band radial compression device, while manual compression was utilized for venous approach closure. RESULTS Thirteen procedures were successfully performed using the arm-only combined transarterial and transvenous access approach, yielding favorable outcomes. The procedures included dural arteriovenous fistula embolization (seven cases), cerebral arteriovenous malformation embolization (four cases), venous sinus thrombosis catheter-directed thrombolysis and intravenous thrombectomy (one case), and cerebral venous sinus stenosis manometry (one case). All procedures were uneventful, allowing patients to ambulate on the same day. At discharge, all patients exhibited modified Rankin scores of 0-2, without any access site or perioperative complications. CONCLUSION This double-center study preliminarily demonstrates the feasibility and safety of arm-only combined transarterial and transvenous access applied in neurointerventional procedures for complicated cerebrovascular diseases. The proximal radial artery and forearm superficial vein are recommended as the primary access sites. Unobstructed compression is strongly recommended for radial approach closure. ADVANCES IN KNOWLEDGE This study aimed to add evidence and experience on the arm-only combined transarterial and transvenous access, as a new approach, for neurointerventional treatment that required arteriovenous approaches.
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Affiliation(s)
- Deyuan Zhu
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chuanchuan Wang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Peipei Ma
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Dayong Qi
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wei Cao
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Suya Li
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Meng Du
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Juanling He
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shifei Ye
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Tonghui Song
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Rongguo Hu
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Peng Li
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Tianheng Zheng
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yibin Fang
- Department of Neurovascular Disease, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
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García C, Narata AP, Liu J, Fang Y, Larrabide I. Comparative Study of Automated Algorithms for Brain Arteriovenous Malformation Nidus Extent Identification Using 3DRA. Cardiovasc Eng Technol 2023; 14:801-809. [PMID: 37783951 DOI: 10.1007/s13239-023-00688-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/18/2023] [Indexed: 10/04/2023]
Abstract
PURPOSE When performing a brain arteriovenous malformation (bAVMs) intervention, computer-assisted analysis of bAVMs can aid clinicians in planning precise therapeutic alternatives. Therefore, we aim to assess currently available methods for bAVMs nidus extent identification over 3DRA. To this end, we establish a unified framework to contrast them over the same dataset, fully automatising the workflows. MATERIALS AND METHODS We retrospectively collected contrast-enhanced 3DRA scans of patients with bAVMs. A segmentation network was used to automatically acquire the brain vessels segmentation for each case. We applied the nidus extent identification algorithms over each of the segmentations, computing overlap measurements against manual nidus delineations. RESULTS We evaluated the methods over a private dataset with 22 3DRA scans of individuals with bAVMs. The best-performing alternatives resulted in [Formula: see text] and [Formula: see text] dice coefficient values. CONCLUSIONS The mathematical morphology-based approach showed higher robustness through inter-case variability. The skeleton-based approach leverages the skeleton topomorphology characteristics, while being highly sensitive to anatomical variations and the skeletonisation method employed. Overall, nidus extent identification algorithms are also limited by the quality of the raw volume, as the consequent imprecise vessel segmentation will hinder their results. Performance of the available alternatives remains subpar. This analysis allows for a better understanding of the current limitations.
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Affiliation(s)
- Camila García
- Yatiris Group, PLADEMA Institute, UNICEN, Campus Universitario, Tandil, Argentina.
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Tandil, Argentina.
| | - Ana Paula Narata
- Department of Neuroradiology, University Hospital of Southampton, Southampton, UK
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yibin Fang
- Department of Neurovascular Disease, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ignacio Larrabide
- Yatiris Group, PLADEMA Institute, UNICEN, Campus Universitario, Tandil, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Tandil, Argentina
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Batista S, Almeida Filho JA, Oliveira LDB, Koester S, Pinheiro AC, Dinato RA, Bertani R, Andreão FF, Mounayer C. Evaluating the safety and efficacy of transvenous embolization for brain arteriovenous malformation: A systematic review and meta-analysis. Interv Neuroradiol 2023:15910199231204922. [PMID: 37787162 DOI: 10.1177/15910199231204922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Transvenous embolization is a potential therapy for brain arteriovenous malformation, involving the use of microcatheters to guide an ethylene vinyl alcohol coil for vessel occlusion. However, the safety and efficacy of transvenous embolization are not fully established. OBJECTIVE To evaluate the safety and efficacy of transvenous embolization for brain arteriovenous malformation. METHODS A systematic review of the literature of studies investigating the safety and efficacy of transvenous embolization for brain arteriovenous malformation was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Databases, including PubMed, Cochrane Library, Web of Science, and Embase were queried. RESULTS In the final analysis of 16 studies involving 368 brain arteriovenous malformation cases who received transvenous embolization, the complete occlusion was achieved in 91% (95% CI: 88%, 94%; I2 = 43%, p = 0.04) of cases. The overall rate of good outcomes after discharge was high at 89% (95% CI: 82%, 95%; I2 = 60%, p < 0.01). Ischemic complications were reported in 1% of cases (95% CI: 0%, 2%; I2 = 0%, p = 0.96), while hemorrhagic complications occurred in 6% of cases (95% CI: 3%, 8%; I2 = 8%, p = 0.37), and technical complications rate of 8% (95% CI: 4%, 11%; I2 = 8%, p = 0.36). Finally, only one death was related to the procedure. CONCLUSION Transvenous embolization for brain arteriovenous malformation shows promising safety and effectiveness, with low mortality, a considerable rate of positive outcomes, and a relatively low incidence of complications. The majority of patients achieved complete occlusion, indicating transvenous embolization as a potential option, especially for challenging deep-seated lesions.
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Affiliation(s)
- Sávio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Stefan Koester
- Vanderbilt University, School of Medicine, Nashville, TN, USA
| | - Agostinho Camara Pinheiro
- Department of Neurology, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rafael Alonso Dinato
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Raphael Bertani
- Department of Neurosurgery, University of São Paulo, São Paulo, Brazil
| | - Filipi Fim Andreão
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Charbel Mounayer
- Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, Limousin, France
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Saal-Zapata G, Visconti-Lopez FJ. Worldwide Research Trends on Transvenous Embolization of Brain Arteriovenous Malformations: A Bibliometric and Visualized Study. World Neurosurg 2023; 178:20-27. [PMID: 37393998 DOI: 10.1016/j.wneu.2023.06.118] [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: 06/05/2023] [Accepted: 06/25/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Transvenous embolization (TVE) of brain arteriovenous malformations (bAVMs) is an emerging endovascular technique that has shown high cure rates in selected cases. The rationale of our study was to determine authorship and worldwide institutional trends and contributions to the knowledge in this topic. METHODS Web of Science database was used. A total of 63 articles were included based on predefined inclusion criteria, which were manually reviewed. The bibliometric analysis involved the use of quantitative bibliometric indicators and network analysis with co-authorship and co-occurrence of terms, which were performed using the bibliometrix package in R and VOSviewer, respectively. RESULTS The first article was published in 2010, with the largest number of articles published in 2022 (10 articles). The average number of citations per document was 11.38, and the annual growth rate was 14.35%. The top 10 authors with the most scientific production on TVE of bAVMs were from France, and the most cited study was published by Iosif C in 2015, followed by Consoli A in 2013, and Chen CJ in 2018. Journal of Neurointerventional Surgery was the journal with the most articles published. The most commonly used keywords were dural arteriovenous fistula, Onyx, vascular disorders, and neurological surgery around 2016, and intervention around 2021. CONCLUSIONS TVE of bAVMs is an emerging technique. Our search identified some scientific articles, without randomized clinical trials, but many case series from single institutions. French and German institutions are the pioneers in the field, and further research is required in specialized endovascular centers.
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Affiliation(s)
- Giancarlo Saal-Zapata
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara Irigoyen-EsSalud, La Victoria, Lima, Peru; Department of Interventional Neurosurgery, Clínica Angloamericana, San Isidro, Lima, Peru
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Valero-Moreno F, Pullen MW, Navarro-Martínez G, Ruiz-Garcia H, Domingo RA, Martínez JL, Suarez-Meade P, Damon A, Quiñones-Hinojosa A, Sandhu SJ, Tawk RG, Fox WC. Absence of the torcular, review of venous sinus anatomy, and the simplified dural sinus classification. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05559-w. [PMID: 37014451 DOI: 10.1007/s00701-023-05559-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/08/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Classically, the torcular Herophili is described as the symmetric junction between the superior sagittal sinus (SSS), transverse sinuses (TSs), and straight sinus (SS). However, finding this pattern in practice is not standard. Anatomical variations are common, and different drainage patterns should be expected. Existing literature proposes highly detailed descriptions and classifications of this region. Still, a simplified and practical categorization is not available. METHODS We present an anatomical finding of the torcular Herophili discovered on a cadaveric dissection. Then, we conducted a retrospective study examining the 100 most recent cranial magnetic resonance venographies (MRVs) from the Mayo Clinic, labeling them with a new proposed dural sinus classification system. Images were initially classified by two authors and further validated by a board-certified neurosurgeon and a board-certified neuroradiologist from our institution. To measure consistency in image identification, two additional international neurosurgeons were asked to classify a subset of the same MRV images, and their answers were compared. RESULTS Of the MRV cohort, 33 patients were male and 67 were female. Their ages ranged from 18 to 86 years, with a mean of 47.35 years and a median of 49 years. Upon examination, 53 patients presented as confluent (53%), 9 as SSS divergent (9%), 25 as SS divergent (25%), 11 as circular (11%), and 2 as trifurcated (2%). The inter-rater reliability ranked very good; agreement between the two neurosurgeons was 83% (κ = 0.830, p < 0.0005). CONCLUSION The confluence of the venous sinuses is a highly variable anatomical area that is rarely evaluated with neuroimaging before surgery. The classic textbook configuration is not the rule. Using a simplified classification system may increase awareness and hopefully patient safety by preparing the physician for anatomical variations that they will encounter in a surgical or clinical scenario.
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Affiliation(s)
- Fidel Valero-Moreno
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Michael W Pullen
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | | | - Henry Ruiz-Garcia
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Ricardo A Domingo
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | | | - Paola Suarez-Meade
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Aaron Damon
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | | | - Sukhwinder Js Sandhu
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - W Christopher Fox
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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Zeleňák K, Šalát D, Kolarovszki B, Kurča E, Zeleňáková J, Koçer N. Embolization of Ruptured Infratentorial Pial AVM in Pregnancy. Life (Basel) 2023; 13:life13040896. [PMID: 37109425 PMCID: PMC10144631 DOI: 10.3390/life13040896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/12/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
A primigravida 22-year-old woman, at a gestation of 23 weeks, experienced bleeding from a pial arteriovenous malformation (AVM) located in the right cerebellum. After interdisciplinary consensus and with the informed consent of the patient and her family, AVM embolization was performed. Complete occlusion of the AVM was achieved by embolization with PHIL (precipitating hydrophobic injectable liquid). The calculated dose in the uterus was less than 1 µSv, which represents a negligible risk of harmful effects on the fetus. She delivered a baby at 37 weeks of gestation by cesarean section without complications. No congenital disorders were diagnosed by standard screening methods until the age of the newborn was two years. The angiography protocol must be optimized to minimize the radiation dose. Adequate shielding protection of the uterus is important. Premature termination of pregnancy is not necessary. Multidisciplinary care of neurologists, neurosurgeons, interventional radiologists, anesthesiologists, neonatologists, and obstetricians is necessary.
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Role of the anterior choroidal artery in the endovascular treatment of brain arteriovenous malformations. Acta Neurol Belg 2023; 123:57-67. [PMID: 35147868 DOI: 10.1007/s13760-022-01878-4] [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: 07/27/2021] [Accepted: 01/27/2022] [Indexed: 11/01/2022]
Abstract
The anterior choroidal artery (AchA) is a very important vessel that supplies certain crucial structures that have poor collateral circulation. When the AchA is recruited to supply brain arteriovenous malformations (BAVMs), can the AchA act as a safe path through which endovascular treatment (EVT) be performed? As few studies or reports have investigated this matter, we performed a review to expound upon the role of the AchA in the EVT of BAVMs. In this review, we discussed the anatomy and variation of the AchA, the angioarchitecture of BAVMs fed by the AchA, the status of EVT for BAVMs and its associated problems and their solutions, the choice of embolic materials, new EVT techniques, the complications and prognoses of EVT through the AchA, etc. The review revealed that although EVT of BAVMs through the AchA is challenging and can result in unpredictable complications, it may be an appropriate option prior to surgery and radiation therapies or serve as a curative procedure. A complete and thorough understanding of the functional anatomy and variant of the AchA and proper EVT techniques are crucial for successful embolization of BAVMs via the AchA.
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Letchuman V, Mittal AM, Gupta HR, Ampie L, Raper D, Armonda RA, Sheehan JP, Kellogg RT, Park MS. The Era of Onyx Embolization: A Systematic and Literature Review of Preoperative Embolization Before Stereotactic Radiosurgery for the Management of Cerebral Arteriovenous Malformations. World Neurosurg 2023; 170:90-98. [PMID: 36396047 DOI: 10.1016/j.wneu.2022.11.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/13/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The current treatment paradigm for intracranial arteriovenous malformations (AVMs) focuses on reducing the risk of intracranial hemorrhage using various therapeutic means including embolization, stereotactic radiosurgery (SRS), and microsurgical resection. To improve AVM obliteration rates with SRS, pre-radiosurgical embolization has been trialed in a number of studies to reduce the volume of the AVM nidus prior to radiosurgery. This study aimed to review the efficacy of pre-radiosurgical embolization in the pre-Onyx era compared to the current Onyx era. METHODS A systematic review was performed using PubMed to identify studies with 20 or more AVM patients, embolization material, and obliteration rates for both embolization + stereotactic radiosurgery (E+SRS) and SRS-only groups. RESULTS Seventeen articles consisting of 1133 eligible patients were included in this study. A total of 914 (80.7%) patients underwent embolization prior to SRS. Onyx was used as the embolysate in 340 (37.2%) patients in the E+SRS cohorts. Mean obliteration rate for the embolized cohort was 46.9% versus 46.5% in the SRS-only cohort. When comparing obliteration rates based on embolysate material, obliteration rate was 42.1% with Onyx+SRS and 50.0% in the non-Onyx embolysate + SRS cohort. CONCLUSIONS Onyx (ethylene vinyl-alcohol copolymer dissolved in dimethyl sulfoxide and suspended in micronized tantalum powder) has been increasingly used for the embolization of intracranial AVMs with increased success regarding its ease of use from a technical standpoint and performs similarly to other embolysate materials.
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Affiliation(s)
- Vijay Letchuman
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
| | - Aditya M Mittal
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Herschel R Gupta
- University of Missouri - Kansas City, School of Medicine, Kansas City, Missouri, USA
| | - Leonel Ampie
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA; Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Daniel Raper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Rocco A Armonda
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ryan T Kellogg
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Min S Park
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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Israrahmed A, Agarwal R, Chauhan G. Endovascular embolisation of a complex mandibular AVM: a hybrid transarterial and transvenous approach. BMJ Case Rep 2023; 16:e251589. [PMID: 36693701 PMCID: PMC9884935 DOI: 10.1136/bcr-2022-251589] [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] [Indexed: 01/26/2023] Open
Abstract
Mandibular arteriovenous malformations (AVMs) are rare lesions which can present with life-threatening haemorrhage. Endovascular embolisation can be life saving for these patients. We discuss a patient of mandibular AVM, who initially presented with reports of massive oral bleeding. The lesion was only partially embolised via transarterial route, as the nidus could not be penetrated completely. In view of rebleeding within 72 hours from the same site, a second embolisation procedure was done via combined, transarterial and transvenous approaches. Coils and onyx were used as embolising agents. Complete embolisation was achieved via combined approach. No further bleeding episodes were seen at 1-year follow-up. Endovascular embolisation of mandibular AVMs can be technically challenging and, hence, a sound knowledge of the anatomy as well as the possible modification of technique is essential to achieve complete obliteration of the lesion and to maximise the benefit of embolisation and to avoid major radical surgery.
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Affiliation(s)
| | | | - Gaurav Chauhan
- Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Anadani M, Lena J. Transvenous embolization of conus spinal arteriovenous malformation: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 5:CASE22382. [PMID: 36647251 PMCID: PMC9844523 DOI: 10.3171/case22382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/07/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Spinal arteriovenous malformations (AVMs) are the most challenging spinal vascular malformations. Endovascular transarterial embolization of spinal AVM has been well described. However, transvenous embolization has not been previously reported. In this case report, the authors describe transvenous embolization of a recurrent intramedullary/conus spinal AVM that was previously deemed unamenable to endovascular therapy. OBSERVATIONS A 30-year-old female presented with debilitating lumbar back pain and was found to have an intramedullary spinal AVM at the level of the conus medullaris. Initially, the AVM was treated with endovascular arterial embolization and subsequently with microsurgical resection. However, on follow-up angiography, the AVM had recurred. Further arterial embolization was deemed not possible because of anatomical challenges. After careful consideration, endovascular transvenous embolization was performed with successful occlusion of the AVM nidus. LESSONS Transvenous embolization is an alternative route for endovascular treatment of spinal AVMs that have an accessible single draining vein.
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Affiliation(s)
- Mohammad Anadani
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Jonathan Lena
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
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Abbas R, Al-Saiegh F, Atallah E, Naamani KE, Tjoumakaris S, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH. Treatment of Intracerebral Vascular Malformations: When to Intervene. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00739-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Chen X, Zhang L, Zhu H, Wang Y, Fan L, Ni L, Dong L, Lv M, Liu P. Transvenous embolization of hemorrhagic brain arteriovenous malformations: Case reports and literature review. Front Neurol 2022; 13:813207. [PMID: 36071902 PMCID: PMC9443662 DOI: 10.3389/fneur.2022.813207] [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: 11/11/2021] [Accepted: 07/12/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Transvenous embolization (TVE) has been proven to be safe and feasible as an alternative management of brain arteriovenous malformations (AVMs). We presented four patients with a hemorrhagic brain AVM who underwent TVE and reviewed the relevant literature. Methods Four patients underwent TVE of a hemorrhagic brain AVM in our center between July 2019 and July 2020. We retrospectively collected and analyzed the clinical and imaging data of these patients and those reported in previously published studies. Results Four patients with a hemorrhagic brain AVM were included. Nidus sizes ranged from 0.79 to 2.56 cm. Spetzler-Martin grade ranged from grade II to grade III. The AVM nidus was located in a deep brain region in three patients. One patient underwent TVE alone and three underwent combined transarterial and transvenous approaches. Digital subtraction angiography (DSA) demonstrated complete obliteration of the vascular malformation after embolization in all four patients. Three patients were independent [modified Rankin Scale (mRS) score ≤ 2] at discharge. All four patients were independent at the last follow-up. AVM obliteration was confirmed in all four patients at the last angiographic follow-up. Conclusion Transvenous embolization can be used as an alternative treatment for contemporary management of brain AVMs, appropriate patient selection is essential to achieve a good clinical outcome.
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Affiliation(s)
- Xiheng Chen
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Longhui Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haoyu Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yajie Wang
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Liwei Fan
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Leying Ni
- Department of Rehabilitation Medicine, The Second Hospital of Anhui Medical University, Hefei, China
| | - Linggen Dong
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Lv
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Ming Lv
| | - Peng Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Peng Liu
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Castillo-Rangel C, Marín G, Hernandez-Contreras KA, Zarate-Calderon C, Vichi-Ramirez MM, Cortez-Saldias W, Rodriguez-Florido MA, Riley-Moguel ÁE, Pichardo O, Torres-Pineda O, Vega-Quesada HG, Lopez-Elizalde R, Ordoñez-Granja J, Alvarado-Martinez HH, Vega-Quesada LA, Aranda-Abreu GE. Atlas of Nervous System Vascular Malformations: A Systematic Review. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081199. [PMID: 36013378 PMCID: PMC9410064 DOI: 10.3390/life12081199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/27/2022] [Accepted: 08/04/2022] [Indexed: 11/24/2022]
Abstract
Vascular malformations are frequent in the head and neck region, affecting the nervous system. The wide range of therapeutic approaches demand the correct anatomical, morphological, and functional characterization of these lesions supported by imaging. Using a systematic search protocol in PubMed, Google Scholar, Ebsco, Redalyc, and SciELO, the authors extracted clinical studies, review articles, book chapters, and case reports that provided information about vascular cerebral malformations, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 385,614 articles were grouped; using the inclusion and exclusion criteria, three of the authors independently selected 51 articles about five vascular cerebral malformations: venous malformation, brain capillary telangiectasia, brain cavernous angiomas, arteriovenous malformation, and leptomeningeal angiomatosis as part of Sturge–Weber syndrome. We described the next topics—“definition”, “etiology”, “pathophysiology”, and “treatment”—with a focus on the relationship with the imaging approach. We concluded that the correct anatomical, morphological, and functional characterization of cerebral vascular malformations by means of various imaging studies is highly relevant in determining the therapeutic approach, and that new lines of therapeutic approaches continue to depend on the imaging evaluation of these lesions.
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Affiliation(s)
- Carlos Castillo-Rangel
- Department of Neurosurgery, “Hospital Regional 1º de Octubre”, Institute of Social Security and Services for State Workers (ISSSTE), Mexico City 07300, Mexico
| | - Gerardo Marín
- Biophysics Department, Brain Research Institute, Xalapa 91192, Mexico
- Correspondence: ; Tel.: +52-296-102-5707
| | | | | | | | - Wilmar Cortez-Saldias
- Department of Neurosurgery, “Hospital Regional 1º de Octubre”, Institute of Social Security and Services for State Workers (ISSSTE), Mexico City 07300, Mexico
| | - Marco Antonio Rodriguez-Florido
- National Center of Medicine, “Siglo XXI: Dr. Bernardo Sepúlveda Gutiérrez”, Mexican Social Security Institute (IMSS), Mexico City 07300, Mexico
| | - Ámbar Elizabeth Riley-Moguel
- Department of Neurosurgery, “Hospital Regional 1º de Octubre”, Institute of Social Security and Services for State Workers (ISSSTE), Mexico City 07300, Mexico
| | - Omar Pichardo
- Department of Neurosurgery, “Hospital Regional 1º de Octubre”, Institute of Social Security and Services for State Workers (ISSSTE), Mexico City 07300, Mexico
| | | | - Helena G. Vega-Quesada
- Department of Internal Medicine, General Hospital of Zone No. 71 “Lic. Benito Coquet Lagunes”, Veracruz 91700, Mexico
| | - Ramiro Lopez-Elizalde
- Department of Neurosurgery, “Hospital Regional 1º de Octubre”, Institute of Social Security and Services for State Workers (ISSSTE), Mexico City 07300, Mexico
| | - Jaime Ordoñez-Granja
- Department of Neurosurgery, “Hospital Regional 1º de Octubre”, Institute of Social Security and Services for State Workers (ISSSTE), Mexico City 07300, Mexico
| | | | - Luis Andrés Vega-Quesada
- Department of Cardiology, Cardiology Hospital of Zone No. 34, Mexican Institute of Social Security (IMSS), Ciudad de México 06600, Mexico
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Ghatge S, Itti P. Curative Embolization of Small Brain Arteriovenous Malformations by Ethyl Vinyl Alcohol Copolymer: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e27219. [PMID: 36035052 PMCID: PMC9399823 DOI: 10.7759/cureus.27219] [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] [Accepted: 07/24/2022] [Indexed: 11/30/2022] Open
Abstract
The right choice in treating small (Spetzler-Ponce grade A) brain arteriovenous malformations (AVMs) is a matter of debate with varying views from neurology, neurosurgery, and interventional neuroradiology points of view. The Spetzler-Martin 1 and 2 brain AVMs, especially those in eloquent and deep areas that are difficult to access by micro-neurosurgery, are most suitable for a complete cure by endovascular embolization with ethyl vinyl alcohol (EVOH)-based agents. A literature search was done with keywords such as endovascular embolization of small brain AVM. Data from 13 articles are included in the study based on predetermined inclusion and exclusion criteria. Meta-analysis for the complete cure rate was done, publication bias was removed, and regression analysis showed a 76% cure rate with a 95% confidence interval (CI). Major complications were hemorrhage and neurological deficit, which ranged from 0-20% and 0-16% with a mean proportion of 0.11 and 0.09, respectively. Long-term (3-6 months) follow-up data showed 0-4% recurrence at three months, 0-8% recurrence at six months, and 2-10% permanent disability. The mortality rate ranged from 3% to 4%. Three illustrative cases with data from the author’s institute are included in the article. To conclude, endovascular embolization for small brain AVMs is a satisfactory treatment modality, however, prospective registries and randomized controlled trials involving embolization versus neurosurgery and/or stereotactic radiosurgery (SRS) may validate the role of embolization in small brain AVMs as curative treatment.
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Razavi SAS, Mirbolouk MH, Gorji R, Ebrahimnia F, Sasannejad P, Zabihyan S, Seraj FQM, Etemadrezaie H, Esmaeilzadeh M, Blanc R, Piotin M, Baharvahdat H. Endovascular treatment as the first-line approach for cure of low-grade brain arteriovenous malformation. Neurosurg Focus 2022; 53:E8. [PMID: 35901720 DOI: 10.3171/2022.4.focus22122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/18/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE While microsurgery has been proposed as the first-line treatment for patients with low-grade (Spetzler-Martin grade I or II) brain arteriovenous malformations (bAVMs), recent studies have shown promising results for endovascular treatment (EVT) as a single proper choice for the management of this group of bAVMs. In this study, the authors evaluated the safety and efficacy of EVT as a first-line strategy for curing low-grade bAVMs at their center. METHODS All patients with low-grade bAVMs managed primarily by EVT between 2015 and 2021 were enrolled in this study. Patients were evaluated and treated by the same team and followed with the same protocol. The primary endpoint was the efficacy of EVT on the cure of low-grade bAVMs. The second endpoint was the safety of EVT for the treatment of low-grade bAVMs, including procedural complications and long-term clinical outcomes. RESULTS A total of 109 patients were enrolled and represented in the study population. The mean patient age was 31.6 ± 14.8 years. Forty-eight AVMs (44%) were Spetzler-Martin grade I and 61 (56%) were grade II. Of 99 patients who completed their EVT sessions, complete exclusion was achieved in 89 patients (89.9%). Overall, complete exclusion was achieved in 59.6% of patients after a single EVT session. At the 6-month follow-up, 106 patients (97.2%) had a favorable outcome. Four patients (4.6%) experienced transient neurological deficits, and 1 patient (0.9%) had a permanent neurological deficit. CONCLUSIONS EVT can be offered as the first choice of treatment for select patients with low-grade bAVMs, with a high cure rate and low morbidity.
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Affiliation(s)
- Seyed Ali Shariat Razavi
- 1Section of Neurovascular Intervention, Neurosurgical Department, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran; and
| | - Mohammad Hossein Mirbolouk
- 1Section of Neurovascular Intervention, Neurosurgical Department, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran; and
| | - Reza Gorji
- 1Section of Neurovascular Intervention, Neurosurgical Department, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran; and
| | - Feizollah Ebrahimnia
- 1Section of Neurovascular Intervention, Neurosurgical Department, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran; and
| | - Payam Sasannejad
- 1Section of Neurovascular Intervention, Neurosurgical Department, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran; and
| | - Samira Zabihyan
- 1Section of Neurovascular Intervention, Neurosurgical Department, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran; and
| | - Farid Qoorchi Moheb Seraj
- 1Section of Neurovascular Intervention, Neurosurgical Department, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran; and
| | - Hamid Etemadrezaie
- 1Section of Neurovascular Intervention, Neurosurgical Department, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran; and
| | - Mahla Esmaeilzadeh
- 1Section of Neurovascular Intervention, Neurosurgical Department, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran; and
| | - Raphaël Blanc
- 2Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Michel Piotin
- 2Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Humain Baharvahdat
- 1Section of Neurovascular Intervention, Neurosurgical Department, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran; and.,2Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
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De Leacy R, Ansari SA, Schirmer CM, Cooke DL, Prestigiacomo CJ, Bulsara KR, Hetts SW. Endovascular treatment in the multimodality management of brain arteriovenous malformations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee. J Neurointerv Surg 2022; 14:1118-1124. [PMID: 35414599 DOI: 10.1136/neurintsurg-2021-018632] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/07/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The purpose of this review is to summarize the data available for the role of angiography and embolization in the comprehensive multidisciplinary management of brain arteriovenous malformations (AVMs METHODS: We performed a structured literature review for studies examining the indications, efficacy, and outcomes for patients undergoing endovascular therapy in the context of brain AVM management. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS The multidisciplinary evaluation and treatment of brain AVMs continues to evolve. Recommendations include: (1) Digital subtraction catheter cerebral angiography (DSA)-including 2D, 3D, and reformatted cross-sectional views when appropriate-is recommended in the pre-treatment assessment of cerebral AVMs. (I, B-NR) . (2) It is recommended that endovascular embolization of cerebral arteriovenous malformations be performed in the context of a complete multidisciplinary treatment plan aiming for obliteration of the AVM and cure. (I, B-NR) . (3) Embolization of brain AVMs before surgical resection can be useful to reduce intraoperative blood loss, morbidity, and surgical complexity. (IIa, B-NR) . (4) The role of primary curative embolization of cerebral arteriovenous malformations is uncertain, particularly as compared with microsurgery and radiosurgery with or without adjunctive embolization. Further research is needed, particularly with regard to risk for AVM recurrence. (III equivocal, C-LD) . (5) Targeted embolization of high-risk features of ruptured brain AVMs may be considered to reduce the risk for recurrent hemorrhage. (IIb, C-LD) . (6) Palliative embolization may be useful to treat symptomatic AVMs in which curative therapy is otherwise not possible. (IIb, B-NR) . (7) The role of AVM embolization as an adjunct to radiosurgery is not well-established. Further research is needed. (III equivocal, C-LD) . (8) Imaging follow-up after apparent cure of brain AVMs is recommended to assess for recurrence. Although non-invasive imaging may be used for longitudinal follow-up, DSA remains the gold standard for residual or recurrent AVM detection in patients with concerning imaging and/or clinical findings. (I, C-LD) . (9) Improved national and international reporting of patients of all ages with brain AVMs, their treatments, side effects from treatment, and their long-term outcomes would enhance the ability to perform clinical trials and improve the rigor of research into this rare condition. (I, C-EO) . CONCLUSIONS Although the quality of evidence is lower than for more common conditions subjected to multiple randomized controlled trials, endovascular therapy has an important role in the management of brain AVMs. Prospective studies are needed to strengthen the data supporting these recommendations.
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Affiliation(s)
- Reade De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sameer A Ansari
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Daniel L Cooke
- Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
| | | | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Steven W Hetts
- Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
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He Y, Bai W, Xu B, Kang X, Xue J, He Y, Li T. Perioperative Complications of Transvenous Embolization of Ruptured Intracranial Arteriovenous Malformations. Front Neurol 2022; 13:873186. [PMID: 35432177 PMCID: PMC9009503 DOI: 10.3389/fneur.2022.873186] [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: 02/10/2022] [Accepted: 03/09/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeTo investigate the perioperative complications of transvenous embolization of ruptured intracranial arteriovenous malformations.Materials and MethodsA total of 27 patients with ruptured intracranial arteriovenous malformations underwent transvenous embolization were enrolled from November 2016 to May 2020 in our prospective database. Perioperative complications and angiographic characteristics were analyzed retrospectively.ResultsComplete disappearance of the nidus occured in 22 (88%) of 25 patients with technically feasible AVMs immediately after embolization. Two cases were partially treated by transarterial embolization due to the failure of microcatheter placement into the draining vein. Seven (25.9%, 7/27) patients had perioperative complications, including three cases of intraoperative hemorrhage, three cases of postoperative hemorrhage and one case of ischemic infarction. No significant differences in complication rates between patients with nidus ≥3 cm and <3 cm (P = 0.659), eloquent area and non-eloquent (P = 0.137), deep location and superficial (P = 0.637), deep venous drainage and cortical vein (P = 1.0), the number of venous drainage (P = 0.49), the angle of draining vein entering venous sinus <90° and ≥90° (P = 1.0), aneurysms (P = 0.058) and the time between hemorrhage and TVE (P = 1.0) were found. Three of these patients received ventriculostomy, two of which received lumbar drainage treatments at the same time, and four patients just received conservative management. Good outcomes (mRS ≤ 2) at the 1-month evaluation were achieved in 5 of the patients who had complications, but poor outcome (mRS = 5) at the 1-month evaluation was in 1 patient, and 1 lethal complication occurred.ConclusionThe most common complication of AVMs with transvenous endovascular embolization is cerebral hemorrhage. The prevention of complications may improve the efficacy of AVM embolization, but the current quality of evidence is low and limited in guiding policy development and improving the TVE for AVMs. It is, therefore, necessary to develop clinical research programs in this field.
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Affiliation(s)
- Yanyan He
- Department of Cerebrovascular Disease and Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
| | - Weixing Bai
- Department of Cerebrovascular Disease and Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
- Weixing Bai
| | - Bin Xu
- Department of Cerebrovascular Disease and Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
| | - Xiaoyu Kang
- Department of Cerebrovascular Disease and Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
| | - Jiangyu Xue
- Department of Cerebrovascular Disease and Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
| | - Yingkun He
- Department of Cerebrovascular Disease and Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
- *Correspondence: Yingkun He
| | - Tianxiao Li
- Department of Cerebrovascular Disease and Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan University People's Hospital, Zhengzhou, China
- Department of Cerebrovascular Disease and Neurosurgery, Henan Provincial People's Hospital, Zhengzhou, China
- Henan Provincial NeuroInterventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease, and Henan Engineering Research Center of Cerebrovascular Intervention Innovation, Zhengzhou, China
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Aboukais R, Devalckeneer A, Boussemart P, Bourgeois P, Menovsky T, Leclerc X, Vinchon M, Lejeune JP. Is malignant edema and hemorrhage after occlusion of high-flow arteriovenous malformation related to the size of feeding arteries and draining veins? Neurochirurgie 2022; 68:e1-e7. [DOI: 10.1016/j.neuchi.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 11/16/2022]
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22
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Zhang W, Wei H, Tian Q, Han S, Han W, Guo Y, Wang G, Zhang S, Deng G, Wang J, Chen Q, Li M. Efficacy and safety of embolization for arteriovenous malformations of the basal ganglia and thalamus via the transarterial approach. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:306. [PMID: 35433967 PMCID: PMC9011271 DOI: 10.21037/atm-22-384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/18/2022] [Indexed: 11/06/2022]
Abstract
Background To evaluate the effectiveness and safety profile of transarterial embolization in the treatment of brain arteriovenous malformations (bAVMs) within the basal ganglia and thalamus. Methods A retrospective clinical study was performed on 22 patients with bAVMs localized within the basal ganglia and thalamus who were treated with transarterial embolization (December 2012 and January 2019) in our center. The bAVMs were embolized via the transarterial approach with Onyx or Glubran according to the anatomical structure. A detachable or undetachable microcatheter was used in the procedure according to the length of the feeding artery. The data of these patients were retrospectively analyzed. Results Among the 22 patients, 9 bAVMs were located in the basal ganglia and 13 were located in the thalamus. Twenty patients presented with hemorrhage (90.9%), leaving 2 patients (9.1%) who had no symptoms. According to the Spetzler-Martin grading classification, 13 bAVMs (59.1%) were grade 3, 7 (31.8%) were grade 4, and 2 (9.1%) were grade 5. Procedure-related complications occurred in only 1 patient (4.5%). No deaths related to the operation occurred. All patients achieved anatomic stabilization and no bleeding was observed in the follow-up. Conclusions Selective embolization via the transarterial approach is safe and effective for bAVMs originating within the basal ganglia and thalamus. Our results demonstrate a low rate of complications and an elevated degree of anatomical disruption in the endovascular treatment of bAVMs stemming from the basal ganglia and thalamus.
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Affiliation(s)
- Wei Zhang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Heng Wei
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qi Tian
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shoumeng Han
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Wenrui Han
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yujia Guo
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Guijun Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shenqi Zhang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Gang Deng
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Junming Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Mingchang Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
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23
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Transvenous Embolization Technique for Brain Arteriovenous Malformations. Neurosurg Clin N Am 2022; 33:185-191. [DOI: 10.1016/j.nec.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Pérez-Alfayate R, Grasso G. State of the Art and Future Direction in Diagnosis, Molecular Biology, Genetics, and Treatment of Brain Arteriovenous Malformations. World Neurosurg 2022; 159:362-372. [PMID: 35255635 DOI: 10.1016/j.wneu.2021.08.111] [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: 07/19/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022]
Abstract
Brain arteriovenous malformations (bAVMs) are uncommon and represent a heterogeneous group of lesions. Although these 2 facts have delayed research on this topic, knowledge about the pathophysiology, diagnosis, and treatment of bAVMs has evolved in recent years. We conducted a review of the literature to update the knowledge about diagnosis, molecular biology, genetic, pathology, and treatment by searching for the following terms: "Epidemiology AND Natural History," "risk of hemorrhage," "intracranial hemorrhage," "diagnosis," "angiogenesis," "molecular genetics," "VEGF," "KRAS," "radiosurgery," "endovascular," "microsurgery," or "surgical resection." Our understanding of bAVMs has significantly evolved in recent years. The latest investigations have helped in defining some molecular pathways involved in the pathology of bAVM. Although there is still more to learn and discover, describing these pathways will allow the creation of targeted treatments that could improve the prognosis of patients with bAVMs.
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Affiliation(s)
- Rebeca Pérez-Alfayate
- Department of Neurosurgery, Neuroscience Institute, Hospital Clínico San Carlos, Madrid, Spain.
| | - Giovanni Grasso
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
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25
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Denison T, Morrell MJ. Neuromodulation in 2035: The Neurology Future Forecasting Series. Neurology 2022; 98:65-72. [PMID: 35263267 PMCID: PMC8762584 DOI: 10.1212/wnl.0000000000013061] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 11/08/2021] [Indexed: 11/15/2022] Open
Abstract
Neuromodulation devices are approved in the United States for the treatment of movement disorders, epilepsy, pain, and depression, and are used off-label for other neurologic indications. By 2035, advances in our understanding of neuroanatomical networks and in the mechanism of action of stimulation, coupled with developments in material science, miniaturization, energy storage, and delivery, will expand the use of neuromodulation devices. Neuromodulation approaches are flexible and modifiable. Stimulation can be targeted to a dysfunctional brain focus, region, or network, and can be delivered as a single treatment, continuously, according to a duty cycle, or in response to physiologic changes. Programming can be titrated and modified based on the clinical response or a physiologic biomarker. In addition to keeping pace with clinical and technological developments, neurologists in 2035 will need to navigate complex ethical and economic considerations to ensure access to neuromodulation technology for a rapidly expanding population of patients. This article provides an overview of systems in use today and those that are anticipated and highlights the opportunities and challenges for the future, some of which are technical, but most of which will be addressed by learning about brain networks, and from rapidly growing experience with neuromodulation devices.
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Affiliation(s)
- Tim Denison
- From the Department of Engineering Science (T.D.), University of Oxford, UK; Department of Neurology and Neurological Sciences (M.J.M), Stanford University, CA; and NeuroPace (M.J.M), Mountain View, CA
| | - Martha J Morrell
- From the Department of Engineering Science (T.D.), University of Oxford, UK; Department of Neurology and Neurological Sciences (M.J.M), Stanford University, CA; and NeuroPace (M.J.M), Mountain View, CA.
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26
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Roberts GS, Loecher MW, Spahic A, Johnson KM, Turski PA, Eisenmenger LB, Wieben O. Virtual injections using 4D flow MRI with displacement corrections and constrained probabilistic streamlines. Magn Reson Med 2021; 87:2495-2511. [PMID: 34971458 PMCID: PMC8884720 DOI: 10.1002/mrm.29134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 11/10/2022]
Abstract
PURPOSE Streamlines from 4D-flow MRI have been used clinically for intracranial blood-flow tracking. However, deterministic and stochastic errors degrade streamline quality. The purpose of this study is to integrate displacement corrections, probabilistic streamlines, and novel fluid constraints to improve selective blood-flow tracking and emulate "virtual bolus injections." METHODS Both displacement artifacts (deterministic) and velocity noise (stochastic) inherently occur during phase-contrast MRI acquisitions. Here, two displacement correction methods, single-step and iterative, were tested in silico with simulated displacements and were compared with ground-truth velocity fields. Next, the effects of combining displacement corrections and constrained probabilistic streamlines were performed in 10 healthy volunteers using time-averaged 4D-flow data. Measures of streamline length and depth into vasculature were then compared with streamlines generated with no corrections and displacement correction alone using one-way repeated-measures analysis of variance and Friedman's tests. Finally, virtual injections with improved streamlines were generated for three intracranial pathology cases. RESULTS Iterative displacement correction outperformed the single-step method in silico. In volunteers, the combination of displacement corrections and constrained probabilistic streamlines allowed for significant improvements in streamline length and increased the number of streamlines entering the circle of Willis relative to streamlines with no corrections and displacement correction alone. In the pathology cases, virtual injections with improved streamlines were qualitatively similar to dynamic arterial spin labeling images and allowed for forward/reverse selective flow tracking to characterize cerebrovascular malformations. CONCLUSION Virtual injections with improved streamlines from 4D-flow MRI allow for flexible, robust, intracranial flow tracking.
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Affiliation(s)
- Grant S Roberts
- Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Michael W Loecher
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Alma Spahic
- Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Kevin M Johnson
- Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Patrick A Turski
- Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Laura B Eisenmenger
- Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Oliver Wieben
- Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, USA
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27
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Tran AT, Mai DT, Huyen NT, Đào VP, Phung DT, Pham QT. Transvenous retrograde embolization of ruptured brain arteriovenous malformations: A case report and review of the literature. Radiol Case Rep 2021; 17:298-302. [PMID: 34876954 PMCID: PMC8633821 DOI: 10.1016/j.radcr.2021.10.062] [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: 10/24/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 11/05/2022] Open
Abstract
Hemorrhagic stroke due to ruptured brain arteriovenous malformations (AVMs) is a common cause in young stroke patients. When the ruptured AVMs are in deep location, the choice of endovascular intervention with the arterial approach to AVM embolization is routine but in many cases, it is not feasible due to the inability to access because of the small and tortuous arterial branch, however, the intravenous approach also results in high complete obliteration rates but also carries a higher risk of stroke than the intra-arterial route. We describe a 36-year-old female patient diagnosed with intracranial and intraventricular hemorrhage who underwent complete transvenous embolization of the ruptured AVMs, and achieved near-complete clinical recovery after 1 month with the modified Rankin scale 1.
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Affiliation(s)
| | - Duy Ton Mai
- Stroke Center, Bach Mai hospital, Hanoi, Vietnam
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28
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Waldeck S, Chapot R, von Falck C, Froelich MF, Brockmann M, Overhoff D. First Experience in the Control of the Venous Side of the Brain AVM. J Clin Med 2021; 10:jcm10245771. [PMID: 34945067 PMCID: PMC8708276 DOI: 10.3390/jcm10245771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 11/28/2021] [Accepted: 12/06/2021] [Indexed: 11/16/2022] Open
Abstract
Background and purpose: Brain arteriovenous malformations (AVM) are increasingly curable with endovascular embolization. This study examines the preliminary experience with a novel double-sided hybrid approach in the treatment of cerebral arteriovenous malformations (AVM) versus a purely single-sided intra-arterial approach. Materials and methods: The single-center study cohort included 18 patients with brain AVMs (Spetzler–Martin Grade 2 or 3) having stand-alone endovascular treatment with either the arterial-side-only pressure cooker technique (aPCT) (group 1; n = 9) or a double-sided hybrid intra-arterial and transvenous approach (HIPRENE) (group 2; n = 9). Results: Patients belonging to group 2 had lower rates of intra-procedural hemorrhaging (66.7% vs. 33.3%, p = 0.169) and needed fewer treatment sessions to achieve nidus occlusion (1.7 vs. 1.2, p = 0.136). The HIPRENE treatment regime led to higher nidus occlusion rates after the initial treatment compared to aPCT (77.7% vs. 44.4%, p = 0.167). Group 2 patients had a lower rate of neuromonitoring events (22.2% vs. 44.4%, p = 0.310) and fewer accounts of blood flow obstruction in post-operative MRIs (33.3% vs. 55.6%, p = 0.319). Conclusion: A double-sided hybrid intra-arterial and transvenous approach might have benefits for curative endovascular brain AVM treatment in patients with Spetzler–Martin Grade 2 or 3. In our small study cohort, the HIPRENE treatment regime had higher nidus occlusion rates after the first treatment, which reduces the number of treatment sessions and lowers intra- and post-operative complication rates. Further randomized controlled studies are awaited to corroborate our preliminary outcomes.
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Affiliation(s)
- Stephan Waldeck
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Bundeswehr Central Hospital Koblenz, Rübenacher Straße 170, 56072 Koblenz, Germany;
- Institute of Neuroradiology, University Medical Centre, Johannes Gutenberg University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany;
- Correspondence: ; Tel.: +49-(0)261-281-2800
| | - Rene Chapot
- Department of Neuroradiology, Alfried Krupp Krankenhaus, Alfried-Krupp-Strasse 21, 45131 Essen, Germany;
| | - Christian von Falck
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hanover, Germany;
| | - Matthias F. Froelich
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany;
| | - Marc Brockmann
- Institute of Neuroradiology, University Medical Centre, Johannes Gutenberg University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany;
| | - Daniel Overhoff
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Bundeswehr Central Hospital Koblenz, Rübenacher Straße 170, 56072 Koblenz, Germany;
- Department of Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany;
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29
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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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30
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Govindarajan V, Burks JD, Luther EM, Thompson JW, Starke RM. Medical Adjuvants in the Treatment of Surgically Refractory Arteriovenous Malformations of the Head and Face: Case Report and Review of Literature. Cerebrovasc Dis 2021; 50:493-499. [PMID: 34198289 DOI: 10.1159/000515168] [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: 11/17/2020] [Accepted: 02/10/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Arteriovenous malformations (AVMs) of the brain and face present unique challenges for clinicians. Cerebral AVMs may induce hemorrhage or form aneurysms, while facial AVMs can cause significant disfigurement and pain. Moreover, facial AVMs often draw blood supply from arteries providing critical blood flow to other important structures of the head which may make them impossible to treat curatively. Medical adjuvants may be an important consideration in the management of these patients. SUMMARY We conducted a systematic review of the literature to identify other instances of molecular target of rapamycin (mTOR) inhibitors used as medical adjuvants for the treatment of cranial and facial AVMs. We also present 2 cases from our own institution where patients were treated with partial embolization, followed by adjuvant therapy with rapamycin. After screening a total of 75 articles, 7 were identified which described use of rapamycin in the treatment of inoperable cranial or facial AVM. In total, 21 cases were reviewed. The median treatment duration was 12 months (3-24.5 months), and the highest recorded dose was 3.5 mg/m2. 76.2% of patients demonstrated at least a partial response to rapamycin therapy. In 2 patients treated at our institution, symptomatic and radiographic improvement were noted 6 months after initiation of therapy. Key Messages: Early results have been encouraging in a small number of patients with inoperable AVM of the head and face treated with mTOR inhibitors. Further study of medical adjuvants such as rapamycin may be worthwhile.
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Affiliation(s)
- Vaidya Govindarajan
- Department of Neurological Surgery,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Joshua D Burks
- Department of Neurological Surgery,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Evan M Luther
- Department of Neurological Surgery,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - John W Thompson
- Department of Neurological Surgery,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Robert M Starke
- Department of Neurological Surgery,University of Miami Miller School of Medicine, Miami, Florida, USA
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31
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Memon MZ, Nisar T, Gupta G, Singla A, Khandelwal P. Single Arm Access for Combined Transarterial and Transvenous Neurointerventional Procedures. World Neurosurg 2021; 150:121-126. [PMID: 33812065 DOI: 10.1016/j.wneu.2021.03.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 11/18/2022]
Abstract
A concurrent arterial and venous access is routinely obtained for diagnosis and treatment of various neurovascular diseases. Traditionally, venous access is obtained by accessing the femoral vein or through direct internal jugular puncture. Although complication rates are low, life-threatening severe complications have been reported. Moreover, venous access can be challenging in large body habitus patients through these traditional routes. There is a growing trend of utilizing radial artery access for neuroendovascular procedures. Nevertheless, the use of upper limb veins in neurointerventional procedures is rare. We present 3 cases of the concurrent arterial and venous approach through the radial artery and cephalic or basilic vein of the forearm for diagnostic cerebral arteriography and venography. Radial access was obtained by using the standard technique, and venous access was obtained by cannulating cephalic or basilic vein using ultrasound guidance, and a 5F or 6F short sheath was placed. Venous angiography and catheterization of right and left internal jugular veins were then performed using a Simmons (SIM) 2 catheter alone or using 6F Envoy guide catheter coaxially over the SIM 2 catheter if an additional support for microcatheter was needed. Procedures were successfully completed with no adverse effects, and patients were discharged home the same day. We also describe the technique for the reformation of the SIM 2 catheter in the venous system for catheterization of right and left internal jugular veins through the arm access.
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Affiliation(s)
- Muhammad Zeeshan Memon
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
| | - Taha Nisar
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Gaurav Gupta
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Amit Singla
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Priyank Khandelwal
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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32
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Guest W, Krings T. Brain Arteriovenous Malformations: The Role of Imaging in Treatment Planning and Monitoring Response. Neuroimaging Clin N Am 2021; 31:205-222. [PMID: 33902875 DOI: 10.1016/j.nic.2020.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Brain arteriovenous malformations (AVMs) are characterized by shunting between pial arteries and cortical or deep veins, with the presence of an intervening nidus of tortuous blood vessels. These lesions present a therapeutic challenge, because their natural history entails a risk of intracranial hemorrhage, but treatment may cause significant morbidity. In this article, imaging features of AVMs on MR imaging and catheter angiography are reviewed to stratify the risk of hemorrhage and guide appropriate management. The angioarchitecture of AVMs may evolve over time, spontaneously or in response to treatment, necessitating ongoing imaging surveillance.
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Affiliation(s)
- Will Guest
- Department of Neuroradiology, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada
| | - Timo Krings
- Department of Neuroradiology, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada.
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33
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Multimodal Treatment of Pediatric Ruptured Brain Arteriovenous Malformations: A Single-Center Study. CHILDREN-BASEL 2021; 8:children8030215. [PMID: 33799749 PMCID: PMC7998913 DOI: 10.3390/children8030215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/03/2021] [Accepted: 03/09/2021] [Indexed: 11/17/2022]
Abstract
Bleeding from ruptured brain arteriovenous malformations (bAVMs) represents the most prevalent cause of pediatric intracranial hemorrhage, being also the most common initial bAVM manifestation. A therapeutic approach in these patients should aim at preventing rebleeding and associated significant morbidity and mortality. The purpose of this study was to determine the clinical outcomes of pediatric patients who initially presented at our institution with ruptured bAVMs and to review our experience with a multimodality approach in the management of pediatric ruptured bAVMs. We retrospectively reviewed pediatric patients’ medical records with ruptured bAVMs who underwent interventional treatment (microsurgery, embolization, or radiosurgery; solely or in combination) at our institution between 2011 and 2020. We identified 22 patients. There was no intraoperative and postoperative intervention-related mortality. Neither procedure-related complications nor rebleeding were observed after interventional treatment. Modified Rankin Scale (mRS) assessment at discharge revealed 19 patients (86.4%) with favorable outcomes (mRS 0–2) and 3 patients (13.6%) classified as disabled (mRS 3). Microsurgery ensured the complete obliteration in all patients whose postoperative digital subtraction angiography (DSA) was available. Management of high-grade bAVMs with radiosurgery or embolization can provide satisfactory outcomes without a high disability risk.
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34
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Waqas M, Dossani RH, Vakharia K, Rai HH, Chin F, Tso MK, Rajah GB, Snyder KV, Davies JM, Levy EI, Iyer VS, Siddiqui AH. Complete flow control using transient concurrent rapid ventricular pacing or intravenous adenosine and afferent arterial balloon occlusion during transvenous embolization of cerebral arteriovenous malformations: case series. J Neurointerv Surg 2021; 13:324-330. [PMID: 33593797 DOI: 10.1136/neurintsurg-2020-016945] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/03/2020] [Accepted: 12/14/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND There are no reports that describe complete flow control using concurrent transient rapid ventricular pacing or intravenous (IV) adenosine and afferent arterial balloon flow arrest to aid transvenous embolization of cerebral arteriovenous malformations (AVM). We describe our experience with the use of this technique in patients undergoing transvenous AVM embolization. METHODS Consecutive patients in whom transvenous embolization was attempted at our institute between January 2017 and July 2019 were included. Anatomical AVM features, number of embolization stages, technique of concurrent transient rapid ventricular pacing and afferent arterial balloon flow arrest, complications, and clinical and radiological outcomes were recorded and tabulated. RESULTS Transvenous AVM embolization was attempted in 12 patients but abandoned in two patients for technical reasons. Complete embolization was achieved in 10 patients, five of whom had infratentorial AVMs. All 10 had a single primary draining vein. Rapid ventricular pacing was used in nine cases; IV adenosine injection was used in one case to achieve cardiac standstill. Complete AVM nidus obliteration was achieved with excellent neurologic outcome in nine cases, with transvenous embolization alone in two cases, and with staged transarterial followed by transvenous embolization in the others. Two patients developed hemorrhagic complications intraprocedurally. One patient was managed conservatively and the other operatively with AVM excision and hematoma evacuation; both made an excellent recovery without any neurologic deficits at 3 months. CONCLUSION Complete flow control using concurrent transient rapid ventricular pacing with afferent arterial balloon flow arrest technique is safe and feasible for transvenous embolization of select AVMs.
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Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Hamid H Rai
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Felix Chin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Michael K Tso
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Gary B Rajah
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Vijay S Iyer
- Department of Cardiology, Gates Vascular Institute att Kaleida Health, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA .,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
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Goyal M, Ospel JM, Kashani N, Siddiqui AH, Hanel R, Almekhlafi M, Chapot R. What neurointerventionists think about the treatment of unruptured brain arteriovenous malformations: the complexity of moving towards evidence-based treatment. Neuroradiology 2021; 62:411-416. [PMID: 31974635 DOI: 10.1007/s00234-020-02365-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, CA, USA. .,Department of Diagnostic Imaging, University of Calgary, Calgary, CA, USA.
| | - Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Calgary, CA, USA.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nima Kashani
- Department of Clinical Neurosciences, University of Calgary, Calgary, CA, USA.,Department of Diagnostic Imaging, University of Calgary, Calgary, CA, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, USA
| | - Ricardo Hanel
- Baptist Neurological Institute, Baptist Health System, Jacksonville, USA
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, CA, USA.,Department of Diagnostic Imaging, University of Calgary, Calgary, CA, USA
| | - René Chapot
- Department of Interventional Neuroradiology, Alfred Krupp Krankenhaus, Essen, Germany
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36
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Lucatelli P, Corona M, Teodoli L, Nardis P, Cannavale A, Rocco B, Trobiani C, Cipollari S, Zilahi de Gyurgyokai S, Bezzi M, Catalano C. Use of Phil Embolic Agent for Bleeding in Non-Neurological Interventions. J Clin Med 2021; 10:jcm10040701. [PMID: 33670124 PMCID: PMC7916888 DOI: 10.3390/jcm10040701] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 01/26/2023] Open
Abstract
Objective: To evaluate the safety and efficacy of the Phil liquid embolic agent in non-neurological embolization procedures. M&M: Thirty-five patients with a mean age of 62.5 years underwent percutaneous embolization using Phil for the treatment of visceral arterial bleedings in 20/35 patients (including three gluteal, one bladder, two superior mesenteric, three epigastric, one deep femoral, five internal iliac, four intercostal, and one lingual arteries), splanchnic pseudoaneurysms in 11/35 patients (including three hepatic, five splenic, and three renal arteries), pancreatic bleeding metastasis in 1/35 patient, and gastric bleeding varices in 3/35 patients. Phil is composed of a non-adhesive copolymer dissolved in DMSO (Anhydrous Dimethyl Sulfoxide) with different viscosity. Procedures were performed slowly under continuous fluoroscopic guidance to avoid embolization of non-target vessels. Results: Clinical success was obtained with a single intervention in 34 cases (97.15%), while a repeated procedure was required in one case (2.85%). No technical complications nor non-target embolization occurred. A case of post-embolic syndrome was noted (2.85%) in one patient. DMSO administration-related pain was successfully controlled by medical therapy. Conclusion: Phil can be considered a safe and effective embolic agent for the treatment of non-neurologic bleeding.
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Hou K, Ji T, Luan T, Yu J. CT angiographic study of the cerebral deep veins around the vein of Galen. Int J Med Sci 2021; 18:1699-1710. [PMID: 33746586 PMCID: PMC7976576 DOI: 10.7150/ijms.54891] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/19/2021] [Indexed: 11/30/2022] Open
Abstract
Research on the anatomy of cerebral deep veins (CDVs) around the vein of Galen (VG) is very important and has fundamental clinical significance. Large-scale anatomical studies of CDVs using computed tomography angiography (CTA) are rarely reported. A retrospective study of the CDVs around the VG was conducted in Chinese patients of Han nationality. One hundred cases were included in the final analysis. The patients were aged from 17 to 78 years (mean: 42.3 years). Also, 46% of the patients were female. The diameter of the internal cerebral vein (ICV) at its beginning and termination points ranged from 0.4 to 2.8 mm (1.49 ± 0.39 mm) and 0.4 to 3.5 mm (2.05 ± 0.47 mm), respectively. There was statistical significance regarding the diameter of the ICV at its beginning and termination points (P <0.01). The ICV length ranged from 28.5 to 47.9 mm (36.86 ± 3.74 mm). The length of the straight sinus (SS) ranged from 30.2 to 57.8 mm (43.6 ± 6.37 mm). The length of the VG ranged from 1.5 to 41.8 mm (9.30 ± 4.76 mm). The angle at the VG and SS transition area ranged from 25.4 to 110.6° (77.2 ± 18.0°). This study was a meaningful attempt to conduct anatomical research of CDVs using CTA. Preoperative familiarity with the normal venous structure and its variation around the VG would be helpful for endovascular treatment.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Tiefeng Ji
- Department of Radiology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Tengfei Luan
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
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38
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Cai H, Chen L, Zhang N, Tang W, Yang F, Li Z. Long-term efficacy and safety of curative embolization of brain arteriovenous malformations using the dual microcatheter technique: A single-institution case series and literature review. Clin Neurol Neurosurg 2020; 201:106417. [PMID: 33370624 DOI: 10.1016/j.clineuro.2020.106417] [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: 10/05/2020] [Revised: 11/28/2020] [Accepted: 11/28/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Brain arteriovenous malformations (bAVMs) are among the most common causes of cerebral hemorrhage in adolescents. For multiple-feeder bAVMs, complete exclusion of the nidus by endovascular embolization is challenging. This case series and literature review examined the long-term efficacy and safety of bAVM embolization using the dual microcatheter technique (DMCT). METHODS A total of 38 consecutive patients who underwent endovascular treatment for bAVMs with the DMCT along with all cases reported in the literature were retrospectively reviewed. Patient demographics, clinical presentation, bAVM angioarchitecture, treatment, complications, and long-term outcome were independently assessed. RESULTS Patients with bAVM (24 male and 14 female, mean age: 33.87 ± 13.70 years) treated at our institution were followed up for 97.76 ± 14.51 months. Angiographic obliteration was achieved in a single embolization session in 27/38 (71.05 %) cases; 4/38 (10.53 %) required multiple sessions, and 7/38 (18.42 %) underwent embolization combined with microsurgery or radiotherapy. Neurologic improvement at 90 days was observed in 29/38 patients (76.32 %). At the final follow-up, 34/38 patients (89.47 %) had a favorable clinical outcome. Two patients experienced recurrence during the follow-up period. In total, 55 patients were ultimately analyzed in our literature review. Complete exclusion of bAVMs was achieved in 35 patients (63.63 %), including in 54.54 % after a single endovascular treatment session. One patient died of hemorrhagic complication after endovascular treatment for an overall mortality rate of 1.82 %. CONCLUSIONS DMCT is safe for bAVM embolization and shows long-term efficacy, especially for multiple-feeder bAVMs.
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Affiliation(s)
- Heng Cai
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang 110004, People's Republic of China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang 110004, People's Republic of China
| | - Liangyu Chen
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang 110004, People's Republic of China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang 110004, People's Republic of China
| | - Nan Zhang
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang 110004, People's Republic of China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang 110004, People's Republic of China
| | - Wei Tang
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang 110004, People's Republic of China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang 110004, People's Republic of China
| | - Fangyu Yang
- Department of Neurosurgery, PLA North Military Command Region General Hospital, Shenyang 110004, People's Republic of China
| | - Zhiqing Li
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang 110004, People's Republic of China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang 110004, People's Republic of China.
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39
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De Sousa JMB, Iosif C, Sganzerla LZ, Rafie AN, Borodetsky V, Rouchaud A, Saleme S, Mounayer C. Selection of Patients for Treatment of Brain Arteriovenous Malformations by the Transvenous Approach: Relationship with Venous Anatomy and Risk of Hemorrhagic Complications. AJNR Am J Neuroradiol 2020; 41:2311-2316. [PMID: 33122201 DOI: 10.3174/ajnr.a6810] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/04/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Intracranial hemorrhage represents a severe complication of brain arteriovenous malformation treatment. The aim of this cohort was to report the rate of hemorrhagic complications after transvenous endovascular embolization and analyze the potential angioarchitectural risk factors as well as clinical outcomes. MATERIALS AND METHODS During an 11-year period, 57 patients underwent transvenous endovascular embolization. All cases of hemorrhagic complications were identified. We analyzed the following variables: sex, age, hemorrhagic presentation, Spetzler-Martin grade, size of the AVM before the transvenous treatment, number of venous collectors, pattern of drainage, presence of dilated veins, and technical aspects. Univariate and multivariate multiple regression analyses were performed to evaluate the potential risk factors for procedure-related hemorrhagic complications. RESULTS Hemorrhagic complications (either intraprocedural or periprocedural) unrelated to a perforation due to micronavigation occurred in 8 (14.0%) procedures. Significant (mRS > 2) and persistent neurologic deficits were present in 2 (3.5%) patients at 6-month control. Larger nidi, especially >3 cm (P = .03), and a larger number of venous collectors have shown a statistically significant correlation with hemorrhagic complications. Only the number of venous collectors was identified as an independent predictor of hemorrhagic complications in the multivariate analysis (OR, 8.7; 95% confidence interval, 2.2-58.2) (P = .006). CONCLUSIONS Larger nidus sizes and an increased number of venous collectors may increase the risk of hemorrhagic complications when implementing transvenous endovascular treatment of AVMs. The technique is effective and promising, especially with small nidi and single venous collectors.
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Affiliation(s)
- J M B De Sousa
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - C Iosif
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - L Z Sganzerla
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - A N Rafie
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - V Borodetsky
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - A Rouchaud
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - S Saleme
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
| | - C Mounayer
- From the Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, Limoges, France
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40
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Chen CJ, Ding D, Derdeyn CP, Lanzino G, Friedlander RM, Southerland AM, Lawton MT, Sheehan JP. Brain arteriovenous malformations: A review of natural history, pathobiology, and interventions. Neurology 2020; 95:917-927. [PMID: 33004601 DOI: 10.1212/wnl.0000000000010968] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/08/2020] [Indexed: 11/15/2022] Open
Abstract
Brain arteriovenous malformations (AVMs) are anomalous direct shunts between cerebral arteries and veins that convalesce into a vascular nidus. The treatment strategies for AVMs are challenging and variable. Intracranial hemorrhage and seizures comprise the most common presentations of AVMs. However, incidental AVMs are being diagnosed with increasing frequency due to widespread use of noninvasive neuroimaging. The balance between the estimated cumulative lifetime hemorrhage risk vs the risk of intervention is often the major determinant for treatment. Current management options include surgical resection, embolization, stereotactic radiosurgery (SRS), and observation. Complete nidal obliteration is the goal of AVM intervention. The risks and benefits of interventions vary and can be used in a combinatorial fashion. Resection of the AVM nidus affords high rates of immediate obliteration, but it is invasive and carries a moderate risk of neurologic morbidity. AVM embolization is minimally invasive, but cure can only be achieved in a minority of lesions. SRS is also minimally invasive and has little immediate morbidity, but AVM obliteration occurs in a delayed fashion, so the patient remains at risk of hemorrhage during the latency period. Whether obliteration can be achieved in unruptured AVMs with a lower risk of stroke or death compared with the natural history of AVMs remains controversial. Over the past 5 years, multicenter prospective and retrospective studies describing AVM natural history and treatment outcomes have been published. This review provides a contemporary and comprehensive discussion of the natural history, pathobiology, and interventions for brain AVMs.
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Affiliation(s)
- Ching-Jen Chen
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Dale Ding
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Colin P Derdeyn
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Giuseppe Lanzino
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Robert M Friedlander
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Andrew M Southerland
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Michael T Lawton
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Jason P Sheehan
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ.
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41
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Galvan Fernandez J, Martínez-Galdámez M, Schüller Arteaga M, Ortega-Quintanilla J, Hermosín A, Crespo-Vallejo E, Rodriguez-Arias CA. Arm-only access for combined transarterial and transvenous neurointerventional procedures. J Neurointerv Surg 2020; 13:39-41. [PMID: 32759328 DOI: 10.1136/neurintsurg-2020-016540] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/16/2020] [Accepted: 07/28/2020] [Indexed: 11/04/2022]
Abstract
A simultaneous arterial and venous approach has been widely described for the endovascular treatment of dural arteriovenous fistula (DAVFs) and recently for arteriovenous malformation (AVMs). Conventional venous approaches are performed by direct internal jugular puncture or by femoral access. Although complication rates are low, there are potential life-threatening complications that should be avoided. The advantages of radial artery access have been widely proven, nevertheless the use of upper limb veins in neurointervention are rarely reported. We present five cases of the simultaneous arteriovenous approach through the radial artery and superficial veins of the forearm for the treatment of intracranial neurovascular diseases.
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Affiliation(s)
- Jorge Galvan Fernandez
- Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Mario Martínez-Galdámez
- Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Miguel Schüller Arteaga
- Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Antonio Hermosín
- Interventional Radiology Unit, Hospital Universitario Fundacion Jimenez Diaz, Madrid, Madrid, Spain
| | - Eduardo Crespo-Vallejo
- Interventional Radiology Unit, Hospital Universitario Fundacion Jimenez Diaz, Madrid, Madrid, Spain
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42
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Higbie C, Khatri D, Ligas B, Ortiz R, Langer D. N-Butyl Cyanoacrylate Transvenous Arteriovenous Malformation Embolization with Arterial Balloon Assistance: Defining Parameters for a Transvenous Approach as a Potential Upfront Treatment Option in Managing Cerebral Arteriovenous Malformations. Asian J Neurosurg 2020; 15:434-439. [PMID: 32656149 PMCID: PMC7335129 DOI: 10.4103/ajns.ajns_357_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/03/2020] [Accepted: 02/08/2020] [Indexed: 11/04/2022] Open
Abstract
Complete obliteration of arteriovenous malformations (AVMs) using a transvenous approach as the primary and stand-alone treatment modality has been increasingly considered as a useful endovascular approach in the treatment of AVMs. AVMs are typically treated with microsurgery, stereotactic radiosurgery, endovascular embolization, or some combination of the three methods. Preservation of the draining vein is a key requisite common to all treatment modalities. Transvenous embolization (TVE) is conventionally not recommended as a stand-alone treatment for the vast majority of AVMs and has been thought to be best indicated when traditional approaches are considered less safe and when specific evaluation criteria are met. We report a case of a 35-year-old asymptomatic male diagnosed with a small intracranial AVM adjacent to the right motor strip which was managed utilizing this approach. We employed endovascular embolization via a transvenous approach with arterial balloon assistance due to the small size of the nidus, eloquent location, en passage arterial supply proximal to the venous varix, and a single draining vein from the fistula. This case illustrates the selective indications and technical nuances of TVE approach in managing AVMs as a potential upfront treatment option. When patients harbor AVMs with specific angio-architectural findings as outlined, TVE utilizing Onyx or N-butyl cyanoacrylate can be safely performed as a primary treatment modality.
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Affiliation(s)
- Catherine Higbie
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York, USA
| | - Deepak Khatri
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York, USA
| | - Barbara Ligas
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York, USA
| | - Rafael Ortiz
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York, USA
| | - David Langer
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York, USA
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43
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Mohanty A, Kan P. Commentary: Adenosine-Induced Cardiac Arrest for Transvenous Embolization of Midbrain Arteriovenous Malformation. Oper Neurosurg (Hagerstown) 2020; 18:E191-E192. [PMID: 31872244 DOI: 10.1093/ons/opz391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 10/28/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alina Mohanty
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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44
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Telischak NA, Yedavalli V, Massoud TF. Tortuosity of superior cerebral veins: Comparative magnetic resonance imaging morphometrics in normal subjects and arteriovenous malformation patients. Clin Anat 2020; 34:326-332. [PMID: 32196753 DOI: 10.1002/ca.23589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/10/2020] [Accepted: 03/13/2020] [Indexed: 12/23/2022]
Abstract
Blood vessel tortuosity results from increased diameter and length in response to higher hemodynamic loads. Tortuosity metrics have not been determined for abnormal superior cerebral veins (SCVs) draining cerebral arteriovenous malformations (AVMs). Draining vein (DV) tortuosity may influence safety and efficacy of retrograde microcatheter navigation during transvenous treatment of pial AVMs. Here, we quantify SCV tortuosity in normal subjects and AVM patients using two image segmentation methods. We used contrast-enhanced brain magnetic resonance (MR) images to define the axis of each SCV through a regularly spaced set of three-dimensional (3D) points defining its skeleton curve. We then calculated two metrics: the "sum of angles metric" (SOAM), which adds all angles of curvature along a vessel and normalizes by vessel length, and the "distance metric" (DM), a tortuosity measure providing a ratio of vessel length to linear distance between vessel endpoints. We analyzed 168 metrics in 43 veins of eight normal subjects and 41 veins of seven AVM patients. In normal subjects, the mean SOAM and DM for SCVs were 21.34 ± 7.49 °/mm and 1.42 ± 0.25, respectively. In AVM patients, DVs had a significantly higher mean SOAM of 30.43 ± 11.38 °/mm (p = .02) and DM of 2.79 ± 1.77 (p = .01) than normal subjects. In AVM patients, DVs were significantly more tortuous than matched contralateral uninvolved SCVs, which were similar in tortuosity to normal subject SCVs. We thus report normative tortuosity metrics of brain SCVs and show that AVM cortical DVs are significantly more tortuous than normal SCVs. Knowledge of these comparative tortuosities is valuable in planning endovenous AVM embolotherapies.
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Affiliation(s)
- Nicholas A Telischak
- Division of Neuroimaging and Neurointervention, Stanford Initiative for Multimodality neuro-Imaging in Translational Anatomy Research (SIMITAR), Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Vivek Yedavalli
- Division of Neuroimaging and Neurointervention, Stanford Initiative for Multimodality neuro-Imaging in Translational Anatomy Research (SIMITAR), Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Tarik F Massoud
- Division of Neuroimaging and Neurointervention, Stanford Initiative for Multimodality neuro-Imaging in Translational Anatomy Research (SIMITAR), Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
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Brahimaj BC, Keigher K, Lopes DK. Transvenous arteriovenous malformation embolization. J Neurointerv Surg 2019; 12:332. [DOI: 10.1136/neurintsurg-2019-015515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 10/31/2019] [Accepted: 11/10/2019] [Indexed: 11/04/2022]
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Abstract
Neuroendovascular surgery and interventional neuroradiology both describe the catheter-based (most often) endovascular diagnosis and treatment of vascular lesions affecting the brain and spinal cord. This article traces the evolution of these techniques and their current role as the dominant and frequently standard approach for many of these conditions. The article also discusses the important changes that have been brought to bear on open cerebrovascular neurosurgery by neuroendovascular surgery and their effects on resident and fellow training and describes new concepts for clinical care.
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Yedavalli V, Telischak NA, Jain MS, Massoud TF. Three-Dimensional Angles of Confluence of Cortical Bridging Veins and the Superior Sagittal Sinus on MR Venography: Does Drainage of Adjacent Brain Arteriovenous Malformations Alter this Spatial Configuration? Clin Anat 2019; 33:293-299. [PMID: 31749197 DOI: 10.1002/ca.23521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 10/27/2019] [Indexed: 11/11/2022]
Abstract
Few neuroimaging anatomic studies to date have investigated in detail the point of entry of cortical bridging veins (CBVs) into the superior sagittal sinus (SSS). Although we know that most CBVs join the SSS at an acute angle opposite to the direction of SSS blood flow, the three-dimensional (3-D) spatial configuration of these venous confluences has not been studied previously. This anatomical information would be pertinent to several clinically applicable scenarios, such as in planning intracranial surgical approaches that preserve bridging veins; studying anatomical factors in the pathophysiology of SSS thrombosis; and when planning endovascular microcatheterization of pial veins to retrogradely embolize brain arteriovenous malformations (AVMs). We used the concept of Euclidean planes in 3-D space to calculate the arccosine of these CBV-SSS angles of confluence. To test the hypothesis that pial AVM draining veins may not be any more acutely angled or difficult to microcatheterize at the SSS than for normal CBVs, we measured 70 angles of confluence on magnetic resonance venography images of 11 normal, and nine AVM patients. There was no statistical difference between normal and AVM patients in the CBV-SSS angles projected in 3-D space (56.2° [SD = 22.4°], and 46.2° [SD = 22.3°], respectively; P > 0.05). Hence, participation of CBVs in drainage of pial AVMs should not confer any added difficulty to their microcatheterization across the SSS, when compared to the acute angles found in normal individuals. This has useful implications for potential choices of strategies requiring endovascular transvenous retrograde approaches to treat AVMs. Clin. Anat. 33:293-299, 2020. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Vivek Yedavalli
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Nicholas A Telischak
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Mika S Jain
- Department of Physics, Stanford University School of Humanities and Sciences, Stanford, California.,Department of Computer Science, Stanford University School of Engineering, Stanford, California
| | - Tarik F Massoud
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford University School of Medicine, Stanford, California
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Al-Smadi AS, Ansari SA, Shokuhfar T, Malani A, Sattar S, Hurley MC, Potts MB, Jahromi BS, Alden TD, Dipatri AJ, Shaibani A. Safety and outcome of combined endovascular and surgical management of low grade cerebral arteriovenous malformations in children compared to surgery alone. Eur J Radiol 2019; 116:8-13. [PMID: 31153578 DOI: 10.1016/j.ejrad.2019.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/17/2019] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To evaluate the outcomes of combined preoperative embolization and microsurgical resection in comparison with microsurgical resection alone as the current standard of care for low-grade cerebral arteriovenous malformations (AVM) in the pediatric population. MATERIALS & METHODS We performed a single-center retrospective study of pediatric patients presenting with Spetzler-Martin (SM) grade I and II cerebral AVMs at a high-volume tertiary pediatric hospital between January 2005 and September 2016. Low grade AVM patients were divided into two groups: pre-operative embolization with subsequent microsurgical resection or microsurgical resection alone. Patient demographics, clinical and imaging presentations, AVM morphological characteristics, post-operative complications, and mid to long-term clinical outcomes were studied. Post-embolization and post-surgical outcomes were assessed prior to and after treatment, at 3 months and at final follow-up using the modified Rankin Scale (mRS) to compare both final independent (mRS 0-2) and favorable (no change or improved mRS) clinical outcomes for comparison between study groups. Statistical associations of patient demographics, AVM characteristics/SM grading, and treatment modality group with post-operative complications were performed using univariate logistic regression analysis. RESULTS Thirty-four patients with low grade cerebral AVMs met the study inclusion criteria (mean age 10.6 ± 3.4 years; range 3-16 years, 22M:12 F). Twenty patients (59%) presented with ruptured AVMs. Twenty-five patients (73.5%) underwent combined treatment with embolization and microsurgical resection, while 9/34 (26.5%) underwent microsurgical resection alone. A total of 35 embolization procedures performed in 25 patients (Mode, 1; Range, 1-7) were associated with two minor post-embolization and 7 subsequent post-surgical (28%) complications, resulting in clinical deterioration in a single patient. Microsurgical resection alone was associated with 3 post-surgical complications (33%), resulting in permanent neurological disability in a single patient. There was no significance association of post-operative complications with either treatment modality group, combined treatment versus surgical resection alone [OR:1.13; 95% CI:0.23-5.62; p-value 0.88]. SM Grade II and eloquent locations were found to be significantly associated with post-surgical complications of low grade pediatric cerebral AVMs [OR 13.2 and OR 8 respectively, p-value 0.004 and 0.005). On mean follow-up time of 35.7 months, final clinical outcome was favorable in the majority of both treatment arms with no dependent (mRS>2) patients in the combined endovascular and surgical cohort. Two patients in the surgical cohort failed to achieve independent functional status, primarily due to a pre-operative morbid status (p-value 0.015). However, there was no significant difference in favorable outcomes between the treatment groups [p-value 0.14]. CONCLUSION Our study suggests equivalent safety and favorable clinical outcomes related to combined endovascular embolization and microsurgical resection of low grade pediatric cerebral AVMs in comparison to microsurgical resection alone. On long term clinical follow-up, the vast majority of patients achieved an independent and favorable functional status irrespective of pre-operative embolization.
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Affiliation(s)
- Anas S Al-Smadi
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Sameer A Ansari
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Tahaamin Shokuhfar
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Aresha Malani
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Saadia Sattar
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Michael C Hurley
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Matthew B Potts
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Babak S Jahromi
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Tord D Alden
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Arthur J Dipatri
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Ali Shaibani
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States.
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Bazarde HA, Wenz F, Hänggi D, Etminan N. Radiosurgery of Brain Arteriovenous and Cavernous Malformations. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-52619-5_10-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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