1
|
De Simone M, Fontanella MM, Choucha A, Schaller K, Machi P, Lanzino G, Bijlenga P, Kurz FT, Lövblad KO, De Maria L. Current and Future Applications of Arterial Spin Labeling MRI in Cerebral Arteriovenous Malformations. Biomedicines 2024; 12:753. [PMID: 38672109 PMCID: PMC11048131 DOI: 10.3390/biomedicines12040753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/28/2024] Open
Abstract
Arterial spin labeling (ASL) has emerged as a promising noninvasive tool for the evaluation of both pediatric and adult arteriovenous malformations (AVMs). This paper reviews the advantages and challenges associated with the use of ASL in AVM assessment. An assessment of the diagnostic workup of AVMs and their variants in both adult and pediatric populations is proposed. Evaluation after treatments, whether endovascular or microsurgical, was similarly examined. ASL, with its endogenous tracer and favorable safety profile, offers functional assessment and arterial feeder identification. ASL has demonstrated strong performance in identifying feeder arteries and detecting arteriovenous shunting, although some studies report inferior performance compared with digital subtraction angiography (DSA) in delineating venous drainage. Challenges include uncertainties in sensitivity for specific AVM features. Detecting AVMs in challenging locations, such as the apical cranial convexity, is further complicated, demanding careful consideration due to the risk of underestimating total blood flow. Navigating these challenges, ASL provides a noninvasive avenue with undeniable merits, but a balanced approach considering its limitations is crucial. Larger-scale prospective studies are needed to comprehensively evaluate the diagnostic performance of ASL in AVM assessment.
Collapse
Affiliation(s)
- Matteo De Simone
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Via S. Allende, 84081 Baronissi, Italy
| | - Marco Maria Fontanella
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazza Spedali Civili 1, 25123 Brescia, Italy; (M.M.F.); (L.D.M.)
| | - Anis Choucha
- Department of Neurosurgery, Aix Marseille University, APHM, UH Timone, 13005 Marseille, France;
- Laboratory of Biomechanics and Application, UMRT24, Gustave Eiffel University, Aix Marseille University, 13005 Marseille, France
| | - Karl Schaller
- Division of Neurosurgery, Diagnostic Department of Clinical Neurosciences, Geneva University Hospitals (HUG), Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland; (K.S.); (P.B.)
| | - Paolo Machi
- Division of Interventional Neuroradiology, Department of Radiology and Medical Informatic, Geneva University Hospitals (HUG), Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland; (P.M.); (F.T.K.); (K.-O.L.)
| | - Giuseppe Lanzino
- Department of Neurosurgery and Interventional Neuroradiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA;
| | - Philippe Bijlenga
- Division of Neurosurgery, Diagnostic Department of Clinical Neurosciences, Geneva University Hospitals (HUG), Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland; (K.S.); (P.B.)
| | - Felix T. Kurz
- Division of Interventional Neuroradiology, Department of Radiology and Medical Informatic, Geneva University Hospitals (HUG), Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland; (P.M.); (F.T.K.); (K.-O.L.)
| | - Karl-Olof Lövblad
- Division of Interventional Neuroradiology, Department of Radiology and Medical Informatic, Geneva University Hospitals (HUG), Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland; (P.M.); (F.T.K.); (K.-O.L.)
| | - Lucio De Maria
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Piazza Spedali Civili 1, 25123 Brescia, Italy; (M.M.F.); (L.D.M.)
- Division of Neurosurgery, Diagnostic Department of Clinical Neurosciences, Geneva University Hospitals (HUG), Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland; (K.S.); (P.B.)
| |
Collapse
|
2
|
Demartini Z, Guerios E. Letter to the Editor regarding the paper "Bleeding pediatric AVM with negative pre-operative angiography: the first case report". Childs Nerv Syst 2023; 39:3039-3040. [PMID: 37707625 DOI: 10.1007/s00381-023-06148-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Zeferino Demartini
- Complexo Hospital de Clinicas, Departamento de Neurocirurgia, Universidade Federal do Parana, Curitiba, PR, 80.060-900, Brazil.
- Hospital Pequeno Principe, Curitiba, PR, Brazil.
| | - Enio Guerios
- Complexo Hospital de Clinicas, Departamento de Neurocirurgia, Universidade Federal do Parana, Curitiba, PR, 80.060-900, Brazil
| |
Collapse
|
3
|
El-Sherif AM, Rashad A, Rabie MM, Hegazy M, Adel M, Albialy M, El-Shandawely M, Mahmoud EA. Resource utilization in management of spontaneous intracerebral hemorrhage without systemic risk factors. Does early surgical decompression matter? Clin Neurol Neurosurg 2023; 231:107829. [PMID: 37331206 DOI: 10.1016/j.clineuro.2023.107829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/03/2023] [Accepted: 06/05/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Even though different subtypes of spontaneous ICH are frequently linked to a poor prognosis, their causes, pathological features, and prognoses vary. Atypical intracerebral hemorrhage is the subtype of spontaneous ICH that usually occurs due to an underlying localized vascular lesion. It is unrelated to systemic vascular risk factors, mostly affects children and young adults and is associated with a relatively good outcome. This fact should be considered when planning the evaluation and treatment. Investigating the cause of this subtype is fundamental to providing optimal management. However, if resources do not allow completing the investigations, the cause will be more difficult to discover. Treatment decisions will be made under stress to save the patient's life, especially with rapidly deteriorating patients. METHODS We described three cases of spontaneous ICH without systemic risk factors where the bleeding source could not be determined before surgery due to a lack of resources, preventing preoperative vascular investigation. Knowing that the atypical ICH has a distinct identity, regarding etiology and prognosis, encouraged the surgeons to resort to early surgical decompression as an alternative plan. We reviewed the literature searching for supporting evidence. RESULTS The results of treatment of the presented cases were satisfactory. The lack of reported similar cases was brought to light by a literature analysis that sought to provide backing for the proposed management strategy. In the end, we supplied two graphic organizers to help readers remember the different types and treatment of hemorrhagic stroke. CONCLUSION There isn't enough evidence to show that there are other ways to treat atypical intracerebral haemorrhage when resources are limited. The presented cases highlight the importance of decisionmaking in resource-constrained situations when patient outcomes can be improved.
Collapse
Affiliation(s)
- Ahmed M El-Sherif
- Al-Azhar University, Faculty of Medicine, Nasr City, 11651 Cairo, Egypt.
| | - Alaa Rashad
- Al-Azhar University, Faculty of Medicine, Nasr City, 11651 Cairo, Egypt
| | | | | | - Mostafa Adel
- Al-Azhar University, Faculty of Medicine, Al-Hussein Hospital, Egypt
| | - Mohammad Albialy
- Al-Azhar University, Faculty of Medicine, Nasr City, 11651 Cairo, Egypt
| | | | - Ehab Adel Mahmoud
- Uppsala University Hospital, Radiology Department, Neurointervention Unit, Sweden
| |
Collapse
|
4
|
Kochi R, Suzuki Y, Yamazaki H, Aikawa T, Endo H, Tominaga T. Efficacy of repeat arterial spin labeling for angiogram-negative ruptured micro-arteriovenous malformation: A case report. Surg Neurol Int 2023; 14:119. [PMID: 37151432 PMCID: PMC10159299 DOI: 10.25259/sni_200_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023] Open
Abstract
Background:
Diagnosing ruptured micro-arteriovenous malformation (AVM) could be difficult using digital subtraction angiography (DSA) in the acute stage, and a repeat DSA is recommended in DSA-negative cases. Arterial spin labeling (ASL) is a useful noninvasive tool for detecting AVM, but the efficacy of a repeat ASL for DSA and ASL-negative ruptured micro-AVM in the acute stage is unclear. Here, we report a case of ruptured micro-AVM that was not detected in the acute stage by ASL but in the chronic stage by ASL.
Case Description:
A 43-year-old man developed right upper-extremity paralysis, and computed tomography (CT) revealed a left frontal lobe hemorrhage. Magnetic resonance imaging, including ASL, CT angiography, and DSA, showed no abnormal findings associated with hemorrhage in the acute stage. The second ASL 93 days after the hemorrhage showed a high signal on the cortical vein of the left frontal lobe and superior sagittal sinus, and subsequent DSA detected a micro-AVM in the left precentral gyrus.
Conclusion:
Repeat ASL is less invasive and useful for detecting micro-AVMs which showed no findings on ASL and DSA in the acute stage.
Collapse
|
5
|
Park H, Kang HS, Cho WS. Delayed Appearance of Radiologically Occult Cerebral Arteriovenous Malformation : A Case Report and Literature Review. J Korean Neurosurg Soc 2023; 66:199-204. [PMID: 36071567 PMCID: PMC10009249 DOI: 10.3340/jkns.2022.0165] [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: 07/13/2022] [Accepted: 09/06/2022] [Indexed: 11/27/2022] Open
Abstract
It is critical to identify the ruptured cerebral arteriovenous malformations (AVMs) for secondary prevention. However, there are rare cases unidentified on the radiological evaluation. We report on a patient with the delayed appearance of radiologically occult AVM as a probable cause of the previous intracerebral hemorrhage (ICH). An 18-year-old male patient presented with a right temporal ICH. The preoperative radiological examination did not reveal any causative lesions. Because of the intraoperative findings suggesting an AVM, however, only hematoma was evacuated. Disappointedly, there were no abnormal findings on postoperative and follow-up radiographic examinations. Eleven years later, the patient presented with an epileptic seizure, and an AVM was identified in the right temporal lobe where ICH had occurred before. The patient underwent partial glue embolization followed by total surgical resection of the AVM and anterior temporal lobe. Based on the literature review published in the era of magnetic resonance imaging, common clinical presentation of radiologically occult AVMs included headache and seizure. Most of them were confirmed by pathologic examination after surgery. In cases of the ICH of unknown etiology in young patients, long-term follow-up should be considered.
Collapse
Affiliation(s)
- Hangeul Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
6
|
Basilio-Flores JE, Aguilar-Melgar JA, Zevallos CB, Aguirre-Carbajo R, Ortega-Gutierrez S, Pacheco-Fernandez Baca H. Multiple brain arteriovenous malformations: systematic review and individual patient data meta-analysis. Neurosurg Rev 2023; 46:44. [PMID: 36708432 DOI: 10.1007/s10143-023-01951-3] [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: 09/03/2022] [Revised: 01/03/2023] [Accepted: 01/21/2023] [Indexed: 01/29/2023]
Abstract
Multiple brain arteriovenous malformations (bAVM) are rare neurovascular lesions usually related to genetic syndromes. Its management is not well established given its rarity. The objective of this study was to describe the clinical and angiographic features of published cases and to explore their associations with treatment outcomes. We performed a literature search of published cases in Medline and the Regional Index Medici. Additional cases were searched in our single-center registry. Data on the proportions of patients and clinical and angiographic characteristics were extracted. The study outcomes were nidal instability in patients who underwent staged treatment and radiological cure in patients who underwent treatment using any treatment modality. Logistic regression models for the study outcomes were analyzed. Data on the proportions of multiple bAVM patients were summarized with meta-analyses of proportions. We included 118 patients (reported in 68 studies) from the literature and 6 cases identified in our registry. A total of 124 patients harboring 339 bAVM nidi were included in the analyses. Differences between syndromic and non-syndromic cases were observed. The logistic regression analyses showed that angiographically occult untreated bAVM was associated (OR 14.37; 95% CI 2.17 to 95.4) with nidal instability after staged treatment, and deep (OR 5.11; 95% CI 1.51 to 17.27) and eloquent (OR 3.91; 95% CI 1.22 to 12.52) locations were associated with residual disease after treatment. Inconsistent reporting of relevant data throughout the included studies undermined the planned analyses. Some prognostic factors were found to be related to the study outcomes. Study Registration: The protocol of the systematic review was registered in PROSPERO as CRD42021245814.
Collapse
Affiliation(s)
| | | | - Cynthia B Zevallos
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Remy Aguirre-Carbajo
- Department of Neurosurgery, Hospital Nacional Daniel Alcides Carrión, Callao, Peru
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, USA
| | | |
Collapse
|
7
|
Ismail M, Al-Ageely TA, Talib SH, Hadi RT, Al-Taie RH, Aktham AA, Alrawi MA, Salih HR, Al-Jehani H, Hoz SS. Atypical slow-flow paramedian AVM with venous varix. Surg Neurol Int 2022; 13:519. [DOI: 10.25259/sni_920_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background:
Cerebral arteriovenous malformations (CAVMs) are either clinically silent or symptomatic. The most common presentation in more than half of all CAVMs presenting patients is hemorrhage which is accompanied by long-standing neurological morbidity and mortality. This report presents a case of an atypical large, slow-flow paramedian AVM with a dilated venous varix managed with surgery. The impact of the intraoperative findings on the diagnosis and the operative technique will be discussed.
Case Description:
In otherwise, healthy 26-year-old male complained of repeated episodes of generalized seizures and loss of consciousness. Brain magnetic resonance imaging (MRI) revealed a right parietal paramedian arteriovenous malformation (AVM) with signs of an old hemorrhagic cavity beneath it. Digital subtraction angiography demonstrated a slow-filling AVM with dilated venous varix drains into the superior sagittal sinus. However, the exact point of drainage cannot be appreciated. The filling of the AVM occurred precisely with the beginning of the venous phase. Intraoperatively, we noticed a whitish spherical mass, thick hemosiderin tissue, and a large cavity below the nidus; then, a complication-free complete microsurgical resection of this high-grade AVM was performed. Postoperatively, the patient suffered two attacks of seizures in the first few hours after the surgery, for which he received antiepileptics. MRI was clear during follow-up, and the patient was seizure-free and neurologically intact.
Conclusion:
Parietal convexity AVMs are challenging lesions to tackle. However, the chronicity and the slow-filling of the AVM, in this case, can render the surgical pathway more direct and accessible.
Collapse
Affiliation(s)
- Mustafa Ismail
- Department of Neurosurgery, University of Baghdad, College of Medicine, Baghdad, Iraq,
| | - Teeba A. Al-Ageely
- Department of Neurosurgery, University of Baghdad, College of Medicine, Baghdad, Iraq,
| | - Sura H. Talib
- Department of Neurosurgery, University of Al-Mustansiriyah, College of Medicine, Baghdad, Iraq,
| | - Rania Thamir Hadi
- Department of Neurosurgery, University of Baghdad, College of Medicine, Baghdad, Iraq,
| | - Rania H. Al-Taie
- Department of Neurosurgery, University of Al-Mustansiriyah, College of Medicine, Baghdad, Iraq,
| | - Awfa A. Aktham
- Department of Neurosurgery, Tokyo General Hospital, Nakano, Japan,
| | - Mohammed A. Alrawi
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq,
| | - Hayder R. Salih
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq,
| | - Hosam Al-Jehani
- Department of Neurosurgery, Imam Abdulrahman Alfaisal University, Dammam, Saudi Arabia,
| | - Samer S. Hoz
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, United States
| |
Collapse
|
8
|
Kochi R, Endo H, Uchida H, Kawaguchi T, Omodaka S, Matsumoto Y, Tominaga T. Efficacy of arterial spin labeling for detection of the ruptured micro-arteriovenous malformation: illustrative cases. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 3:CASE21597. [PMID: 36131567 PMCID: PMC9379700 DOI: 10.3171/case21597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/18/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND Diagnosis of a microarteriovenous malformation (micro-AVM) is difficult, especially in the acute stage of rupture because of the small size of the nidus and the existence of hematoma. We report two cases of ruptured micro-AVMs detected by arterial spin labeling (ASL). OBSERVATIONS In one case, a 45-year-old male was transported with a complaint of right hemiparesis. Computed tomography (CT) revealed a right parietal lobar hemorrhage. Standard magnetic resonance imaging (MRI) showed no abnormal findings as the cause of the hemorrhage. ASL 23 days after the onset demonstrated high signals on the medial wall of the hematoma. Digital subtraction angiography (DSA) showed a micro-AVM in accordance with the site of high signals on ASL. In another case, a 38-year-old female was transported with a complaint of left hemianopsia. CT on admission revealed a right parietal lobar hemorrhage. Standard MRI showed no abnormal findings as the cause of the hemorrhage. ASL 15 days after the onset demonstrated high signals on the internal wall of the hematoma. DSA showed micro-AVM in accordance with the site of high signaling on ASL. Both cases were successfully treated with open surgery. LESSONS ASL can manifest micro-AVMs as high signals within the hematoma. ASL is a useful less-invasive screening tool for the detection of ruptured micro-AVMs.
Collapse
Affiliation(s)
| | - Hidenori Endo
- Departments of Neurosurgery and
- Neuroendovascular Therapy, Kohnan Hospital, Sendai, Miyagi, Japan
| | | | | | - Shunsuke Omodaka
- Division of Advanced Cerebrovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan; and
| | - Yasushi Matsumoto
- Division of Advanced Cerebrovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan; and
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| |
Collapse
|
9
|
Zhang Y, Zhang B, Liang F, Liang S, Zhang Y, Yan P, Ma C, Liu A, Guo F, Jiang C. Radiomics features on non-contrast-enhanced CT scan can precisely classify AVM-related hematomas from other spontaneous intraparenchymal hematoma types. Eur Radiol 2018; 29:2157-2165. [DOI: 10.1007/s00330-018-5747-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/03/2018] [Accepted: 09/10/2018] [Indexed: 12/19/2022]
|
10
|
Srinivasan VM, Gressot LV, Daniels BS, Jones JY, Jea A, Lam S. Management of intracerebral hemorrhage in pediatric neurosurgery. Surg Neurol Int 2017; 7:S1121-S1126. [PMID: 28194298 PMCID: PMC5299152 DOI: 10.4103/2152-7806.196919] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 04/07/2016] [Indexed: 12/03/2022] Open
Affiliation(s)
- Visish M Srinivasan
- Department of Neurosurgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Loyola V Gressot
- Department of Neurosurgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Bradley S Daniels
- Department of Neurosurgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Jeremy Y Jones
- Department of Neurosurgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Andrew Jea
- Department of Neurosurgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| | - Sandi Lam
- Department of Neurosurgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas, USA
| |
Collapse
|
11
|
Chen J, Chen L, Zhang C, He J, Li P, Zhou J, Zhu J, Wang Y. Glioma coexisting with angiographically occult cerebrovascular malformation: A case report. Oncol Lett 2016; 12:2545-2549. [PMID: 27698825 PMCID: PMC5038180 DOI: 10.3892/ol.2016.4916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 05/17/2016] [Indexed: 11/08/2022] Open
Abstract
Angiographically occult cerebrovascular malformation (AOVM) is a type of complex cerebrovascular malformation that is not visible on digital subtraction angiography (DSA). Vascular malformation coexisting with glioma is clinically rare, and glioma coexisting with AOVM is even more rare. To the best of our knowledge, the present study is the first to report glioma coexisting with AOVM in the literature. The present study reports a rare case of glioma coexisting with AOVM in a 30-year-old male patient. Computed tomography (CT) scan revealed calcification, hemorrhage and edema in the right frontal lobe. CT angiography revealed a vascular malformation in the right frontal lobe, which was not observed on DSA. Finally, glioma coexisting with AOVM was confirmed by 2.0T magnetic resonance imaging and postoperative pathological examination. The present patient had a positive outcome and no neurological dysfunctions during the 6-month follow-up subsequent to surgery.
Collapse
Affiliation(s)
- Junhui Chen
- Department of Neurosurgery, 101st Hospital of People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Lei Chen
- Department of Neurosurgery, 101st Hospital of People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Chunlei Zhang
- Department of Neurosurgery, 101st Hospital of People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Jianqing He
- Department of Neurosurgery, 101st Hospital of People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Peipei Li
- Department of Neurosurgery, 101st Hospital of People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Jingxu Zhou
- Department of Neurosurgery, 101st Hospital of People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Jun Zhu
- Department of Neurosurgery, 101st Hospital of People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| | - Yuhai Wang
- Department of Neurosurgery, 101st Hospital of People's Liberation Army, Wuxi, Jiangsu 214044, P.R. China
| |
Collapse
|
12
|
Della Puppa A, Drigo P, Mammi I, Amistà P, Iavicoli R, Battistella P, Carollo C. Angiomi cavernosi multipli cerebrali ed epatici. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/197140099300600407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Gli angiomi cavernosi cerebrali (ACC) sono una delle malformazioni vascolari del SNC meno frequenti. É nota peraltro la possibilità di ricorrenza familiare con modalità di trasmissione autosomica dominante. Presentiamo una famiglia italiana, seguita lungamente nel tempo, in cui 10 soggetti in 4 generazioni presentano ACC. Il reperto cerebrale era associato ad angioma cavernoso epatico (ACE) in 2 soggetti e ad angioma cavernoso retinico (ACR) in uno. La TC, eseguita in 9 soggetti, ha dimostrato una maggior capacità rispetto alla RM di rilevare le calcificazioni spesso presenti in queste malformazioni; la RM ha evidenziato d'altra parte un numero maggiore di cavernomi, soprattutto in sede sottotentoriale. 7 pazienti sono stati sottoposti ad esame angiografico con tecnica digitale sottrattiva. In nessun caso è stata dimostrata malformazione angiomatosa di tipo artero-venoso ed in 1 solo caso è stata rilevata una lieve persistenza di contrasto nelle fasi capillare-venose. Riteniamo meritevole di segnalazione questa famiglia per: l'associazione di ACC con ACE segnalata in 1 solo caso in letteratura (Filling - Katz) e la contemporanea associazione, pur in un solo paziente, di ACR; la costante molteplicità delle lesioni cerebrali, quasi sempre presenti sia in sede sopra che sottotentoriale; il contrasto tra la povertà dei sintomi e l'imponenza del quadro radiologico e la sua variabilità espressiva nelle diverse generazioni; l'elevato numero di soggetti affetti rispetto ad altre famiglie riportate in letteratura. I rilievi clinico-radiologici nella presente casistica ed i dati riportati dalla letteratura suggeriscono la necessità di uno studio neuroradiologico complementare TC ed RM nei soggetti affetti da ACC e nei familiari. Va peraltro tenuta presente la possibilità attuale di selezionare i pazienti da sottoporre ad angiografia tradizionale sulla base dei reperti ottenibili con angio-RM. Va sottolineata infine l'opportunità di una attenta e ponderata valutazione della terapia chirurgica proposta da molti autori, data la relativa benignità del decorso clinico riscontrata nei soggetti della nostra serie casistica.
Collapse
Affiliation(s)
| | - P. Drigo
- Dipartimento di Pediatria Complesso Ospedale-Università di Padova
| | - I. Mammi
- Dipartimento di Pediatria Complesso Ospedale-Università di Padova
| | | | | | - P.A. Battistella
- Dipartimento di Pediatria Complesso Ospedale-Università di Padova
| | | |
Collapse
|
13
|
Oya S, Nejo T, Fujisawa N, Tsuchiya T, Indo M, Nakamura T, Matsui T. Usefulness of repetitive intraoperative indocyanine green-based videoangiography to confirm complete obliteration of micro-arteriovenous malformations. Surg Neurol Int 2015; 6:85. [PMID: 26015873 PMCID: PMC4443402 DOI: 10.4103/2152-7806.157445] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 03/04/2015] [Indexed: 11/17/2022] Open
Abstract
Background: It is difficult to intraoperatively confirm the total disappearance of arteriovenous (AV) shunts during surgery for microarteriovenous malformations (micro-AVMs), especially when the nidus is extremely small or diffuse on preoperative angiography. Although intraoperative angiography is effective for evaluating residual shunts, procedure-related risks raise important concerns. The purpose of this study was to assess the usefulness of intraoperative indocyanine green-based videoangiography (ICG–VA) to determine complete disappearance of micro-AVMs during surgery. Methods: We retrospectively analyzed eight patients with ruptured micro-AVMs who were treated using craniotomy with ICG–VA at our institution. Results: Two patients underwent emergency partial evacuation of hematoma and external decompression before the diagnostic angiography. While three patients had a nidus smaller than 1 cm, five patients had only early draining veins without an appreciable nidus. The draining veins were superficial in six cases and deep in two cases. The average interval from onset to surgery was 33 days (range, 2–57). ICG–VA was repetitively conducted until disappearance of the AV shunt was confirmed. No residual AV shunt was observed on postoperative radiological examinations. In all cases, the diagnosis of AVM was confirmed from the results of postoperative pathological examination. Conclusions: ICG–VA could detect early draining veins more clearly in situ than diagnostic angiography. Although it is not as effective for visualizing lesions with deep draining veins, repetitive ICG–VA was safe and effective for confirming the disappearance of AV shunts with superficial drainage.
Collapse
Affiliation(s)
- Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
| | - Takahide Nejo
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
| | - Naoaki Fujisawa
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
| | - Tsukasa Tsuchiya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
| | - Masahiro Indo
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
| | - Takumi Nakamura
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
| | - Toru Matsui
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
| |
Collapse
|
14
|
Alén JF, Lagares A, Paredes I, Campollo J, Navia P, Ramos A, Lobato RD. Cerebral microarteriovenous malformations: a series of 28 cases. J Neurosurg 2013; 119:594-602. [DOI: 10.3171/2013.4.jns121740] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Microarteriovenous malformations (micro-AVMs) are a rare subgroup of brain AVMs characterized by a nidus smaller than 1 cm. The authors' purpose in this study was to assess the clinical presentation, radiological features, therapeutic management, and outcome of these lesions.
Methods
All angiography studies performed at the authors' institution since 2000 for the diagnosis of AVM were retrospectively reviewed. Clinicoradiological findings, therapeutic management, and outcome were evaluated.
Results
Twenty-eight patients had presented with AVMs having a nidus diameter smaller than 1 cm or no clearly identifiable nidus but an early draining vein. All patients, except 2, presented with intracranial hemorrhage, and 12 patients had a focal deficit. Supratentorial hematomas were large (mean volume 25 ml), and in 8 patients hematomas were evacuated urgently. In 6 patients cerebral digital subtraction angiography studies were normal. Magnetic resonance imaging and dynamic MR angiography revealed an AVM in 4 of these 6 patients. Treatment of the AVM consisted of surgery in 16 cases, radiosurgery in 6, and endovascular embolization in 2, and there were no posttreatment deficits. Four patients received no treatment because of their poor condition. The AVM was occluded at the follow-up in all patients treated with surgery or embolization and in 4 of the 6 patients treated with radiosurgery. The Glasgow Outcome Scale (GOS) score was good (GOS 4–5) in 23 patients (82%) and poor (GOS 3–2) in 5 (18%).
Conclusions
Patients with micro-AVMs generally present with large intracranial hemorrhages and neurological deficits. If the initial angiography is negative, then delayed or superselective angiography is recommended. Magnetic resonance imaging may reveal the existence of these lesions. Surgery is the treatment of choice for superficial micro-AVMs, and radiosurgery or embolization can be considered for deep lesions.
Collapse
Affiliation(s)
| | | | | | - Jorge Campollo
- 2Division of Neuroradiology, Hospital 12 de Octubre, Universidad Complutense de Madrid, Spain
| | - Pedro Navia
- 2Division of Neuroradiology, Hospital 12 de Octubre, Universidad Complutense de Madrid, Spain
| | - Ana Ramos
- 2Division of Neuroradiology, Hospital 12 de Octubre, Universidad Complutense de Madrid, Spain
| | | |
Collapse
|
15
|
|
16
|
Mutoh T, Kobayashi S, Ishikawa T, Moroi J, Miyata H, Suzuki A, Yasui N. Pathologically confirmed cryptic vascular malformation as a cause of convexity subarachnoid hemorrhage: case report. Neurosurgery 2012; 70:E1322-8; discussion E1328. [PMID: 21778913 DOI: 10.1227/neu.0b013e31822e0f87] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE We report a rare case of pathologically confirmed cryptic vascular malformation as a cause of primary convexity subarachnoid hemorrhage (SAH) of unknown etiology. CLINICAL PRESENTATION A 48-year-old woman presented with sudden severe headache. Localized right convexity SAH was observed on computed tomography (CT) scan, but the origin could not be detected despite extensive workup covering the entire head by using 3.0-Tesla magnetic resonance (MR) imaging with MR angiography and CT angiography combined with venous-phase imaging with a 320-detector row CT scanner. Subsequent digital subtraction angiography (DSA) performed 2.5 hours after admission failed to reveal any cause of SAH; however, a right frontoparietal avascular region was suspected to be due to a newly developed intracerebral hematoma. The lesion was simultaneously confirmed by angiographic cone-beam CT imaging. Because she remained neurologically intact, we decided to perform a follow-up study later with medical management. However, she developed left hemiparesis 3 hours after DSA. CT scan demonstrated progression of the hematoma, and her symptoms gradually worsened. Emergent surgical exploration along the SAH superficial to the postcentral sulcus and hematoma evacuation were performed, with favorable functional outcome. Pathological examination confirmed cryptic vascular malformation with several abnormally dilated arterioles within the subarachnoid space surrounded by a thick SAH clot. CONCLUSION It is important to consider the possibility of ruptured cryptic vascular malformation as a cause of nontraumatic nonaneurysmal convexity SAH when recurrent hemorrhage occurs despite thorough diagnostic workup, because surgical resection may be the only curative treatment option to eliminate the risk of rebleeding and disabling symptoms.
Collapse
Affiliation(s)
- Tatsushi Mutoh
- Department of Surgical Neurology, Research Institute for Brain and Blood Vessels-AKITA, Akita, Japan.
| | | | | | | | | | | | | |
Collapse
|
17
|
Angiographically visible and invisible arteriovenous malformation in the same patient. J Stroke Cerebrovasc Dis 2011; 21:504-6. [PMID: 21784663 DOI: 10.1016/j.jstrokecerebrovasdis.2011.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 06/14/2011] [Accepted: 06/16/2011] [Indexed: 11/22/2022] Open
Abstract
A pathologically confirmed angiographically visible and invisible arteriovenous malformation in the same patient is described. The potential clinical significance of these observations is detailed and discussed.
Collapse
|
18
|
Honegger J, Fahlbusch R, Lieb W, Seyer H, Kuchle M, Huk W, Buchfelder M. Cavernous hemangioma of the optic chiasm. Neuroophthalmology 2009. [DOI: 10.3109/01658109008997267] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
19
|
Elhammady MSA, Baskaya MK, Heros RC. Early elective surgical exploration of spontaneous intracerebral hematomas of unknown origin. J Neurosurg 2009; 109:1005-11. [PMID: 19035712 DOI: 10.3171/jns.2008.109.12.1005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The management of non-life threatening spontaneous intraparenchymal hemorrhage with no obvious medical etiology in patients and the lack of findings on images has not been clearly defined. In general, the current practice is to treat these patients conservatively and repeat studies to rule out a treatable cause 6 weeks to 3 months later; more often than not these repeated studies fail to reveal any findings, and the patient is treated conservatively. For years, the senior author (R.C.H.) has treated these patients with early surgical exploration. This study was undertaken prospectively to ascertain the frequency of positive findings during surgical exploration. METHODS Between 2000 and 2007, the authors prospectively collected data from 9 cases (4 cerebellar, 4 lobar, and 1 caudate head) of unexplained intraparenchymal hemorrhages. The patient age ranged from 18 to 45 years (mean 31.2 years). All patients were normotensive, had no underlying medical problems explaining such a hemorrhage, and failed to exhibit findings on cerebral angiograms. Magnetic resonance images with contrast showed no abnormal vasculature or enhancement. Eight patients underwent elective surgical exploration in the subacute stage, and urgent decompression of the clot was necessary in 1. RESULTS In 7 (77.8%) of the 9 cases, histopathological examination revealed a cause for the hemorrhage (3 "cryptic" arteriovenous malformations, 3 cavernomas, and 1 neoplasm). A good outcome was achieved in all 8 patients who underwent elective surgery. CONCLUSIONS The authors recommend elective surgical exploration of intracerebral hematomas of unknown etiology provided that the hematoma is surgically accessible and the patient is relatively young and healthy. Early exploration and resection can provide a cure and eliminate the risk of rebleeding when a vascular lesion is found or guide further treatment in cases of tumor.
Collapse
Affiliation(s)
- Mohamed Samy A Elhammady
- Department of Neurological Surgery, University of Miami School of Medicine, Lois Pope Life Center, Miami, Florida, USA
| | | | | |
Collapse
|
20
|
Nishizaki T, Ikeda N, Kurokawa Y, Okamura T, Abiko S. Ruptured internal carotid artery anterior wall aneurysm identified during vasospasm: case report. Neurosurgery 2006; 57:E811. [PMID: 17152665 DOI: 10.1093/neurosurgery/57.4.e811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE AND IMPORTANCE Aneurysms of the paraclinoid segment arising from the anterolateral wall of the proximal internal carotid artery (ICA) are usually located in the intradural space, and the proximal neck of the aneurysm is closely adjacent to the dural ring. Although most of these aneurysms can be identified by cerebral angiography, the top of the aneurysm can be flattened because of its relationship to the undersurface of the clinoid process. We report a rare case of a ruptured ICA anterolateral wall aneurysm that was not identified by initial angiography but was clearly observed at the time of vasospasm. CLINICAL PRESENTATION A 59-year-old female patient was transferred to our hospital because of sudden loss of consciousness. Initial angiography failed to disclose any aneurysm except for one projecting to the right at the C3-C4 portion of the left ICA. A left frontotemporal craniotomy with drilling of the anterior clinoid process was performed 1 day after the onset of subarachnoid hemorrhage. Within the operative field, however, no hemorrhage was detected near the C3-C4 portion of the left ICA. Subsequent angiography performed during vasospasm clearly demonstrated a ruptured aneurysm in the anterior paraclinoid segment of the right ICA. INTERVENTION After drilling the anterior clinoid process and cutting the dural ring, we successfully clipped the aneurysm. The aneurysm was saccular, with a broad neck that extended below the dural ring. Intraoperative inspection demonstrated that the dome of the aneurysm was in a subclinoid location, suggesting that most of the aneurysm might have been flattened by the dural ring at the time of initial angiography but before the onset of vasospasm. CONCLUSION The presented case suggests that this type of aneurysm may be missed by routine angiography performed before and after vasospasm. If initial angiography fails to reveal the origin of the subarachnoid hemorrhage but computed tomography still discloses hemorrhage from an ICA aneurysm, repeated angiography should be considered within 14 days after the onset of subarachnoid hemorrhage to confirm whether the aneurysm has arisen from the anterior clinoid segment of the ICA.
Collapse
Affiliation(s)
- Takafumi Nishizaki
- Department of Neurosurgery, Ube Industrial Central Hospital, 750, Nishikiwa, Ube, Yamaguchi, 755-0151, Japan.
| | | | | | | | | |
Collapse
|
21
|
Perrini P, Lanzino G. The association of venous developmental anomalies and cavernous malformations: pathophysiological, diagnostic, and surgical considerations. Neurosurg Focus 2006; 21:e5. [PMID: 16859258 DOI: 10.3171/foc.2006.21.1.6] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
✓Developmental venous anomalies (DVAs) are often associated with intracranial cavernous malformations (CMs). The frequency of this association and the observation of de novo CMs located near a known, preexisting DVA raise speculations as to the possible etiopathogenetic relationship between the two. In this article, the authors review the recent literature dealing with the potential etiopathogenetic, prognostic, and therapeutic implications of the association between DVAs and CMs.
Collapse
Affiliation(s)
- Paolo Perrini
- Neurosurgical Department, University of Florence, Italy
| | | |
Collapse
|
22
|
Nishizaki T, Ikeda N, Kurokawa Y, Okamura T, Abiko S. Ruptured Internal Carotid Artery Anterior Wall Aneurysm Identified During Vasospasm: Case Report. Neurosurgery 2005. [DOI: 10.1227/01.neu.0000178238.36637.43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
23
|
Berker M, Ulus A, Palaoglu S, Soylemezoglu F, Ay H, Cekirge S. Intracranial Haemorrhage Probably Due to an Angiographically Occult AVM after Carotid Stenting. A Case Report. Interv Neuroradiol 2004; 9:315-20. [PMID: 20591259 DOI: 10.1177/159101990300900313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2003] [Accepted: 03/20/2003] [Indexed: 11/16/2022] Open
Abstract
SUMMARY Angiographically occult vascular malformations refer to cerebrovascular malformations that are not demonstrable on technically satisfactory cerebral angiography. Authors herein present a very unusual intracranial bleeding complication related to an angiographically occult vascular malformation after extracranial carotid artery stenting procedure. A 52-year-old male patient admitted to the hospital with 2 episodes of amaurosis fugax in the left eye. Cervical carotid angiography and bilateral carotid Doppler ultrasonography revealed a 98% stenosis of the left internal carotid artery just distal to the bifurcation. Post-stenting control cervical carotid angiography revealed neither any residual stenosis nor a developmental venous anomaly. The patient developed left pupil dilatation with loss of consciousness two hours after the neurovascular intervention. Emergent cranial CT showed acute subdural haematoma, intracerebral and subarachnoid haemorrhage with massive midline shift. He underwent an emergent craniotomy with left temporal lobectomy. Abnormal cortical vascular structures with prominent engorgement were remarkable over the posterior temporal cortex. Histopathological studies confirmed the diagnosis of an occult AVM. Classically, these lesions are not visualized with angiography.Our patient's cerebral angiography and MR investigations were all normal. To our knowledge this is the first case in literature in which intracranial haemorrhage (acute subdural haematoma, intracerebral haematoma, SAH) occurred due to hyperperfusion of angiographically occult vascular malformation.
Collapse
Affiliation(s)
- M Berker
- Department of Neurosurgery, Hacettepe University School of Medicine; Ankara, Turkey - -
| | | | | | | | | | | |
Collapse
|
24
|
Topcuoglu MA, Ogilvy CS, Carter BS, Buonanno FS, Koroshetz WJ, Singhal AB. Subarachnoid hemorrhage without evident cause on initial angiography studies: diagnostic yield of subsequent angiography and other neuroimaging tests. J Neurosurg 2003; 98:1235-40. [PMID: 12816270 DOI: 10.3171/jns.2003.98.6.1235] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to assess the diagnostic yield of imaging tests performed in patients in whom the cause of subarachnoid hemorrhage (SAH) had not been demonstrated on initial angiography. METHODS By reviewing medical records of 806 patients with SAH who had been admitted during a 6.5-year period, the authors identified 86 in whom initial transfemoral catheter angiography failed to reveal the cause of SAH. Clinical and radiological data were analyzed to determine the diagnostic yield of subsequent catheter angiography, computerized tomography (CT) angiography, magnetic resonance (MR) angiography, and MR imaging of the brain and spine for various subtypes of SAH (bleeding not visualized on CT studies [CT-negative SAH], perimesencephalic SAH, and nonperimesencephalic SAH). Of 41 patients with nonperimesencephalic SAH, 36, 32, and 21 underwent repeated catheter angiography, CT angiography, and MR angiography, respectively; brain MR imaging was performed in 23 patients (18 with Gd and 15 with susceptibility contrast sequences), and spine MR imaging in 17. Of 36 patients with perimesencephalic SAH, 31, 23, and 17 underwent repeated catheter angiography, CT angiography, and MR angiography, respectively; brain MR imaging was performed in 18 patients (17 with Gd and 11 with susceptibility contrast sequences), and spine MR imaging in 14. Of nine patients with SAH not visualized on CT scanning, three, one, and six underwent repeated catheter angiography, CT angiography, and MR angiography, respectively; brain MR imaging was performed in eight patients (five with Gd and three with susceptibility contrast sequences), and spine MR imaging in seven. The cause of SAH could be determined in only four patients, all with nonperimesencephalic SAH. The only test that yielded a diagnosis was catheter angiography (three aneurysms on the second and one on the third angiography, all surgically secured). Diffusion-weighted MR imaging demonstrated small, deep infarcts in five patients. CONCLUSIONS Repeated catheter angiography remains the most sensitive test to determine the cause of SAH that is not demonstrated on initial angiography, particularly in the subtype of nonperimesencephalic SAH. Newer, noninvasive imaging techniques provide little diagnostic yield.
Collapse
Affiliation(s)
- Mehmet A Topcuoglu
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | | | | | | | | | | |
Collapse
|
25
|
Abstract
Cavernous malformations are commonly being recognized on CT and MR imaging in both asymptomatic and symptomatic patients. The diagnosis of CMs can often be made on MR imaging based on the characteristic morphology of the subacute and chronic blood products. An atypical appearance of a CM in the setting of a recent hemorrhage requires follow-up imaging to confirm the diagnosis. Deep CMs have a significant clinical event rate that justifies close follow up or surgical treatment if possible.
Collapse
Affiliation(s)
- Peter P Rivera
- University of Toronto Vascular Malformation Study Group, Toronto Western Hospital, Fell Pavilion 3-210, 339 Bathurst Street, Toronto, ON M5T 2S8, Canada.
| | | | | |
Collapse
|
26
|
Edwards RJ, Clarke Y, Renowden SA, Coakham HB. Trigeminal neuralgia caused by microarteriovenous malformations of the trigeminal nerve root entry zone: symptomatic relief following complete excision of the lesion with nerve root preservation. J Neurosurg 2002; 97:874-80. [PMID: 12405376 DOI: 10.3171/jns.2002.97.4.0874] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECT Within a series of 341 consecutive patients who underwent posterior fossa surgery for trigeminal neuralgia (TN), in five the cause was found to be a microarteriovenous malformation (micro-AVM) located in the region of the trigeminal nerve root entry zone (REZ). The surgical management and clinical outcomes of these cases are presented. METHODS Patients were identified from a prospectively collected database of all cases of TN treated at one institution between 1980 and 2000. Presentation was clinically indistinguishable from TN caused by vascular compression. Preoperative imaging, including computerized tomography scanning (two cases) and magnetic resonance (MR) imaging and MR angiography (three cases), failed to demonstrate an AVM except for one case in which multiple abnormal vessels were identified in the trigeminal REZ on an MR image obtained using a 1.5-tesla magnet. All patients underwent a standard retromastoid craniotomy. In all cases a small AVM embedded in the trigeminal REZ was identified and completely excised, with preservation of the trigeminal nerve. All patients experienced immediate relief of pain following surgery. Postoperatively, in one patient a small pontine hematoma developed, resulting in permanent trigeminal nerve anesthesia in the V2 and V3 divisions. All patients were free from pain at a mean follow-up period of 30 months. CONCLUSIONS These rare lesions are usually angiographically occult, but may sometimes be identifiable on high-resolution MR images. Total microsurgical resection with nerve preservation is possible, although operative complications are relatively common, reflecting the intimate association between these lesions and the pons. Complete resection is advised not only for symptom relief, but also to eliminate the theoretical risk of pontine hemorrhage.
Collapse
Affiliation(s)
- Richard J Edwards
- Department of Neurosurgery, Frenchay Hospital, Bristol, United Kingdom
| | | | | | | |
Collapse
|
27
|
Reisch R, Bettag M, Perneczky A. Transoral transclival removal of anteriorly placed cavernous malformations of the brainstem. SURGICAL NEUROLOGY 2001; 56:106-15; discussion 115-6. [PMID: 11580947 DOI: 10.1016/s0090-3019(01)00529-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The natural history of brain stem cavernous malformations is unfavorable because of their high hemorrhage rate and resulting neurological deterioration among patients. However, direct surgery of intrinsic and anteriorly situated cavernomas is hazardous and leads to a bad postoperative outcome because of trauma to lateral and dorsally situated eloquent areas of the brain stem. METHODS We review the cases of two patients with symptomatic cavernous malformations of the anterior brain stem and describe the usefulness of a transoral-transclival approach. A 23-year-old man developed progressive hemihypaesthesia and paraesthesia, hemiparesis with gait ataxia, dysarthria, dysphonia, and dysphagia. A 38-year-old woman suffered from an acute onset of vertigo with nausea and vomiting, diplopia, and paraesthesia of the left hand and foot. In both patients, computed tomography demonstrated the presence of brain stem hemorrhage, because of cavernous malformation. Magnetic resonance imaging showed a close proximity of the lesions to the pia mater only on the ventral surface of the brain stem. RESULTS In both patients, the cavernomas could be safely approached and completely resected via a transoral transclival route. Three months after surgery, neurological examination revealed marked neurological improvement. The 23-year-old patient showed slight gait ataxia, no hemiparesis, no cranial nerve palsies; the 38-year-old woman demonstrated no neurological symptoms except for minimal motor dysfunction of the left hand. In both cases, under perioperative prophylactic antibiotics, no meningitis was observed. The patients could subsequently return to their previous employment. CONCLUSION The transoral transclival approach for ventrally situated brain stem cavernomas allows a largely atraumatic resection of the lesion.
Collapse
Affiliation(s)
- R Reisch
- Department of Neurosurgery, Johannes Gutenberg University, Mainz, Germany
| | | | | |
Collapse
|
28
|
Abstract
This paper highlights the importance of cavernous haemangiomas as clinically significant lesions and the role of imaging, particularly MRI, in suggesting the diagnosis. An understanding of the pathology of these lesions helps to explain the features demonstrated by imaging techniques.
Collapse
Affiliation(s)
- M R Sage
- Division of Medical Imaging, Flinders Medical Centre, Bedford Park, South Australia, Australia.
| | | |
Collapse
|
29
|
Tsien C, Souhami L, Sadikot A, Olivier A, del Carpio-O'Donovan R, Corns R, Patrocinio H, Parker W, Podgorsak E. Stereotactic radiosurgery in the management of angiographically occult vascular malformations. Int J Radiat Oncol Biol Phys 2001; 50:133-8. [PMID: 11316556 DOI: 10.1016/s0360-3016(00)01568-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the role of stereotactic radiosurgery in the treatment of angiographically occult vascular malformations (AOVMs). METHODS AND MATERIALS From 1987 to 1996, 21 patients, 10 males and 11 females, median age of 41 years (range: 7-75 years), with an intracerebral AOVM underwent stereotactic radiosurgery at our institution. All were considered at high risk for surgical intervention. The vascular lesions were located in the brainstem (17 patients), basal ganglia (2), occipital lobe (1), and cerebellum (1). Diagnosis was based on high-resolution magnetic resonance imaging (MRI). Clinical presentation at onset included previous intracerebral hemorrhage (20 patients) and epilepsy (1). All patients were treated with a linac-based radiosurgical technique. The median dose delivered was 25 Gy (range 13-50 Gy), typically prescribed to the 80-90% isodose surface (range 50-90%), which corresponded to the periphery of the vascular malformation. Patients were followed by clinical neurologic assessment and by MRI on a regular interval basis. RESULTS Follow-up was obtained in 20 patients; clinical or MRI information was not available for 1 patient, and this patient was excluded from our analysis. At a median follow-up of 77 months (range: 4-141 months), follow-up MRIs postradiosurgery do not demonstrate any changes in the appearance of the AOVM. Four patients developed an intracranial bleed at 4, 8, 35, and 57 months postradiosurgery. Annual hemorrhage rates were considerably higher in the observation period preradiosurgery than postradiosurgery (30% vs. 3.2%, p < 0.001). Complications postradiosurgery were observed in 4 patients. Three patients developed mild to moderate edema surrounding the radiosurgical target, expressed at 5, 8, and 24 months, respectively. In all cases, the edema was transient and resolved completely on subsequent MRIs. One of the 4 patients developed radiation necrosis 8 months after radiosurgery. CONCLUSION The use of stereotactic radiosurgery in the treatment of AOVM continues to be controversial. Our results appear to show a reduction in the risk of symptomatic hemorrhage post treatment. Patients with previous history of hemorrhage or progressive neurologic deficit and small, well circumscribed lesions may benefit from a trial of stereotactic radiosurgery.
Collapse
Affiliation(s)
- C Tsien
- Department of Radiation Oncology, McGill University Hospital Center, Montreal, Quebec, Canada
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
|
31
|
|
32
|
Fujii M, Akimura T, Ozaki S, Kato S, Ito H, Neshige R. An angiographically occult arteriovenous malformation in the medial parietal lobe presenting as seizures of medial temporal lobe origin. Epilepsia 1999; 40:377-81. [PMID: 10080523 DOI: 10.1111/j.1528-1157.1999.tb00722.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We present an unusual case of a patient who was diagnosed with temporal lobe epilepsy and whose seizures were reduced markedly after excision of an angiographically occult arteriovenous malformation (AVM) located in the left medial parietal lobe. A 38-year-old man had complex partial seizures characterized by motionless staring with oroalimentary and behavioral automatisms since the age of 15 years. Magnetic resonance imaging (MRI) demonstrated a small lesion extending from the left posterior cingulate gyrus to the precuneus. There was no MRI evidence of mesial temporal sclerosis. Intracranial EEG recordings showed ictal onset from the left medial parietal lobe propagating to the medial temporal lobes. Clinical signs appeared when these discharges reached the temporal lobes. After excision of the lesion (which was histologically confirmed as an AVM), together with the marginal cortex, seizures were reduced significantly. Careful diagnostic evaluation of lesions such as the this one may reveal an epileptogenic lesion (zone) far from the region where scalp ictal discharges seem to arise. In our case, we hypothesize that false localization was due to propagation of ictal discharges from the parietal focus through the limbic system.
Collapse
Affiliation(s)
- M Fujii
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Japan
| | | | | | | | | | | |
Collapse
|
33
|
Hino A, Fujimoto M, Yamaki T, Iwamoto Y, Katsumori T. Value of repeat angiography in patients with spontaneous subcortical hemorrhage. Stroke 1998; 29:2517-21. [PMID: 9836762 DOI: 10.1161/01.str.29.12.2517] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Neuroradiological investigations do not disclose a source of bleeding in some patients with spontaneous subcortical hemorrhage. These patients may harbor undetected vascular malformations and may be at risk of rebleeding in the future. We investigated patients with subcortical hemorrhage with use of repeat angiography and MRI to determine the incidence of occult vascular malformations and the risk of bleeding during follow-up. METHODS We reviewed a consecutive series of 137 patients with subcortical hemorrhage during a 10-year period (June 1987 through June 1997). If the patient was <65 years old and the first angiogram and/or MRI did not show a source of bleeding, repeat angiography was recommended. All angiographic and MRI studies were reviewed. The relationship between the identified bleeding source and clinical variables such as patient age, sex, and history of hypertension and the size and location of the hematoma were examined. RESULTS One hundred seven patients (78%) underwent angiography on admission, 10 (7%) had immediate surgery for hematoma without angiography, and 20 (15%) had neither angiography nor surgery. Overall, an etiology for the hemorrhage was found in 55 cases (40%). Vascular malformations were common in young patients without preexisting hypertension. A second angiogram was obtained in 22 patients, and 4 arteriovenous malformations were demonstrated. Rebleeding at the site of the initial hemorrhage was not observed after a mean follow-up of 68 months. CONCLUSIONS Angiography performed acutely after hemorrhage may not demonstrate vascular malformations. Consideration should be given to repeat angiography in patients who do not have a specific cause for hemorrhage.
Collapse
Affiliation(s)
- A Hino
- Department of Neurosurgery, Saiseikai Shigaken Hospital, Shiga, Japan
| | | | | | | | | |
Collapse
|
34
|
Chang SD, Levy RP, Adler JR, Martin DP, Krakovitz PR, Steinberg GK. Stereotactic radiosurgery of angiographically occult vascular malformations: 14-year experience. Neurosurgery 1998; 43:213-20; discussion 220-1. [PMID: 9696072 DOI: 10.1097/00006123-199808000-00011] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Radiosurgery is generally effective in obliterating true arteriovenous malformations, but less is known about its effects on angiographically occult vascular malformations (AOVMs). Since July 1983, 57 patients with surgically inaccessible AOVMs of the brain were treated using helium ion (47 patients) or linear accelerator (10 patients) radiosurgery. This study retrospectively evaluates the response of these AOVMs to treatment. METHODS All patients presented with previous hemorrhage. The mean patient age was 35.6 years (range, 13-71 yr). The mean AOVM volume was 2.25 cm3 (range, 0.080-15.2 cm3), treated with a mean of 18.0 Gy equivalent (physical dose x relative biological effectiveness, which is 1.3 for helium ion Bragg peak) (range, 7.0-40 Gy equivalent). The Drake scale scores before treatment were as follows: excellent (25 patients), good (26 patients), and poor (6 patients). The mean follow-up period was 7.5 years (range, 9 mo-13.8 yr). RESULTS Eighteen patients (32%) bled symptomatically (20 hemorrhages) after radiosurgery. Sixteen hemorrhages occurred within 36 months after radiosurgery (9.4% annual bleed rate; 16 hemorrhages/171 patient yr); 4 hemorrhages occurred more than 36 months after treatment (1.6% annual bleed rate; 4 hemorrhages/257 patient yr) (P < 0.001). Complications included symptomatic radiation edema (four patients, 7%), necrosis (one patient, 2%), and increased seizure frequency (one patient, 2%). Eight patients underwent surgical resection of their AOVMs 8 to 59 months after radiosurgery because of subsequent hemorrhage. The Drake scale scores after treatment were as follows: excellent (25 patients), good (24 patients), poor (3 patients), and dead (5 patients, 3 of whom died as a result of causes unrelated to the AOVMs or radiosurgery). CONCLUSION Radiosurgery may be useful for AOVMs located in surgically inaccessible regions of the brain. A significant decrease in bleed rate exists more than 3 years after treatment compared with the bleed rate within 3 years of treatment. Because current neuroradiological techniques are not able to image obliterative response in these slow-flow vascular lesions, longer term clinical follow-up is required.
Collapse
Affiliation(s)
- S D Chang
- Department of Neurosurgery, Stanford Stroke Center, Stanford University School of Medicine, California, USA
| | | | | | | | | | | |
Collapse
|
35
|
Kraemer DL, Griebel ML, Lee N, Friedman AH, Radtke RA. Surgical outcome in patients with epilepsy with occult vascular malformations treated with lesionectomy. Epilepsia 1998; 39:600-7. [PMID: 9637602 DOI: 10.1111/j.1528-1157.1998.tb01428.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE This retrospective study reports the long-term surgical outcome of patients with medically refractory epilepsy and vascular malformations who were treated with lesionectomy. A detailed analysis of surgical failures had been performed in an attempt to define predictors of surgical success and failure. METHODS Fifteen patients with medically intractable epilepsy and angiographically occult vascular malformations (AOVMs) were treated surgically with lesionectomy at Duke University Medical Center. Lesionectomy consisted of removal of the AOVM and surrounding hemosiderin-stained brain only, without the use of electrocorticography (ECoG) to guide resection. RESULTS Eleven (73%) patients are seizure free after lesionectomy. Three showed no significant improvement, and one patient died, presumably after a seizure. Age of onset, duration of seizures, age at resection, and gender did not affect outcome. All patients with neocortical AOVMs in whom EEG findings correlated with the site of the lesion were seizure free after lesional resection. Treatment failures were associated with the presence of multiple intracranial lesions, poorly localized or diffuse EEG findings, discordant positron emission tomography (PET) imaging, or with a lesion in close proximity to the limbic system. CONCLUSIONS Lesionectomy, with removal of surrounding hemosiderin-stained brain, can be considered the procedure of choice in carefully selected patients with epilepsy with occult vascular malformations.
Collapse
Affiliation(s)
- D L Kraemer
- Swedish Epilepsy Center, Seattle, Washington 98122, USA
| | | | | | | | | |
Collapse
|
36
|
Larson JJ, Ball WS, Bove KE, Crone KR, Tew JM. Formation of intracerebral cavernous malformations after radiation treatment for central nervous system neoplasia in children. J Neurosurg 1998; 88:51-6. [PMID: 9420072 DOI: 10.3171/jns.1998.88.1.0051] [Citation(s) in RCA: 162] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECT Radiation is a common treatment modality for pediatric brain tumors. The authors present a retrospective review of six children who developed cerebral cavernous malformations after they underwent radiation treatment for central nervous system (CNS) neoplasia and propose two possible models to explain the formation of cavernous malformations. METHODS Three boys, aged 13, 9, and 17 years, suffered intracerebral hemorrhages from cerebral cavernous malformations 87, 94, and 120 months, respectively, after they received whole-brain radiation therapy (WBRT) for acute lymphocytic leukemia. A 10-year-old girl and a 19-year-old man developed temporal lobe cavernous malformations 46 and 48 months, respectively, after they received radiation therapy for posterior fossa astrocytomas. A 12-year-old girl developed a temporal lobe cavernous malformation 45 months after WBRT was administered for a medulloblastoma. In all of these cases the cavernous malformation appeared in the irradiated field, was not known to be present prior to radiation therapy, and developed after a latency period following treatment. The incidence of cavernous malformations in these patients suggests that children who undergo radiation therapy of the brain may have an increased risk of hemorrhage. CONCLUSIONS Two possible models may explain the formation of cavernous malformations following brain radiation in these patients. First, the cavernous malformations may form de novo in response to the radiation. Second, the cavernous malformations may have been present, but radiographically occult, at the time of radiation therapy and may have hemorrhaged in response to the radiation. The authors conclude that cavernous malformations may develop after brain radiation and propose a possible mechanism for this formation.
Collapse
Affiliation(s)
- J J Larson
- Department of Neurosurgery, University of Cincinnati College of Medicine, Ohio 45267-0515, USA
| | | | | | | | | |
Collapse
|
37
|
Duffau H, Capelle L, Sichez JP, Faillot T, Bitar A, Arthuis F, Van Effenterre R, Fohanno D. Early radiologically proven rebleeding from intracranial cavernous angiomas: report of 6 cases and review of the literature. Acta Neurochir (Wien) 1997; 139:914-22. [PMID: 9401650 DOI: 10.1007/bf01411299] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Although intracranial cavernomas are known to cause haemorrhage, data concerning the frequency, severity and delay of recurrent bleedings are controversial. We report a series of 6 patients with histologically proven cavernoma, presenting with early clinical signs and radiological proof of rebleeding, that is occurring in the first month after initial overt haemorrhage. These 6 cases have been selected from a series of 142 patients seen between 1980 and 1995 in our department with cavernous angiomas or so-called AOVMs, of whom 93 presented with clinical symptoms of haemorrhage (34 patients presented symptoms of one or more rebleeding, but only 6 had radiological proof). All patients suffered neurological worsening due to the rebleeding, with an increase of the size of the haematoma on the CT scan. Five MRIs were performed at the acute stage: 3 showed evidence of cavernoma (60%). All patients underwent surgery at the acute stage of the rebleeding, with 5 improvements and 1 stabilization. A cavernous angioma was found in 5 cases at first surgery, but a further operation was necessary in the last patient to find and remove the cavernoma, after a second rebleeding following the first intervention. Our series reveals a high frequency of rebleeding after a first intracranial haemorrhage from a cavernous angioma, and highlights the precocity of such rebleedings. Therefore, we advocate early aggressive surgical management: in cases of cavernoma revealed by a first clinical overt haemorrhage, when there is strong radiological suspicion at the acute stage; and in all cases of rebleeding, even without radiological evidence of malformation, in the absence of vascular risk factors. Surgical indication must be discussed in particular cases of cavernomas of the brain stem when neither the haematoma nor the cavernoma reach the surface, and in deep supratentorial cavernomas, when the neurological status is good, because of the therapeutic risk.
Collapse
Affiliation(s)
- H Duffau
- Department of Neurosurgery 1, Hôpital de la Salpêtrière, Paris, France
| | | | | | | | | | | | | | | |
Collapse
|
38
|
Maeda K, Kurita H, Nakamura T, Usui M, Tsutsumi K, Morimoto T, Kirino T. Occurrence of severe vasospasm following intraventricular hemorrhage from an arteriovenous malformation. Report of two cases. J Neurosurg 1997; 87:436-9. [PMID: 9285611 DOI: 10.3171/jns.1997.87.3.0436] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The authors present two rare cases of severe cerebral vasospasm following the rupture of arteriovenous malformations (AVMs). Computerized tomography revealed intracerebral hemorrhage in the thalamus in one case and in the putamen in the other, both accompanied by cast formation of intraventricular clots without radiological evidence of subarachnoid hemorrhage. Initial angiograms showed arterial narrowing of the bilateral internal carotid arteries in the supraclinoid portion but failed to demonstrate an arteriovenous shunt. Subsequent angiograms clearly demonstrated the existence of an AVM. Radiological features and possible mechanisms are discussed.
Collapse
Affiliation(s)
- K Maeda
- Department of Neurosurgery, Aizu Central Hospital, Fukushima, Japan
| | | | | | | | | | | | | |
Collapse
|
39
|
Van Roost D, Kristof R, Wolf HK, Keller E. Intracerebral capillary telangiectasia and venous malformation: a rare association. SURGICAL NEUROLOGY 1997; 48:175-83. [PMID: 9242245 DOI: 10.1016/s0090-3019(96)00396-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The vascular malformations of the brain have been classified into arteriovenous, venous, cavernous, and capillary malformations as four discrete entities. Various combinations of two discrete malformations in one lesion have been reported, some of which can be considered as established associations, while others appear to be very rare. Mixed vascular malformations evoke reflections on possible interrelations in the pathogenesis of the discrete components. CASE DESCRIPTIONS We report a case of intracerebral capillary telangiectasia associated with a venous malformation in a supratentorial paraventricular location in a 45-year-old woman with a history of headache. The capillary telangiectasia was diagnosed by stereotactic biopsy. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) strongly suggested the presence of a venous malformation by demonstrating a transcerebral draining vein running through the center of the capillary telangiectasia. The association of capillary telangiectasia and venous malformation has been reported only twice before and exclusively in the posterior fossa, as opposed to the more frequent, established associations of capillary telangiectasia and cavernous malformation, and venous malformation and cavernous malformation, respectively. CONCLUSIONS Against the background of the established associations, this rare observation possibly places capillary telangiectasias, cavernous malformations, and venous malformations within the spectrum of a single disease. The common pathogenetic role of a focal venous outflow obstruction is discussed.
Collapse
Affiliation(s)
- D Van Roost
- Department of Neurosurgery, University of Bonn, Germany
| | | | | | | |
Collapse
|
40
|
Chang SD, Steinberg GK, Rosario M, Crowley RS, Hevner RF. Mixed arteriovenous malformation and capillary telangiectasia: a rare subset of mixed vascular malformations. Case report. J Neurosurg 1997; 86:699-703. [PMID: 9120635 DOI: 10.3171/jns.1997.86.4.0699] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
In this report, the authors discuss the case of a patient with a mixed cerebrovascular malformation in which an arteriovenous malformation (AVM) was associated with a capillary telangiectasia. Recent reports have contained reviews of various subsets of mixed malformations. To the authors' knowledge, however, this is the first report of a mixed vascular malformation with both arterial and capillary components. The patient underwent complete resection of the AVM after presenting with a clinical hemorrhage. She required a second operation to resect the capillary telangiectasia after new symptoms developed several months following the first procedure. The authors conclude that a mixed AVM-capillary telangiectasia is a rare but distinct entity.
Collapse
Affiliation(s)
- S D Chang
- Department of Neurosurgery, Stanford University School of Medicine, California, USA
| | | | | | | | | |
Collapse
|
41
|
Pechstein U, Zentner J, Van Roost D, Schramm J. Surgical management of brain-stem cavernomas. Neurosurg Rev 1997; 20:87-93. [PMID: 9226665 DOI: 10.1007/bf01138189] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We present a series of seven patients who were operated on for symptomatic brain-stem cavernomas. The following approaches were used: medial suboccipital (N = 4), lateral suboccipital (N = 1), subtemporal-transtentorial (N = 1), and frontal transcortical-transventricular-subchorioidal-trans velum interpositum (N = 1). Intraoperative motor (N = 4) and somatosensory (N = 1) evoked potential monitoring revealed temporary changes in 3 patients. Immediately postoperatively, the following additional deficits were observed in 6 patients: oculomotor nerve paresis (N = 2), abducens nerve paresis (N = 3), facial nerve paresis (N = 2), deafness (N = 1), and increased ataxia (N = 3). One patient died due to septic complications not related to surgery. After a mean observation time of 2 years, 2 patients had improved, 3 were unchanged, and 1 patient deteriorated as compared to his preoperative status. In conclusion, surgical treatment of brain-stem cavernomas, although carrying a significant risk of temporary neurological deterioration is recommended in symptomatic patients in whom the cavernoma seems to reach the surface of the brain-stem. Intraoperative functional topographic mapping and monitoring have proven useful tools lowering the surgical risks in these patients.
Collapse
Affiliation(s)
- U Pechstein
- Department of Neurosurgery, University of Bonn, Fed. Rep. of Germany
| | | | | | | |
Collapse
|
42
|
Furuya K, Sasaki T, Suzuki I, Kim P, Saito N, Kirino T. Intramedullary angiographically occult vascular malformations of the spinal cord. Neurosurgery 1996; 39:1123-30; discussion 1131-2. [PMID: 8938766 DOI: 10.1097/00006123-199612000-00011] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE This study was performed to elucidate the differences between angiographically occult vascular malformations of the spinal cord and the histological subtypes. METHODS The cases of six patients with spinal intramedullary angiographically occult vascular malformations encountered during the past 10 years were examined regarding clinical course, neuroradiological manifestations, and surgical consideration. RESULTS There were four cavernous malformations and two arteriovenous malformations. The cervical section of the spinal cord was involved in four cases, and the thoracic section of the spinal cord was involved in two. All of the patients had presented with motor weakness and sensory disturbance below the level of the lesion. Two distinct clinical courses were observed; they were neurological decline with repeated episodes of relapse and remission (four patients) and continuing neurological decline (two patients). Although a mixed-intensity core surrounded by a low-intensity rim is thought to be characteristic of cavernous malformations, we were not able to differentiate the histological types on the basis of magnetic resonance imaging findings alone. CONCLUSION In cases of spinal intramedullary angiographically occult vascular malformations, even if clinical course and magnetic resonance imaging findings are consistent with cavernous malformation, other histological subtypes need to be considered. Surgery should be considered for symptomatic patients, because symptoms and signs that are probably caused by bleeding tend to worsen rather than stabilize.
Collapse
Affiliation(s)
- K Furuya
- Department of Neurosurgery, Faculty of Medicine, University of Tokyo, Japan
| | | | | | | | | | | |
Collapse
|
43
|
Awada A, Russell N, al Rajeh S, Omojola M. Non-traumatic cerebral hemorrhage in Saudi Arabs: a hospital-based study of 243 cases. J Neurol Sci 1996; 144:198-203. [PMID: 8994124 DOI: 10.1016/s0022-510x(96)00232-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This is a retrospective study involving 243 Saudi Arabs with non-traumatic cerebral hemorrhages confirmed by CT scan. Intracerebral hemorrhages accounted for about 20% of all strokes in this population. THe male to female ratio was 2.74 which is slightly higher than those reported from elsewhere. Peak frequency was around 60 years. Hypertension was the most common cause accounting for 64% of the cases, hemopathies/coagulopathies for 10% and arteriovenous malformations (AVMs) for 6%. THe cause was undetermined in 21% of patients. Amyloid angiopathy was probably underrepresented due to lack of autopsy correlation. The etiologies were, however, age-related with a clear predominance of AVMs and coagulation disorders before the age of 40 years. Hypertensive hemorrhages were located in the putamen in 46% of cases compared to 20% in non-hypertensive patients while 52% of non-hypertensive hemorrhages were lobar in location compared to 20.5% in hypertensives. Early mortality (19%) in our series was relatively low compared to reports from the industrialized world.
Collapse
Affiliation(s)
- A Awada
- Section of Neurology, King Fahad National Guard Hospital, Riyadh, Saudi Arabia
| | | | | | | |
Collapse
|
44
|
Nagata K, Nikaido H, Mori T. Successful removal of cryptic arteriovenous malformation located at the upper ventral pons via subtemporal transtentorial approach. SURGICAL NEUROLOGY 1996; 46:116-21. [PMID: 8685818 DOI: 10.1016/0090-3019(96)00053-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lesions located at the ventral portion of the brain stem are still difficult to access surgically. We report herein a case of ventral pontine cryptic arteriovenous malformation that was successfully removed via a subtemporal-transtentorial approach. CASE REPORT An 18-year-old female patient experienced repetitive hemorrhagic attacks leading to a massive pontine hemorrhage with several neurologic deficits. Since angiography and magnetic resonance imaging failed to delineate the hemorrhagic origin, a combination of multiple approaches was initially attempted. The subtemporal-transtentorial approach made it possible to obtain an adequate operative view in this case. An angioma observed at the septum of the multilocular hematoma was totally removed. Pathologic examination of the resected specimen revealed it to be an arteriovenous malformation. Postoperatively, the patient showed unexpectedly good recovery despite the original massive pontine hemorrhage. CONCLUSIONS Several surgical approaches to the ventral pons have been proposed in the literature. While the subtemporal-transtentorial approach was useful in our patient, multiple routes should be considered to access a massive lesion of unknown extent at the ventral pons. The unexpected recovery observed in our patient suggests that surgery is an option in the treatment of this type of lesion.
Collapse
Affiliation(s)
- K Nagata
- Department of Neurosurgery, Showa General Hospital, Tokyo, Japan
| | | | | |
Collapse
|
45
|
Baykal S, Ceylan S, Dinç H, Kuzeyli K, Soylev E, Usul H, Aktürk F. Clinical and radiological evaluation of angiographically occult, calcified intracranial vascular malformation. Case report. Neurosurg Rev 1996; 19:119-21. [PMID: 8837112 DOI: 10.1007/bf00418082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In this study, we present an angiographically occult, calcified intracranial vascular malformation. This lesion is rare and has some therapeutic difficulties and different approaches by authors. In this article, we also discuss the clinical, radiological characteristic features of this lesion. We pay attention on the totally calcified malformation.
Collapse
Affiliation(s)
- S Baykal
- Department of Neurosurgery, KTU Medical Faculty, Trabzon, Turkey
| | | | | | | | | | | | | |
Collapse
|
46
|
|
47
|
Maraire JN, Awad IA. Intracranial cavernous malformations: lesion behavior and management strategies. Neurosurgery 1995; 37:591-605. [PMID: 8559286 DOI: 10.1227/00006123-199510000-00001] [Citation(s) in RCA: 210] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Intracranial cavernous malformations are vascular anomalies consisting of endothelium-lined caverns filled with blood at various stages of thrombosis and organization and separated by a collagenous stroma devoid of mature vessel wall elements. They occur in an estimated 0.45 to 0.9% of the population, with male and female patients equally affected and all ages represented. They commonly manifest as seizures, gross intracranial hemorrhage, and focal neurological deficits. Lesions are frequently multiple in the same patient, and 10 to 30% are associated with familial clustering. Several reports have documented a dynamic clinical-radiological lesion behavior with de novo lesion genesis, intralesional and perilesional hemorrhage, and corresponding fluctuations in lesion size. Hemorrhagic risk and neurological disability seem to be related to multiple factors, including lesion location, age, gender, state of reproductive cycle, and previous hemorrhage. Lesions may behave aggressively with repetitive hemorrhages and cumulative disability or may remain quiescent for many years. Management strategies include expectant follow-up in patients with asymptomatic or inaccessible lesions, excision of symptomatic and accessible lesions, and radiosurgery of progressively symptomatic lesions in inoperable locations. Relevant disease-specific outcome parameters are proposed to guide clinical decisions and future research. Prospective, stratified, hypothesis-driven studies using rigorous epidemiological methods must be undertaken to delineate patient and lesion factors influencing clinical aggressiveness. Biological studies are essential to uncover strategies to predict and modify lesion behavior.
Collapse
Affiliation(s)
- J N Maraire
- Neurovascular Surgery Program, Yale University School of Medicine, New Haven, Connecticut, USA
| | | |
Collapse
|
48
|
Day M, Morgan M, Wang SC, Roman M. Familial cavernous angioma without clinical haemorrhage. J Clin Neurosci 1995; 2:224-8. [DOI: 10.1016/s0967-5868(95)80006-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/1994] [Accepted: 02/08/1995] [Indexed: 11/29/2022]
|
49
|
Kida Y, Kobayashi T, Tanaka T. Treatment of symptomatic AOVMs with radiosurgery. ACTA NEUROCHIRURGICA. SUPPLEMENT 1995; 63:68-72. [PMID: 7502732 DOI: 10.1007/978-3-7091-9399-0_14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
In spite of great success in the treatment cerebral AVMs with stereotactic radiosurgery, the role of this treatment modality in angiographically occult vascular malformations (AOVMs) is not recognized. Since the installation of the Gamma-knife, we have treated 20 cases of AOVMs by radiosurgery. There were 13 males and 7 females, the age ranged from 3 to 58 years with an average age of 34.0 years. Their clinical presentations at the onset were haemorrhage in 11, convulsive seizure in 7 and progressive neurological deficits in 2. Two cases had multiple lesions. Among 20 symptomatic lesions, 14 were located supratentorially, 4 in the brain stem and 2 in the cerebellar hemispheres. Following localization with MRI and dose planning, the lesions were treated by radiosurgery and the doses ranged from 15 to 20 Gy at the margins. Follow-up studies indicate a significant control of rebleeding as well as of the convulsive seizure. Imaging studies demonstrated the shrinkage of the lesion in 3 and reduced enhancement with Gadolinium-DTPA in some others. Adverse effects, chiefly related to radiation-induced oedema, occurred in 5. But they were generally mild and well controlled by medication. Thus the preliminary results indicate a certain usefulness of radiosurgery in the treatment of symptomatic AOVMs.
Collapse
Affiliation(s)
- Y Kida
- Department of Neurosurgery, Komaki City Hospital, Japan
| | | | | |
Collapse
|
50
|
Kida Y, Kobayashi T, Tanaka T, Oyama H, Iwakoshi T. Gamma-radiosurgery of Angiographically Occult Vascular Malformations. ACTA ACUST UNITED AC 1995. [DOI: 10.7887/jcns.4.239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|