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Corpus-Gutiérrez V, Beltrán-Guevara PA, Angarita-Avendaño M, Ramirez-Velandia F, Del Castillo-Forero MA, Bejarano-Mora L, Puentes-Vargas JC. Postoperative Hemorrhage in Patients with Aneurysms Associated with Arteriovenous Malformations. A Systematic Review and Meta-Analysis. World Neurosurg 2025; 196:123719. [PMID: 39864803 DOI: 10.1016/j.wneu.2025.123719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2024] [Revised: 01/17/2025] [Accepted: 01/18/2025] [Indexed: 01/28/2025]
Abstract
OBJECTIVE To compare the rates of postoperative hemorrhages (PHs) for aneurysms associated with brain arteriovenous malformation (AVM) evaluating the lesion that was initially treated. METHODS A systematic review of the literature was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was performed in PubMed, Embase, and Scopus. After the data extraction, the total numbers and percentages were calculated through summary statistics and were subject to meta-analysis. The methodological quality and risk of bias were assessed using the ROBINS-I tool and to determine the certainty of the evidence, we utilized the Grading of Recommendations, Assessment, Development, and Evaluation methodology. RESULTS Out of the 738 records screened, 28 studies were chosen for data extraction with a total of 1671 patients. Hemorrhagic presentation was observed between 38% and 100% of patients across the studies included. The pooled period prevalence of PH after intervention was 6% (95% confidence interval [CI = 0.03-0.07). Stratified analysis according to which lesion was treated first demonstrated a slightly lower rates of PH when aneurysms were treated first, compared when the AVM was managed first or if both lesions were treated simultaneously (P = 0.02). Rates of hemorrhage for lesions in the infratentorial location (0.21; 95% CI = 0.01-0.42) were much higher after intervention compared to noninfratentorial location (0.05; 95% CI = 0.03-0.07), and this difference reached statistical significance (P < 0.01). CONCLUSIONS Hemorrhage rates were lower when treating the aneurysm first, but their risk was higher when treating infratentorial lesions. The decision on which lesion should be treated first should be individualized according to the feeder vessels, the AVM and aneurysmal size, location, and overall functionality of the patients.
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Affiliation(s)
| | - Paula A Beltrán-Guevara
- Neurology and Neurosurgery Research Group, Pontificia Universidad Javeriana, Bogota D.C., Colombia
| | | | - Felipe Ramirez-Velandia
- Neurology and Neurosurgery Research Group, Pontificia Universidad Javeriana, Bogota D.C., Colombia
| | | | - Laura Bejarano-Mora
- Neurology and Neurosurgery Research Group, Pontificia Universidad Javeriana, Bogota D.C., Colombia.
| | - Juan C Puentes-Vargas
- Department of Neurologic Surgery, Pontificia Universidad Javeriana, Neurosurgery Research Group, Bogota D.C., Colombia
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Musmar B, Adeeb N, Roy JM, Abdalrazeq H, Tjoumakaris SI, Atallah E, Salim HA, Kondziolka D, Sheehan J, Ogilvy CS, Riina H, Kandregula S, Dmytriw AA, El Naamani K, Abdelsalam A, Ironside N, Kumbhare D, Ataoglu C, Essibayi MA, Keles A, Muram S, Sconzo D, Rezai A, Erginoglu U, Pöppe J, Sen RD, Griessenauer CJ, Burkhardt JK, Starke RM, Baskaya MK, Sekhar LN, Levitt MR, Altschul DJ, McAvoy M, Aslan A, Abushehab A, Swaid C, Abla AA, Gooch MR, Rosenwasser RH, Stapleton C, Koch M, Srinivasan VM, Chen PR, Blackburn S, Dannenbaum MJ, Choudhri O, Pukenas B, Orbach D, Smith E, Mosimann PJ, Alaraj A, Aziz-Sultan MA, Patel AB, Cuellar HH, Lawton MT, Morcos J, Guthikonda B, Jabbour P. Comparing stand-alone endovascular embolization versus stereotactic radiosurgery in the treatment of arteriovenous malformations with Spetzler-Martin grades I-III: a propensity score matched study. J Neurointerv Surg 2025:jnis-2024-022326. [PMID: 39366733 DOI: 10.1136/jnis-2024-022326] [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: 08/05/2024] [Accepted: 09/18/2024] [Indexed: 10/06/2024]
Abstract
BACKGROUND Arteriovenous malformations (AVMs) are uncommon cerebral lesions that can cause significant neurological complications. Surgical resection is the gold standard for treatment, but endovascular embolization and stereotactic radiosurgery (SRS) are viable alternatives. OBJECTIVE To compare the outcomes of endovascular embolization versus SRS in the treatment of AVMs with Spetzler-Martin grades I-III. METHODS This study combined retrospective data from 10 academic institutions in North America and Europe. Patients aged 1 to 90 years who underwent endovascular embolization or SRS for AVMs with Spetzler-Martin grades I-III between January 2010 and December 2023 were included. RESULTS The study included 244 patients, including 84 who had endovascular embolization and 160 who had SRS. Before propensity score matching (PSM), complete obliteration at the last follow-up was achieved in 74.5% of the SRS group compared with 57.8% of the embolization group (OR=0.47; 95% CI 0.26 to 0.48; P=0.01). After propensity score matching, SRS still achieved significantly higher occlusion rates at last follow-up (78.9% vs 55.3%; OR=0.32; 95% CI 0.12 to 0.90; P=0.03).Hemorrhagic complications were higher in the embolization group than in the SRS group, although this difference did not reach statistical significance after PSM (13.2% vs 2.6%; OR=5.6; 95% CI 0.62 to 50.47; P=0.12). Similarly, re-treatment rate was higher in the embolization group (10.5% vs 5.3%; OR=2.11; 95% CI 0.36 to 12.31; P=0.40) compared with the SRS group. CONCLUSION Our findings indicate that SRS has a significantly higher obliteration rate at last follow-up compared with endovascular embolization. Also, SRS has a higher tendency for fewer hemorrhagic complications and lower re-treatment rate. Further prospective studies are needed.
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Affiliation(s)
- Basel Musmar
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nimer Adeeb
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, Texas, USA
| | - Joanna M Roy
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hammam Abdalrazeq
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hamza Adel Salim
- Department of Radiology, Louisiana State University, Shreveport, Louisiana, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Christopher S Ogilvy
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Howard Riina
- Department of Neurosurgery, New York University Grossman School of Medicine, New York, New York, USA
| | - Sandeep Kandregula
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ahmed Abdelsalam
- Department of Neurosurgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Natasha Ironside
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Deepak Kumbhare
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
| | - Cagdas Ataoglu
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Muhammed Amir Essibayi
- Montefiore Einstein Cerebrovascular Research Lab and Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | - Abdullah Keles
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Sandeep Muram
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel Sconzo
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Arwin Rezai
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Ufuk Erginoglu
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Johannes Pöppe
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Rajeev D Sen
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Christoph J Griessenauer
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Mustafa K Baskaya
- Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Laligam N Sekhar
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - David J Altschul
- Montefiore Einstein Cerebrovascular Research Lab and Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | - Malia McAvoy
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Assala Aslan
- Department of Radiology, Louisiana State University, Shreveport, Louisiana, USA
| | | | - Christian Swaid
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
| | - Adib A Abla
- Department of Neurosurgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Christopher Stapleton
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Matthew Koch
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peng R Chen
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, Texas, USA
| | - Spiros Blackburn
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, Texas, USA
| | - Mark J Dannenbaum
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, Texas, USA
| | - Omar Choudhri
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bryan Pukenas
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Darren Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward Smith
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pascal J Mosimann
- Division of Interventional and Diagnostic Neuroradiology, Department of Radiology, University of Toronto & Toronto Western Hospital, Toronto, Ontario, Canada
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Mohammad A Aziz-Sultan
- Department of Neurosurgery, Brigham and Women Hospital, Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hugo H Cuellar
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
- Department of Radiology, Louisiana State University, Shreveport, Louisiana, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jacques Morcos
- Department of Neurosurgery, UT Health Sciences Center at Houston, McGovern Medical School, Houston, Texas, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, Louisiana State University Health Science Center, Shreveport, Louisiana, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Khan H, Sangah AB, Nasir R, Khan SA, Shaikh SS, Ahmed I, Abbasi MK, Ahmed A, Siddiqui D, Hussain SA, Akhunzada NZ, Godfrey O. Efficacy of radiosurgery with and without angioembolization: A subgroup analysis of effectiveness in ruptured versus unruptured arteriovenous malformations - An updated systematic review and meta-analysis. Surg Neurol Int 2024; 15:467. [PMID: 39777180 PMCID: PMC11704434 DOI: 10.25259/sni_737_2024] [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: 08/30/2024] [Accepted: 11/12/2024] [Indexed: 01/11/2025] Open
Abstract
Background Congenital arterial defects such as cerebral arteriovenous malformations (AVMs) increase brain bleeding risk. Conservative therapy, microsurgical removal, percutaneous embolization, stereotactic radiosurgery (SRS), or a combination may treat this serious disease. This study compares angioembolization with SRS to SRS alone in ruptured or unruptured brain ateriovenous malformations (BAVM) patients. Methods We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations for this study. Until September 2023, PubMed/Medline, Cochrane, and Clinicaltrials.gov were searched for literature. English-language studies comparing SRS alone to embolization with SRS on ruptured or non-ruptured AVMs that could not be operated on were considered. The Newcastle-Ottawa Scale assessed research study quality. Results Results included 46 studies with a total of 7077 participants. There was a greater obliteration rate in the SRS-only group (60.4%) than in the embolization plus SRS group (49.73%). Particularly in the SRS-only group, ruptured AVMs showed a noticeably greater obliteration rate than unruptured AVMs (P = 0.002). However, no notable differences were found in hemorrhagic events or radiation-induced changes between the two groups; however, the SRS-only group had a slightly greater, yet not statistically significant, mortality rate. Conclusion Our data showed that ruptured brain AVMs had a much greater obliteration rate than unruptured ones, mostly due to SRS alone, without embolization. The aggregated data showed no significant changes, whereas SRS alone decreased radiation-induced alterations and hemorrhagic rates but with increased mortality. SRS alone may have a higher risk-to-reward ratio for nidus obliteration in ruptured brain AVM patients, so it should be used without embolization, although more research is needed to determine the effects of immediate and late complications.
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Affiliation(s)
- Hamza Khan
- Department of Neurosurgery, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Abdul Basit Sangah
- Department of Neurosurgery, Liaquat National Hospital, Karachi, Pakistan
| | - Roua Nasir
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Saad Akhtar Khan
- Department of Neurosurgery, Liaquat National Hospital, Karachi, Pakistan
| | | | - Ikhlas Ahmed
- Department of Neurosurgery, Liaquat National Hospital, Karachi, Pakistan
| | - Mohad Kamran Abbasi
- Department of Neurosurgery, Rehman Medical Institute Peshawar, Peshawar, Pakistan
| | - Asma Ahmed
- Department of Neurosurgery, Rehman Medical Institute Peshawar, Peshawar, Pakistan
| | - Dua Siddiqui
- Department of Neurosurgery, Liaquat National Hospital, Karachi, Pakistan
| | - Syeda Ayesha Hussain
- Department of Neurosurgery, Rehman Medical Institute Peshawar, Peshawar, Pakistan
| | | | - Oswin Godfrey
- Department of Neurosurgery, Sohail Trust Hospital, Karachi, Pakistan
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Oslin SJ, Lu VM, Graffeo CS. Systematic reviews and meta-analyses in the cerebrovascular space: essential domains for readers. Neurosurg Rev 2024; 47:454. [PMID: 39168862 DOI: 10.1007/s10143-024-02690-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Revised: 07/30/2024] [Accepted: 08/11/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION Systematic Review and Meta-Analysis (SRMAs) in neurosurgery have significantly increased. With approximately 1 million patients affected by cerebrovascular disease annually, interpreting SRMAs necessitates a systematic approach. The objective of this review is to identify and describe four essential domains for SRMA interpretation. METHODS This review outlines the necessities of reviewing existing literature and methodological frameworks essential for interpreting cerebrovascular neurosurgery SRMAs. Each domain is to accurately assess study design variations, heterogeneity assessment methods, outcome comparability strategies, and the impact of technological advancements and time bias on study outcomes. RESULTS Study design evaluation distinguishes between randomized controlled trials (RCTs) and non-randomized studies. RCTs provide high internal validity, but as seen in the ARUBA trial, can contain internal flaws that necessitate a deeper understanding before application to clinical practices. Non-randomized studies offer valuable real-world insights. A heterogeneity assessment involves readers and writers accurately using forest plots, Cochrane's Q test, Higgins I² statistics, subgroup analysis, and meta-regressions to understand a study's clinical findings. The expertise thresholds, as in the NASCET trial, significantly impact a study's external validity. Strategies such as the GRADE approach can assist in managing diverse outcome measures. Technological advancements, particularly in endovascular procedures and SRS, influence the accuracy of comparing studies across periods, and thus swiftly outdate older studies, lowering the applicability of SRMAs. CONCLUSION Effective interpretation of cerebrovascular neurosurgery SRMAs requires attention to study design, heterogeneity, outcome comparability, and technological advancements. These domains collectively enable evidence-based clinical decision-making and optimized patient care in a dynamic field.
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Affiliation(s)
- Spencer J Oslin
- Department of Neurosurgery, University of Oklahoma, 1000 N Lincoln Blvd, #4000, Oklahoma City, OKC, 73104, USA
| | - Victor M Lu
- Department of Neurosurgery, University of Miami, Jackson Memorial Hospital, Miami, FL, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, University of Oklahoma, 1000 N Lincoln Blvd, #4000, Oklahoma City, OKC, 73104, USA.
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Maroufi SF, Fallahi MS, Khorasanizadeh M, Waqas M, Sheehan JP. Radiosurgery With Prior Embolization Versus Radiosurgery Alone for Intracranial Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2024; 94:478-496. [PMID: 37796184 DOI: 10.1227/neu.0000000000002699] [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: 05/31/2023] [Accepted: 08/02/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The addition of adjuvant embolization to radiosurgery has been proposed as a means of improving treatment outcomes of intracranial arteriovenous malformations (AVMs). However, the relative efficacy and safety of radiosurgery with adjuvant embolization vs radiosurgery alone remain uncertain. Moreover, previous systematic reviews and meta-analyses have included a limited number of studies and did not consider the effects of baseline characteristics, including AVM volume, on the outcomes. This systematic review aimed to evaluate the efficacy of preradiosurgery embolization for intracranial AVMs with consideration to matching status between participants in each treatment group. METHODS A systematic review and meta-analysis were conducted by searching electronic databases, including PubMed, Scopus, and Cochrane Library, up to January 2023. All studies evaluating the utilization of preradiosurgery embolization were included. RESULTS A total of 70 studies (9 matched and 71 unmatched) with a total of 12 088 patients were included. The mean age of the included patients was 32.41 years, and 48.91% of the patients were female. Preradiosurgery embolization was used for larger AVMs and patients with previous hemorrhage ( P < .01, P = .02, respectively). The obliteration rate for preradiosurgery embolization (49.44%) was lower compared with radiosurgery alone (61.42%, odds ratio = 0.56, P < .01), regardless of the matching status of the analyzed studies. Although prior embolization was associated higher rate of cyst formation ( P = .04), it lowered the odds of radiation-induced changes ( P = .04). The risks of minor and major neurological deficits, postradiosurgery hemorrhage, and mortality were comparable between groups. CONCLUSION This study provides evidence that although preradiosurgery embolization is a suitable option to reduce the AVM size for future radiosurgical interventions, it may not be useful for same-sized AVMs eligible for radiosurgery. Utilization of preradiosurgery embolization in suitable lesions for radiosurgery may result in the added cost and burden of an endovascular procedure.
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Affiliation(s)
- Seyed Farzad Maroufi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran , Iran
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran , Iran
| | - Mohammad Sadegh Fallahi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran , Iran
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran , Iran
| | - MirHojjat Khorasanizadeh
- Department of Neurosurgery, Mount Sinai Hospital, Icahn School of Medicine, New York City , New York , USA
| | - Muhammad Waqas
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo , New York , USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
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Waqas M, Monteiro A, Tutino VM, Cappuzzo JM, Vakharia K, Winograd EK, Goulenko V, Gong AD, Snyder KV, Davies JM, Levy EI, Prasad D, Siddiqui AH. Preradiosurgical Embolization of Arteriovenous Malformations Reduces Target Volume - The Main Determinant for Complete Obliteration. World Neurosurg 2024; 181:e117-e125. [PMID: 37619837 DOI: 10.1016/j.wneu.2023.08.066] [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: 02/13/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Embolization and stereotactic radiosurgery (SRS) have increasingly been used to treat complex arteriovenous malformations (AVMs). We studied outcomes of AVM patients treated through a multidisciplinary approach, examined the effect of embolization on SRS success, and analyzed predictors of treatment failure. METHODS We retrospectively reviewed a prospectively maintained database of patients with AVMs treated with Gamma Knife (Leksell) SRS over an 11-year period. Patients with incomplete medical records and follow-up <2 years were excluded. Demographics, clinical presentation, previous rupture history, angiographic nidus size, Spetzler-Martin (S-M) grade, adjunctive endovascular embolization and microsurgical resection, radiologic evidence of obliteration and hemorrhage, and clinical outcomes (modified Rankin Scale [mRS] scores) were recorded. Radiosurgery-related details including nidus volume and number of sessions and radiosurgery-, embolization-, and resection-associated complications were also recorded. RESULTS Eighty-three patients (mean age, 41.0 ± 21.3 years) were included. Mean reduction in AVM nidus target volume with endovascular embolization was 66.0 ± 19.7%. S-M grade reduction was achieved in 51.6% cases. Total obliteration after SRS was achieved in 56 AVMs (67.5%) after 2 years, and in 38 (86.4%) after 4 years. Two (2.4%) patients had rehemorrhage after SRS. Overall complication rate was 3.6%. Median angiographic follow-up was 55.5 months. Favorable outcomes (mRS = 0-2) were seen in 77.1%. SRS target volume was an independent predictor of treatment failure regardless of pre-SRS embolization. CONCLUSIONS High AVM obliteration rates were achieved with judicious use of radiosurgery alone or with embolization. Embolization reduced target nidus volume by an average of 66%. SRS target volume was an independent predictor of treatment failure.
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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
| | - Andre Monteiro
- 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
| | - Vincent M Tutino
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
| | - Justin M Cappuzzo
- 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
| | - Evan K Winograd
- 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
| | - Victor Goulenko
- 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; Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Andrew D Gong
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA; Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 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; Jacobs Institute, 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; Jacobs Institute, 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; Jacobs Institute, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Dheerendra Prasad
- 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; Department of Radiation Medicine, Roswell Park Cancer Institute, Buffalo, NY, 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; Jacobs Institute, 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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7
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Rodríguez Mallma MJ, Vilca-Aguilar M, Zuloaga-Rotta L, Borja-Rosales R, Salas-Ojeda M, Mauricio D. Machine Learning Approach for Analyzing 3-Year Outcomes of Patients with Brain Arteriovenous Malformation (AVM) after Stereotactic Radiosurgery (SRS). Diagnostics (Basel) 2023; 14:22. [PMID: 38201331 PMCID: PMC10871108 DOI: 10.3390/diagnostics14010022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 01/12/2024] Open
Abstract
A cerebral arteriovenous malformation (AVM) is a tangle of abnormal blood vessels that irregularly connects arteries and veins. Stereotactic radiosurgery (SRS) has been shown to be an effective treatment for AVM patients, but the factors associated with AVM obliteration remains a matter of debate. In this study, we aimed to develop a model that can predict whether patients with AVM will be cured 36 months after intervention by means of SRS and identify the most important predictors that explain the probability of being cured. A machine learning (ML) approach was applied using decision tree (DT) and logistic regression (LR) techniques on historical data (sociodemographic, clinical, treatment, angioarchitecture, and radiosurgery procedure) of 202 patients with AVM who underwent SRS at the Instituto de Radiocirugía del Perú (IRP) between 2005 and 2018. The LR model obtained the best results for predicting AVM cure with an accuracy of 0.92, sensitivity of 0.93, specificity of 0.89, and an area under the curve (AUC) of 0.98, which shows that ML models are suitable for predicting the prognosis of medical conditions such as AVM and can be a support tool for medical decision-making. In addition, several factors were identified that could explain whether patients with AVM would be cured at 36 months with the highest likelihood: the location of the AVM, the occupation of the patient, and the presence of hemorrhage.
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Affiliation(s)
| | - Marcos Vilca-Aguilar
- Instituto de Radiocirugía del Perú, Clínica San Pablo, Lima 15023, Peru
- Servicio de Neurocirugía, Hospital María Auxiliadora, Lima 15828, Peru
| | - Luis Zuloaga-Rotta
- Facultad de Ingeniería Industrial y de Sistemas, Universidad Nacional de Ingeniería, Lima 15333, Peru
| | - Rubén Borja-Rosales
- Facultad de Ingeniería Industrial y de Sistemas, Universidad Nacional de Ingeniería, Lima 15333, Peru
| | | | - David Mauricio
- Universidad Nacional Mayor de San Marcos, Lima 15081, Peru
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Sethi A, Chee K, Chatain GP, Wittenberg B, Seinfeld J, Milgrom S, Kavanagh B, Breeze R. Time-Dosed Stereotactic Radiosurgery for the Treatment of Cerebral Arteriovenous Malformations: An Early Institution Experience and Case Series. NEUROSURGERY PRACTICE 2023; 4:e00060. [PMID: 39959396 PMCID: PMC11809988 DOI: 10.1227/neuprac.0000000000000060] [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: 04/13/2023] [Accepted: 07/05/2023] [Indexed: 02/18/2025]
Abstract
BACKGROUND AND OBJECTIVES Stereotactic radiosurgery (SRS) is an effective treatment modality used by neurosurgeons to treat cerebral arteriovenous malformations (AVMs), particularly for treating AVMs <10 cm3. Current strategies include single-staged, dose-staged, and volume-staged SRS, all of which demonstrate varying effectiveness for treating large-volume AVMs (>10 cm3). We introduce a novel refinement called time-dosed SRS for the treatment of large-volume AVMs or AVMs located in eloquent areas. This study aims to detail treatment parameters, outcomes, and complications associated with time-dosed SRS in our early experience study. METHODS We retrospectively reviewed all patients treated using time-dosed SRS at our institution. Data, including AVM location, history of hemorrhage, history of intervention, AVM volume, Spetzler-Martin grade, presence of residual disease, and occurrence of postprocedural complications, were collected. RESULTS Sixteen patients were included. The median total AVM volumes treated were 9.64 cm3 (0.92-46.2 cm3) and 13.2 cm3 (3.0-42.2 cm3) in adults and children, respectively. The median margin doses for adults and children at each of the 3 stages were 10 Gy, 10 Gy (8-10 Gy) and 9 Gy (8-10 Gy), and 10 Gy, 10 Gy (9-10 Gy), and 10 Gy (8-10 Gy), respectively. The median total dose delivered was 29 Gy (27-30 Gy) in adults and 30 Gy (28-30 Gy) in children. The median radiological follow-up length was 35 months (9-62 months) in adults and 31 months (4-72 months) in pediatric patients. Complete obliteration was confirmed by cerebral angiogram in 6 adult patients and 1 pediatric patient. One adult patient and 2 pediatric patients suffered radiation-related toxicity. No patients suffered postprocedural hemorrhage. CONCLUSION Time-dosed SRS seems to be effective for treating large AVMs or those in highly eloquent areas, with a low rate of complications.
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Affiliation(s)
- Akal Sethi
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Keanu Chee
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Gregoire P. Chatain
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Blake Wittenberg
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Joshua Seinfeld
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Sarah Milgrom
- Department of Radiation Oncolgy, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Brian Kavanagh
- Department of Radiation Oncolgy, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Robert Breeze
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
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Al-Smadi MW, Fazekas LA, Aslan S, Bernat B, Beqain A, Al-Khafaji MQM, Priksz D, Orlik B, Nemeth N. A Microsurgical Arteriovenous Malformation Model on Saphenous Vessels in the Rat. Biomedicines 2023; 11:2970. [PMID: 38001970 PMCID: PMC10669800 DOI: 10.3390/biomedicines11112970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
Arteriovenous malformation (AVM) is an anomaly of blood vessel formation. Numerous models have been established to understand the nature of AVM. These models have limitations in terms of the diameter of the vessels used and the impact on the circulatory system. Our goal was to establish an AVM model that does not cause prompt and significant hemodynamic and cardiac alterations but is feasible for follow-up of the AVM's progression. Sixteen female rats were randomly divided into sham-operated and AVM groups. In the AVM group, the saphenous vein and artery were interconnected using microsurgical techniques. The animals were followed up for 12 weeks. Anastomosis patency and the structural and hemodynamic changes of the heart were monitored. The hearts and vessels were histologically analyzed. During the follow-up period, shunts remained unobstructed. Systolic, diastolic, mean arterial pressure, and heart rate values slightly and non-significantly decreased in the AVM group. Echocardiogram results indicated minor systolic function impact, with slight and insignificant changes in aortic pressure and blood velocity, and minimal left ventricular wall enlargement. The small-caliber saphenous AVM model does not cause acute hemodynamic changes. Moderate but progressive alterations and venous dilatation confirmed AVM-like features. The model seems to be suitable for studying further the progression, enlargement, or destabilization of AVM.
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Affiliation(s)
- Mohammad Walid Al-Smadi
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Moricz Zsigmond ut 22, 4032 Debrecen, Hungary; (M.W.A.-S.); (L.A.F.); (S.A.); (A.B.); (M.Q.M.A.-K.)
- Kalman Laki Doctoral School, University of Debrecen, 4032 Debrecen, Hungary
| | - Laszlo Adam Fazekas
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Moricz Zsigmond ut 22, 4032 Debrecen, Hungary; (M.W.A.-S.); (L.A.F.); (S.A.); (A.B.); (M.Q.M.A.-K.)
| | - Siran Aslan
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Moricz Zsigmond ut 22, 4032 Debrecen, Hungary; (M.W.A.-S.); (L.A.F.); (S.A.); (A.B.); (M.Q.M.A.-K.)
| | - Brigitta Bernat
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98, 4032 Debrecen, Hungary; (B.B.); (D.P.)
| | - Anas Beqain
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Moricz Zsigmond ut 22, 4032 Debrecen, Hungary; (M.W.A.-S.); (L.A.F.); (S.A.); (A.B.); (M.Q.M.A.-K.)
| | - Mustafa Qais Muhsin Al-Khafaji
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Moricz Zsigmond ut 22, 4032 Debrecen, Hungary; (M.W.A.-S.); (L.A.F.); (S.A.); (A.B.); (M.Q.M.A.-K.)
| | - Daniel Priksz
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98, 4032 Debrecen, Hungary; (B.B.); (D.P.)
| | - Brigitta Orlik
- Department of Pathology, Faculty of Medicine, University of Debrecen, Nagyerdei krt. 98, 4032 Debrecen, Hungary;
| | - Norbert Nemeth
- Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen, Moricz Zsigmond ut 22, 4032 Debrecen, Hungary; (M.W.A.-S.); (L.A.F.); (S.A.); (A.B.); (M.Q.M.A.-K.)
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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: 11] [Impact Index Per Article: 5.5] [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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11
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Sattari SA, Shahbandi A, Yang W, Feghali J, Xu R, Huang J. Microsurgery versus Microsurgery With Preoperative Embolization for Brain Arteriovenous Malformation Treatment: A Systematic Review and Meta-analysis. Neurosurgery 2023; 92:27-41. [PMID: 36519858 DOI: 10.1227/neu.0000000000002171] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/29/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Preoperative embolization has traditionally been regarded as a safe and effective adjunct to microsurgical treatment of brain arteriovenous malformations (bAVM). However, there is currently no high-level evidence to ascertain this presumption. OBJECTIVE To compare the outcomes of microsurgery (MS) vs microsurgery with preoperative embolization (E + MS) in patients with bAVM through systematic review. METHODS We searched MEDLINE, PubMed, and Embase. The primary outcome was bAVM obliteration. Secondary outcomes were intraoperative bleeding (mL), complications, worsened modified Rankin Scale (mRS), and mortality. The pooled proportions of outcomes were calculated through the logit transformation method. The odds ratio (OR) of categorical data and mean difference of continuous data were estimated through the Mantel-Haenszel and the inverse variance methods, respectively. RESULTS Thirty-two studies met the eligibility criteria. One thousand eight hundred twenty-eight patients were treated by microsurgery alone, and 1088 were treated by microsurgery with preoperative embolization, respectively. The meta-analysis revealed no significant difference in AVM obliteration (94.1% vs 95.6%, OR = 1.15 [0.63-2.11], P = .65), mortality (1.7% vs 2%, OR = 0.88 [0.30-2.58], P = .82), procedural complications (18.2% vs 27.2%, OR = 0.47 [0.19-1.17], P = .10), worsened mRS (21.2% vs 18.5%, OR = 1.08 [0.33-3.54], P = .9), and intraoperative blood loss (mean difference = 182.89 [-87.76, 453.55], P = .19). CONCLUSION The meta-analysis showed no significant difference in AVM obliteration, mortality, complications, worse mRS, and intraoperative blood loss between MS and E + MS groups. For AVMs where MS alone has acceptable results, it is reasonable to bypass unnecessary preoperative embolization given higher postoperative complication risk.
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Affiliation(s)
- Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ataollah Shahbandi
- Tehran School of Medicine, Tehran University of Medical Science, Tehran, Iran
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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12
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Tasiou A, Brotis AG, Tzerefos C, Lambrianou X, Spiliotopoulos T, Alleyne CH, Boccardi E, Karlsson B, Kitchen N, Meling TR, Spetzler RF, Tolias CM, Fountas KN. Critical Appraisal of Randomized Controlled Trials on Unruptured Brain Arteriovenous Malformations. World Neurosurg 2022; 166:e536-e545. [PMID: 35863649 DOI: 10.1016/j.wneu.2022.07.043] [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: 03/14/2022] [Accepted: 07/10/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Brain arteriovenous malformations management remains controversial despite the numerous, available treatment options. Randomized controlled trials (RCTs) theoretically provide the strongest evidence for the assessment of any therapeutic intervention. However, poorly designed RCTs may be associated with biases, inaccuracies, and misleading conclusions. The purpose of our study is to assess reporting transparency and methodological quality of the existing RCTs. METHODS A search was performed in the PubMed, Scopus, Embase, clinicaltrials.gov, and Cochrane databases. The search was limited to English literature. We included all published RCTs reporting on the management of unruptured brain arteriovenous malformations. The eligible studies were evaluated by 5 blinded raters with the CONsolidated Standards of Reporting Trials 2010 statement and the risk-of-bias 2 tool. The inter-rater agreement was assessed with the Fleiss' Kappa. RESULTS A randomized trial of unruptured brain arteriovenous malformations (ARUBA) and treatment of brain arteriovenous malformations (TOBAS) trials were evaluated. ARUBA achieved high CONsolidated standards of reporting trials compliance, while TOBAS showed a moderate one. In ARUBA the introduction, discussion, and other information sections reached the highest compliance rate (80%-86%). The lowest rates were recorded in the results and the methods (62% and 73%, respectively). The inter-rater agreement was moderate to substantial (54.1% to 78.4%). All the examined studies demonstrated a high risk of bias, mainly related to ill-defined intended interventions, missing outcome data, and selection of the reported results. CONCLUSIONS Our study confirmed the high risk of bias mainly attributed to several protocol violations, deviations, minimal external validity and selection, attrition, and allocation biases of the ARUBA trial. Analysis of the TOBAS trial revealed a moderate overall reporting clarity and a high risk of bias.
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Affiliation(s)
- Anastasia Tasiou
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Alexandros G Brotis
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Christos Tzerefos
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Xanthoula Lambrianou
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Theodosios Spiliotopoulos
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | | | - Edoardo Boccardi
- Department of Diagnostic and Interventional Neuroradiology, Niguarda Hospital, Milan, Italy
| | - Bengt Karlsson
- Department of Surgery, Division of Neurosurgery, National University Hospital, Singapore
| | - Neil Kitchen
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, England, UK
| | - Torstein R Meling
- Division of Neurosurgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Christos M Tolias
- Department of Neurovascular Surgery, Kings College Hospital, London, England, UK
| | - Kostas N Fountas
- Department of Neurosurgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Mollier O, Dupin C, Marnat G, Benech J, Vendrely V, Giraud N, Trouette R, Barreau X, Huchet A. [Stereotactic radiotherapy of non-tumoral brain pathologies: Arteriovenous malformations and trigeminal neuralgias]. Cancer Radiother 2022; 26:779-783. [PMID: 36030190 DOI: 10.1016/j.canrad.2022.06.023] [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: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 10/15/2022]
Abstract
Stereotactic radiotherapy and radiosurgery allow delivery of high irradiation doses in a limited volume. These techniques are specially adapted to brain and nervous pathologies. Indication are not only cancers and tumors but also non tumor tissues such as arteriovenous malformations. In some case purpose of stereotactic radiotherapy is solely functional, for example for trigeminal neuralgia. We detail the questions that raise treatment of these non-tumor pathologies. These pathologies imply a multidisciplinary approach that associate radiation oncologists, neuro-radiologist and neurosurgeons.
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Affiliation(s)
- O Mollier
- Service de neurochirurgie A, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - C Dupin
- Service d'oncologie-radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, Bordeaux, France; U1312-BRIC, eq BioGO, Inserm, université de Bordeaux, 33000 Bordeaux, France
| | - G Marnat
- Service de radiologie et de neuro-imagerie diagnostique et thérapeutique, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - J Benech
- Service d'oncologie-radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, Bordeaux, France
| | - V Vendrely
- Service d'oncologie-radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, Bordeaux, France; U1312-BRIC, eq BioGO, Inserm, université de Bordeaux, 33000 Bordeaux, France
| | - N Giraud
- Service d'oncologie-radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, Bordeaux, France
| | - R Trouette
- Service d'oncologie-radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, Bordeaux, France
| | - X Barreau
- Service de radiologie et de neuro-imagerie diagnostique et thérapeutique, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - A Huchet
- Service d'oncologie-radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, Bordeaux, France.
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14
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Süzer MA, Özhan MÖ, Çaparlar CÖ, Eşkin MB, Atik B. Airway management in general anesthesia for endovascular treatment of cerebral arteriovenous malformation: a retrospective observational study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022; 72:359-364. [PMID: 34963618 PMCID: PMC9373514 DOI: 10.1016/j.bjane.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 12/04/2021] [Accepted: 12/11/2021] [Indexed: 12/05/2022]
Abstract
BACKGROUND AND OBJECTIVE This retrospective and observational study aimed to retrospectively evaluate the use of the endotracheal tube (ETT) and the Laryngeal Mask Airway (LMA) for the airway management with respect to airway safety, hemodynamic stability, adverse respiratory events, and recovery characteristics in patients who underwent endovascular treatment (EVT) for cerebrovascular arteriovenous malformation under general anesthesia between 2011 and 2018. METHODS The study included data from the patient's electronic medical records and anesthesia files. The primary outcome measure was the incidence of hemodynamic disturbances and respiratory adverse events during airway management. The secondary outcome measure was the comparison of recovery characteristics. RESULTS The airway was secured using ETT in 41 patients and LMA in 39 patients. Airway safety was established in all patients without a complication throughout the procedure. Mean arterial blood pressure and heart rate were increased to > 20% of baseline levels at intubation and extubation periods in more patients in the ETT group than the LMA group (27 vs. 3; p = 0.07, and 11 vs. 2; p = 0.021). Respiratory adverse events including straining and coughing were observed in ten patients in the ETT group but only in one patient in the LMA group (p = 0.013). Time to extubation, to neurological assessment, and to discharge from the angiography unit were similar (p > 0.05). CONCLUSION It was concluded that LMA provided sufficient airway safety as with ETT and may be used as an alternative to ETT for EVTs under general anesthesia.
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Affiliation(s)
- Mehmet Anıl Süzer
- Private Çankaya Hospital, Department of Anesthesiology and Reanimation, Ankara, Turkey
| | - Mehmet Özgür Özhan
- Private Çankaya Hospital, Department of Anesthesiology and Reanimation, Ankara, Turkey
| | - Ceyda Özhan Çaparlar
- University of Medical Science, Yıldırım Beyazıt Training and Research Hospital, Department of Anesthesiology and Reanimation, Ankara, Turkey
| | - Mehmet Burak Eşkin
- University of Medical Science, Gülhane Training and Research Hospital, Department of Anesthesiology and Reanimation, Ankara, Turkey
| | - Bülent Atik
- Balıkesir University Medical Faculty, Department of Anesthesiology and Reanimation, Balıkesir, Turkey.
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Raveglia F, Moneghini L, Cariati M, Baisi A, Guttadauro A, Cioffi U, Scarci M. Case Report: Multidisciplinary Approach for a Rare Case of Thymic Vascular Malformation. Front Surg 2021; 7:624615. [PMID: 33511152 PMCID: PMC7835703 DOI: 10.3389/fsurg.2020.624615] [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: 10/31/2020] [Accepted: 12/11/2020] [Indexed: 12/04/2022] Open
Abstract
We report the rare case of a 2.5 cm in size mass diagnostic for residual thymus associated with venous vascular malformation (ISSVA classification, 2008) in a 58 years old man. Diagnosis was obtained only after surgical removal that was complicated by a sudden massive bleeding (about 1,500 cc) requiring emergency conversion to median sternotomy. Difficulty in preoperative diagnosis, rarity of histologic pattern, and surgical challenges make this case very interesting for surgeons, pathologists and radiologist. Our message, dealing with mediastinal masses, is: (a) differential diagnosis between the more frequent solid antero-superior mediastinal tumors and vascular malformation should be always considered (b) preoperative angiography should always be performed in case of uncertain diagnosis (c) coil embolization should always be considered to reduce potentially fatal bleeding (d) histologic differentiation with other thymic neoplasms must be always considered.
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Affiliation(s)
- Federico Raveglia
- Department of Thoracic Surgery, Aziende Socio Sanitarie Territoriali-Monza, Monza, Italy
| | - Laura Moneghini
- Department of Pathology, Aziende Socio Sanitarie Territoriali Santi Paolo e Carlo, Milano, Italy
| | - Maurizio Cariati
- Department of Radiology, Aziende Socio Sanitarie Territoriali Santi Paolo e Carlo, Milano, Italy
| | - Alessandro Baisi
- Department of Thoracic Surgery, Aziende Socio Sanitarie Territoriali Santi Paolo e Carlo, Milano, Italy
| | | | - Ugo Cioffi
- Department of Thoracic Surgery, Aziende Socio Sanitarie Territoriali Santi Paolo e Carlo, Milano, Italy
| | - Marco Scarci
- Department of Thoracic Surgery, Aziende Socio Sanitarie Territoriali-Monza, Monza, Italy
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Pal S, Nicholson F, Boet R, Laing A, Collecutt W, Lim A, Hitos K. Multimodality treatment of intracranial arteriovenous malformations in South Island, New Zealand. J Clin Neurosci 2020; 73:74-79. [PMID: 32063451 DOI: 10.1016/j.jocn.2020.01.035] [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: 10/10/2019] [Accepted: 01/06/2020] [Indexed: 11/18/2022]
Abstract
Treatment of intracranial arteriovenous malformations is complex and multidisciplinary. This article presents the treatment model utilized in Christchurch, New Zealand which provides cerebrovascular surgery and interventional neuroradiology to the entire south island (approximate population of 1.1 million). A total of 40 patients treated over a 10 year period (2004-2014) are analysed here. Nine patients were managed surgically and complete resection was achieved in 100% of cases. Permanent mortality was 0% and permanent morbidity was 22% however median mRS improved from 3.0 preoperatively to 1.0 at follow up. Embolisation was utilized in 31 patients (mean age 40), of which 45% presented with haemorrhage, 39% with seizures, 10% with a headache only, and 6% with a deficit. None were found incidentally. The Spetzler-Martin grade 1 cases accounted for 10% of the cohort, 23% were grade II, 42% grade III, 23% grade IV and 3% grade V. A single aneurysm was present in 42% of cases, and multiple in 13%. The nidus was obliterated in 9.6% of cases with a morbidity rate of 6.5% and mortality rate of 3%. Modified Rankin scale improved marginally from 0.9 at diagnosis to 0.88 at final follow up (mean 22 months). There were no cases of recanalization. The total nidus obliteration rate using our algorithm of surgery alone for small accessible lesions, then staged embolization for larger lesions with adjuvant radiosurgery reserved for cases with residual nidus, was 50%.
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Affiliation(s)
- S Pal
- Department of Neurosurgery, Christchurch Hospital, 2 Riccarton Avenue, Christchurch 8011, New Zealand.
| | - F Nicholson
- University of Aberdeen, Scotland, United Kingdom
| | - R Boet
- Department of Neurosurgery, Christchurch Hospital, 2 Riccarton Avenue, Christchurch 8011, New Zealand
| | - A Laing
- Department of Radiology, Christchurch Hospital, Christchurch, New Zealand
| | - W Collecutt
- Department of Radiology, Christchurch Hospital, Christchurch, New Zealand
| | - A Lim
- Department of Radiology, Christchurch Hospital, Christchurch, New Zealand
| | - K Hitos
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; Department of Surgery, Westmead Hospital, Westmead, NSW, Australia
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17
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O'Neill BE, Uluc K, Wood MD, Jaboin J, Cetas JS, Ciporen J, Dogan A. Arteriovenous Malformation Presenting as Symptomatic, Enlarging and Contrast-Enhancing Mass 12 Years After Being Treated with Embolization and Radiotherapy. World Neurosurg 2019; 134:45-49. [PMID: 31629146 DOI: 10.1016/j.wneu.2019.10.055] [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: 08/19/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Gross total resection of arteriovenous malformations (AVMs) of the central nervous system confirmed by formal angiography is accepted as a cure for patients. In some cases, this may not be possible. Even though in these cases other treatment modalities such as endovascular embolization and radiotherapy can be used, long-term follow-up is lacking in the literature. CASE DESCRIPTION Here we report a case of a 57-year-old woman with history of a right-sided parieto-occipital/periatrial AVM, initially treated with a combination of endovascular embolization and radiotherapy. CONCLUSIONS The patient subsequently presented (12 years later) with a symptomatic, enlarging, contrast-enhancing mass at the same location that was angiographically occult but ultimately proven to be an AVM on a background of reactive changes on pathology.
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Affiliation(s)
- Brannan E O'Neill
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Kutluay Uluc
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Matthew D Wood
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jerry Jaboin
- Department of Radiation-Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Justin S Cetas
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Jeremy Ciporen
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Aclan Dogan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.
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18
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Zaki Ghali MG, Kan P, Britz GW. Curative Embolization of Arteriovenous Malformations. World Neurosurg 2019; 129:467-486. [DOI: 10.1016/j.wneu.2019.01.166] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
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19
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Fahed R, Darsaut TE, Mounayer C, Chapot R, Piotin M, Blanc R, Mendes Pereira V, Abud DG, Iancu D, Weill A, Roy D, Nico L, Nolet S, Gevry G, Raymond J. Transvenous Approach for the Treatment of cerebral Arteriovenous Malformations (TATAM): Study protocol of a randomised controlled trial. Interv Neuroradiol 2019; 25:305-309. [PMID: 30843441 PMCID: PMC6547200 DOI: 10.1177/1591019918821738] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 12/05/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Transvenous embolisation is a promising technique but the benefits remain uncertain. We hypothesised that transvenous embolisation leads to a higher rate of arteriovenous malformation angiographic occlusion than transarterial embolisation. METHODS The Transvenous Approach for the Treatment of cerebral Arteriovenous Malformations (TATAM) is an investigator initiated, multicentre, prospective, phase 2, randomised controlled clinical trial. To test the hypothesis that transvenous embolisation is superior to transarterial embolisation for arteriovenous malformation obliteration, 76 patients with arteriovenous malformations considered curable by up to two sessions of endovascular therapy will be randomly allocated 1:1 to treatment with either transvenous embolisation (with or without transarterial embolisation) (experimental arm) or transarterial embolisation alone (control arm). The primary endpoint of the trial is complete arteriovenous malformation occlusion, assessed by catheter cerebral angiography. Complete occlusions will be confirmed at 3 months, while incompletely occluded arteriovenous malformations, considered treatment failures, will then be eligible for complementary treatments by surgery, radiation therapy, or even transvenous embolisation. Standard procedural safety outcomes will also be assessed. Patient selection will be validated by a case selection committee, and participating centres with limited experience in transvenous embolisation will be proctored. DISCUSSION The TATAM trial is a transparent research framework designed to offer a promising but still unvalidated treatment to selected arteriovenous malformation patients. Clinical Trial Registration-URL: http://www.clinicaltrials.gov . Unique identifier: NCT03691870.
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Affiliation(s)
- Robert Fahed
- Department of Interventional
Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Tim E Darsaut
- Department of Surgery, University of
Alberta Hospital, Edmonton, Canada
| | - Charbel Mounayer
- Service de Neuroradiologie, CHU
Dupuytren, Service de Neuroradiologie, Limoges, France
| | - René Chapot
- Department of Neuroradiology,
Alfried-Krupp Krankenhaus Hospital, Essen, Germany
| | - Michel Piotin
- Department of Interventional
Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Raphaël Blanc
- Department of Interventional
Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | | | - Daniel G Abud
- Division of Interventional
Neuroradiology, Medical School of Ribeirão Preto, University of São Paulo,
Brazil
| | - Dana Iancu
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Alain Weill
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Daniel Roy
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Lorena Nico
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
| | - Suzanne Nolet
- Interventional Neuroradiology
Laboratory, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal,
Canada
| | - Guylaine Gevry
- Interventional Neuroradiology
Laboratory, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal,
Canada
| | - Jean Raymond
- Department of Radiology, Centre
Hospitalier de l’Université de Montréal (CHUM), Montreal, Canada
- Interventional Neuroradiology
Laboratory, Centre Hospitalier de l’Université de Montréal (CHUM), Montreal,
Canada
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20
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Embolization of brain arteriovenous malformations with the diluted Onyx technique: initial experience. Neuroradiology 2019; 61:471-478. [PMID: 30712140 DOI: 10.1007/s00234-019-02176-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Insufficient nidus occlusion is a matter of great concern to routine Onyx embolization of brain arteriovenous malformations (AVMs). This paper described an efficient method which using the diluted Onyx embolization technique to treat brain AVM. METHODS The diluted Onyx technique was performed in a series of 15 patients with brain AVMs (10 males, 5 females; age range, 11-44 years). It consists of initial embolization with routine Onyx-18, followed by the diluted Onyx (1.5 mL of Onyx-18 diluted with 0.5 mL of DMSO) through the same microcatheter. The technical skills and angiographic and clinical outcomes were analyzed. RESULTS A total of 15 embolization sessions were performed with diluted Onyx via 16 arterial feeders in these 15 patients. Each patient underwent one attempt of diluted Onyx through a single feeder except one patient. In this patient, the AVM was simultaneously embolized with diluted Onyx through double microcatheters which were placed in two feeders. When the length of reflux reached to 2 cm (or close to the determined length) and the embolic material could not move distally any more despite some rounds of "injection-reflux-waiting," regular Onyx 18 was changed to diluted Onyx. Antegrade flow of embolic material into the nidus was observed in 12 cases but failed in 3. An average of 90% (range 55-100%) estimated size reduction was achieved, and 6 AVMs were completely obliterated. No functionally relevant complications occurred. CONCLUSION The diluted Onyx technique could be a useful adjunct to routine Onyx embolization which may offer more embolic material penetrating into the nidus of AVM, but additional work is needed to validate this technique.
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21
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Fox BR, Robinson JK, Venbrux AC. The Use of Interventional Endovascular Techniques Immediately Before Hysterectomy for a Large Uterine Arteriovenous Malformation. J Gynecol Surg 2018. [DOI: 10.1089/gyn.2017.0144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Bradley R. Fox
- George Washington University School of Medicine, Washington, DC
| | - James K. Robinson
- Department of Minimally Invasive Gynecologic Surgery, MedStar Health, Washington, DC
| | - Anthony C. Venbrux
- Department of Radiology, George Washington University School of Medicine, Washington, DC
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22
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Jin H, Huo X, Jiang Y, Li X, Li Y. Safety and efficacy of endovascular therapy and gamma knife surgery for brain arteriovenous malformations in China: Study protocol for an observational clinical trial. Contemp Clin Trials Commun 2018; 7:103-108. [PMID: 29696173 PMCID: PMC5898568 DOI: 10.1016/j.conctc.2017.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/09/2017] [Accepted: 06/20/2017] [Indexed: 11/08/2022] Open
Abstract
Introduction Brain arteriovenous malformations (BAVMs) are associated with high morbidity and mortality. The treatment of BAVM remains controversial. Microinvasive treatment, including endovascular therapy and gamma knife surgery, has been the first choice in many conditions. However, the overall clinical outcome of microinvasive treatment remains unknown and a prospective trial is needed. Methods This is a prospective, non-randomized, and multicenter observational registry clinical trial to evaluate the safety and efficacy of microinvasive treatment for BAVMs. The study will require up to 400 patients in approximately 12 or more centers in China, followed for 2 years. Main subjects of this study are BAVM patients underwent endovascular therapy and/or gamma knife surgery. The trial will not affect the choice of treatment modality. The primary outcomes are perioperative complications (safety), and postoperative hemorrhage incidence rate and complete occlusion rate (efficacy). Secondary outcomes are elimination of hemorrhage risk factors (coexisting aneurysms and arteriovenous fistula), volume reduction and remission of symptoms. Safety and efficacy of endovascular therapy, gamma knife surgery, and various combination modes of the two modalities will be compared. Operative complications and outcomes at pretreatment, post-treatment, at discharge and at 3 months, 6 months and 2 years follow-up intervals will be analyzed using the modified Rankin Scale (mRS). Discussion The most confusion on BAVM treatment is whether to choose interventional therapy or medical therapy, and the choice of interventional therapy modes. This study will provide evidence for evaluating the safety and efficacy of microinvasive treatment in China, to characterize the microinvasive treatment strategy for BAVMs.
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Key Words
- BAVMs, Brain arteriovenous malformations
- Brain arteriovenous malformation
- CRF, Case report form
- CT, Computed tomography
- ChiCTR, Chinese Clinical Trial Registry
- Clinical trial
- Efficacy
- Endovascular therapy
- FDA, Food and Drug Administration
- Gamma knife
- ICH, Intracerebral hemorrhage
- PRC, People's Republic of China
- REAL-CHINA, Registry of endovascular therapy and Gamma knife surgery for brain Arteriovenous Malformation in China
- SAE, Serious adverse event
- SM, Spetzler Martin grade
- SPIRIT, Recommendations for Interventional Trials
- Safety
- mRS, modified Ranking Scale
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Affiliation(s)
- Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, 100050, Beijing, China.,Beijing Engineering Research Center for Interventional Neuroradiology, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, 100050, Beijing, China
| | - Yuhua Jiang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, 100050, Beijing, China.,Beijing Engineering Research Center for Interventional Neuroradiology, China
| | - Xiaolong Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, 100050, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.6, Tiantan Xili, Dongcheng, 100050, Beijing, China.,Beijing Engineering Research Center for Interventional Neuroradiology, China
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23
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Peres CMA, Souza ECD, Teixeira MJ, Figueiredo EG, Caldas JGM. Impact of Associated Nidal Lesions in Outcome of Brain Arteriovenous Malformations After Radiosurgery with or without Embolization. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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24
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Sackey FNA, Pinsker NR, Baako BN. Highlights on Cerebral Arteriovenous Malformation Treatment Using Combined Embolization and Stereotactic Radiosurgery: Why Outcomes are Controversial? Cureus 2017; 9:e1266. [PMID: 28652950 PMCID: PMC5481174 DOI: 10.7759/cureus.1266] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 05/22/2017] [Indexed: 11/05/2022] Open
Abstract
Cerebral arteriovenous malformations (AVMs) are abnormal tangling between brain arteries and veins causing an arteriovenous shunt called nidus with an intervening network of vessels from the region of formation and spans through the brain. AVM effect is debilitating to the affected individual due to associated persistent intracerebral hemorrhage, resulting in significant occurrences of seizures and neurological damage. Recent innovative treatments involve a combination of embolization (Embo) procedures followed by stereotactic radiosurgery (SRS), designed to optimize less-invasive practice for the obliteration of the AVMs. Three groups of investigators reported different outcomes based on obliteration rates and adverse events, making the effectiveness of options for therapy, controversial. We have taken the case-oriented-approach to highlight on varying outcomes from various studies and provide insights as to why findings from different operation settings could be so conflicting. We chose 18 articles for systematic analysis based on initial electronic database selection of 40 key papers already identified for inclusion, followed by independent blinding assessment by two co-authors. Our evaluation was based first on our specific inclusion criteria, examining method quality, obliteration rates, serious adverse events (SAEs) and mortality rates. Second, we made a comparison between SRS or embo alone treatments versus combined embo/SRS procedures, relative to AVM sizes, following Spetzler-Martin (SM) method. Third, we considered publications which had concrete statistics with well-defined P-values and clarified outcomes for accurate evaluation. We found that patients with small to medium-sized AVM were susceptible to either embo alone or SRS alone treatments, yielding obliteration rates from 71%-100%. Except for one report, giant sizes AVMs were not amenable to these single treatments, subjecting patients to embo/SRS procedures, which yielded mixed results: One group reported 52%-65% obliteration rates, compared to 23%-28% embo alone treatment. A second group contradicted this apparent beneficial outcome, obtaining obliteration rates of 53% with combined treatment compared to 71% with SRS alone, four-year postoperative. A third group reported there was no difference between single and combined treatments and obtained complete obliteration of 70%-82%, ranging from three-five-years postoperative follow-up. In all the cases analyzed, obliteration rates improved with time. SAEs, such as persistent hemorrhage and permanent neurologic deficits (P-NDs), as well as mortality, were minimal during intraoperative and postoperative follow-ups. The problem of conflicting outcomes in combined treatments of AVM by EMBO/SRS exists. Previous investigators, however, have overlooked to address this issue satisfactorily. Our analysis found that the reported inconsistencies in AVM treatment outcomes are attributable to key factors making therapy unpredictable, which includes: the size of the AVM, nidus localization and accessibility of either Embo or radiation dose applied, certain Embo materials lowering obliteration rates by masking radioactive effect on the nidus during SRS and follow-up timing for obtaining obliteration rates determine the extent of obliteration. We have indicated critical factors which require consideration when planning strategies for treatment of AVM patients and have made suggestions of how to overcome such hurdles.
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Affiliation(s)
- Faustina N A Sackey
- Loeb Health Research Institute at Ottawa Hospital, University of Ottawa, Ontario, Canada
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25
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Luksik AS, Law J, Yang W, Garzon-Muvdi T, Caplan JM, Colby G, Coon AL, Tamargo RJ, Huang J. Assessing the Role of Preoperative Embolization in the Surgical Management of Cerebral Arteriovenous Malformations. World Neurosurg 2017; 104:430-441. [PMID: 28512050 DOI: 10.1016/j.wneu.2017.05.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/01/2017] [Accepted: 05/04/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Preoperative embolization is established as an advantageous adjunct in multimodality treatment of cerebral arteriovenous malformations (AVMs). However, the benefit of preoperative embolization in AVMs with favorable surgical risk profile is debatable, because it has yet to be supported by evidence in comparative studies. In this study, we assessed outcome of surgically treated patients in a comparative setting. METHODS Our institutional AVM database of retrospectively and prospectively collected data between 1990 and 2015 was reviewed. Patients with complete clinical data who underwent surgical resection for AVMs were included. We performed a 1:1 ratio propensity score match for baseline variables that differed between patients with or without preoperative embolization. Differences in surgical risk and outcomes were evaluated between these 2 groups. RESULTS AVM size, eloquence, deep drainage, middle cerebral artery feeder, and ruptured presentation differed significantly between the 2 groups. Forty-eight patients without preoperative embolization were matched to 48 with embolization, with no significant differences in baseline variables or AVM characteristics between the 2 groups. We found no significant differences in AVM obliteration and postoperative modified Rankin Scale (mRS) score between embolized and nonembolized patients, respectively. Change in mRS score from preoperative score was also not significant, although more embolized patients had a decline in mRS score. Secondary outcome measures including duration of surgery (P = 0.172), intraoperative bleeding (P = 0.280), duration of hospitalization (P = 0.368), and postoperative symptoms were also similar between both groups. CONCLUSIONS Our data do not support substantial benefit of preoperative embolization for patients with a favorable surgical risk profile. Because of risks and costs with this intervention, the prudent use of preoperative embolization should be individually considered.
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Affiliation(s)
- Andrew S Luksik
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jody Law
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tomas Garzon-Muvdi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Geoffrey Colby
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Microsurgery for intracranial arteriovenous malformation: Long-term outcomes in 445 patients. PLoS One 2017; 12:e0174325. [PMID: 28323878 PMCID: PMC5360342 DOI: 10.1371/journal.pone.0174325] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 03/07/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The management of intracranial arteriovenous malformations(AVMs) poses challenges to the cerebrovascular specialists. OBJECTIVE To review the long-term outcomes of intracranial AVMs treated with microsurgical resections. METHODS We performed a retrospective review of 445 patients with intracranial AVMs treated in our hospital from January 1st, 2008 to December 31st, 2014. The extracted data included demographic characteristics, clinical presentations, Spetzler-Martin (SM) grades, Supplemented Spetzler-Martin (SM-Supp) Grades, treatment modalities, long-term outcomes, and obliteration rates. Outcome was assessed with a post-operative modified Rankin Scale (mRS) score at the last follow-up visit. RESULTS Of the 445 patients treated with microsurgery, 298 (67.0%) patients initially presented with hemorrhage. Based on the SM grading system, the patients were graded as follows: 83(18.6%) Grade I, 156(35.1%) Grade II, 132(29.7%) Grade III, 61(13.7%) Grade IV and 13(2.9%) Grade V. Overall, 344(77.3%) patients had a favorable outcome (mRS score of 0-2). The favorable outcome for Grade I and II were 92.8% and 85.9%, respectively, sharply reducing to 52.5% in patients with Grade IV and 15.4% in patients with Grade V AVMs. 388(87.2%) patients achieved complete obliteration of the AVMs. 63(14.2%) patients experienced recurrent hemorrhage, and the frequency of rehemorrhage was highest in Grade V patients (77.0%), dropping to 3.6% and 3.8% in patients with Grade I and II lesions, respectively. Permanent neurological deficits occurred in 66(14.8%) patients and death in 35(7.9%) patients. There was no difference of AUROC values between SM grading system and SM-supp grading system (0.726 and 0.734, respectively, p = .715). CONCLUSION The Spetzler-Martin grading system is a simple and effective method to estimate the risk of surgery and to evaluate the prognosis. Microsurgical resection for AVMs depends on the SM grades, and the morbidity-mortality rate increases with an increasing SM grade.
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27
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Guo WY, Lee CCJ, Lin CJ, Yang HC, Wu HM, Wu CC, Chung WY, Liu KD. Quantifying the Cerebral Hemodynamics of Dural Arteriovenous Fistula in Transverse Sigmoid Sinus Complicated by Sinus Stenosis: A Retrospective Cohort Study. AJNR Am J Neuroradiol 2017; 38:132-138. [PMID: 27765737 DOI: 10.3174/ajnr.a4960] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/18/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Sinus stenosis occasionally occurs in dural arteriovenous fistulas. Sinus stenosis impedes venous outflow and aggravates intracranial hypertension by reversing cortical venous drainage. This study aimed to analyze the likelihood of sinus stenosis and its impact on cerebral hemodynamics of various types of dural arteriovenous fistulas. MATERIALS AND METHODS Forty-three cases of dural arteriovenous fistula in the transverse-sigmoid sinus were reviewed and divided into 3 groups: Cognard type I, type IIa, and types with cortical venous drainage. Sinus stenosis and the double peak sign (occurrence of 2 peaks in the time-density curve of the ipsilateral drainage of the internal jugular vein) in dural arteriovenous fistula were evaluated. "TTP" was defined as the time at which a selected angiographic point reached maximum concentration. TTP of the vein of Labbé, TTP of the ipsilateral normal transverse sinus, trans-fistula time, and trans-stenotic time were compared across the 3 groups. RESULTS Thirty-six percent of type I, 100% of type IIa, and 84% of types with cortical venous drainage had sinus stenosis. All sinus stenosis cases demonstrated loss of the double peak sign that occurs in dural arteriovenous fistula. Trans-fistula time (2.09 seconds) and trans-stenotic time (0.67 seconds) in types with cortical venous drainage were the most prolonged, followed by those in type IIa and type I. TTP of the vein of Labbé was significantly shorter in types with cortical venous drainage. Six patients with types with cortical venous drainage underwent venoplasty and stent placement, and 4 were downgraded to type IIa. CONCLUSIONS Sinus stenosis indicated dysfunction of venous drainage and is more often encountered in dural arteriovenous fistula with more aggressive types. Venoplasty ameliorates cortical venous drainage in dural arteriovenous fistulas and serves as a bridge treatment to stereotactic radiosurgery in most cases.
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Affiliation(s)
- W-Y Guo
- From the Department of Radiology (W.-Y.G., C.-J.L., H.-M.W., C.-C.W.)
- School of Medicine (W.-Y.G., C.-C.J.L., C.-J.L., H.-C.Y., H.-M.W., C.-C.W., W.-Y.C., K.-D.L.), National Yang-Ming University, Taipei, Taiwan
| | - C-C J Lee
- Department of Neurosurgery (C.-C.J.L., H.-C.Y., W.-Y.C., K.-D.L.), Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine (W.-Y.G., C.-C.J.L., C.-J.L., H.-C.Y., H.-M.W., C.-C.W., W.-Y.C., K.-D.L.), National Yang-Ming University, Taipei, Taiwan
| | - C-J Lin
- From the Department of Radiology (W.-Y.G., C.-J.L., H.-M.W., C.-C.W.)
- School of Medicine (W.-Y.G., C.-C.J.L., C.-J.L., H.-C.Y., H.-M.W., C.-C.W., W.-Y.C., K.-D.L.), National Yang-Ming University, Taipei, Taiwan
| | - H-C Yang
- Department of Neurosurgery (C.-C.J.L., H.-C.Y., W.-Y.C., K.-D.L.), Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine (W.-Y.G., C.-C.J.L., C.-J.L., H.-C.Y., H.-M.W., C.-C.W., W.-Y.C., K.-D.L.), National Yang-Ming University, Taipei, Taiwan
| | - H-M Wu
- From the Department of Radiology (W.-Y.G., C.-J.L., H.-M.W., C.-C.W.)
- School of Medicine (W.-Y.G., C.-C.J.L., C.-J.L., H.-C.Y., H.-M.W., C.-C.W., W.-Y.C., K.-D.L.), National Yang-Ming University, Taipei, Taiwan
| | - C-C Wu
- From the Department of Radiology (W.-Y.G., C.-J.L., H.-M.W., C.-C.W.)
- School of Medicine (W.-Y.G., C.-C.J.L., C.-J.L., H.-C.Y., H.-M.W., C.-C.W., W.-Y.C., K.-D.L.), National Yang-Ming University, Taipei, Taiwan
| | - W-Y Chung
- Department of Neurosurgery (C.-C.J.L., H.-C.Y., W.-Y.C., K.-D.L.), Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine (W.-Y.G., C.-C.J.L., C.-J.L., H.-C.Y., H.-M.W., C.-C.W., W.-Y.C., K.-D.L.), National Yang-Ming University, Taipei, Taiwan
| | - K-D Liu
- Department of Neurosurgery (C.-C.J.L., H.-C.Y., W.-Y.C., K.-D.L.), Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine (W.-Y.G., C.-C.J.L., C.-J.L., H.-C.Y., H.-M.W., C.-C.W., W.-Y.C., K.-D.L.), National Yang-Ming University, Taipei, Taiwan
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Lo Buono V, Bonanno L, Corallo F, Sidoti A, Bramanti P, Marino S. Evaluation of Qualitative Outcomes after Surgical Intervention on Patients Affected by Arteriovenous Malformations. J Stroke Cerebrovasc Dis 2016; 25:2947-2952. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 07/25/2016] [Accepted: 08/07/2016] [Indexed: 10/21/2022] Open
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Gupta R, Adeeb N, Moore JM, Motiei-Langroudi R, Griessenauer CJ, Patel AS, Ogilvy CS, Thomas AJ. Validity assessment of grading scales predicting complications from embolization of cerebral arteriovenous malformations. Clin Neurol Neurosurg 2016; 151:102-107. [PMID: 27821297 DOI: 10.1016/j.clineuro.2016.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 10/27/2016] [Accepted: 10/28/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Endovascular embolization, though initially approved as an adjunctive therapy for surgical excision of cerebral arteriovenous malformations (AVMs), has found extensive use in the management of these lesions. A number of systems have been proposed to stratify AVMs by the procedural risk of embolization, including the Buffalo score and AVM Neuroendovascular grade. An external validity assessment of these systems has not been performed. PATIENTS AND METHODS A retrospective review of all patients who underwent embolization of cerebral AVMs at a single institution, between 2010 and 2016, was performed. Data including patient demographics, AVM characteristics, procedural details, complications, and outcomes were collected. RESULTS Fifty-five embolization procedures in 39 patients (median age 53.1 years) were identified. Ten (25.6%) patients underwent more than 1 embolization procedure. A triaxial catheter system for support was used in 48 (87.3%) of the embolization procedures and a detachable tip microcatheter was used in 28 (50.9%). Complete obliteration of the AVM was achieved in 10.9% of the cases. There was one (2.6%) mortality unrelated to the procedure. Three minor (5.5%) and 2 major (3.6%) clinical complications occurred. Neither Spetzler-Martin grade, Buffalo score, or AVM Neuroendovascular grade correlated with complications. CONCLUSION Neither Buffalo score nor AVM Neuroendovascular grade predicted complications from embolization in the present study. Given the relative infrequency of complications, the number of factors that may influence AVM treatment, recent advancements in endovascular technologies, and the subjectivity inherent in these grading systems, the relative utility of risk stratification scales in the embolization of AVMs remains largely unknown.
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Affiliation(s)
- Raghav Gupta
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Nimer Adeeb
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Justin M Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Rouzbeh Motiei-Langroudi
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Christoph J Griessenauer
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Apar S Patel
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Ajith J Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
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Hashim H, Muda AS, Abdul Aziz A, Abdul Hamid Z. Onyx in Brain Arteriovenous Malformation Embolisation. Malays J Med Sci 2016; 23:59-64. [PMID: 27660546 DOI: 10.21315/mjms2016.23.4.8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/09/2016] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Embolisation has long been used as an adjunct to surgical resection in the treatment of brain arteriovenous malformation (bAVM). The most commonly used embolic material, n-butylcyanoacrylate glue, requires experience and skill to handle its quick and unpredictable flow and polymerisation. A new liquid embolic agent, ethylene vinyl alcohol copolymer (Onyx), is less adhesive and polymerises slowly, which provides better control for radiologists performing embolisation. OBJECTIVE To report our experience in embolisation using Onyx alone or in combination with histoacryl for bAVM embolisation in our tertiary referral centre. METHODS We retrospectively reviewed the anatomy, technical conditions, complications and clinical outcome of all bAVM patients embolised at our centre using Onyx alone or in combination with n-butylcyanoacrylate glue. RESULTS Between 2010 and 2013, 13 patients [6 (46.2%) male; 7 (53.8%) female; aged, 14-57 years] were included, and a total of 31 embolisations were performed. Clinical presentation included hemorrhage [9 (69.2%)], seizures [2 (15.4%)], and headache [2 (15.4%)]. Most AVMs were located in the brain hemispheres [12 (92.3%)] and measured <3 cm [7 (53.8%]. Complete occlusion of the AVM was obtained in 2 (15.4%) patients; 11 (84.6%) patients had partial occlusion [6 (54.5%) had <50% nidus occlusion]. Complications occurred in four procedures involving 3 patients (morbidity, 23.1%). This resulted in the death of 1 patient (mortality, 7.7%) and complete recovery with no disability in 2 patients. CONCLUSION The total nidal occlusion achieved herein is comparable to other similar studies. Our morbidity and mortality were higher compared to other studies which may be attributed to the small number of patients. More data is being collected which may better reflect on our experience.
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Affiliation(s)
- Hilwati Hashim
- Imaging Unit, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia
| | - A Sobri Muda
- Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - Aida Abdul Aziz
- Department of Radiology, Hospital Sungai Buloh, Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia
| | - Zuhanis Abdul Hamid
- Department of Radiology, Institut Kanser Negara, Jalan P7, Presint 7, 62250 Putrajaya, Malaysia
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[Treatment of brain AVMS (TOBAS): A randomized controlled trial and registry]. Neurochirurgie 2016; 62:197-202. [PMID: 27236732 DOI: 10.1016/j.neuchi.2015.12.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 11/23/2015] [Accepted: 12/29/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The management of unruptured and ruptured brain arteriovenous malformations (AVMs) remains controversial. The Treatment of Brain AVM Study (TOBAS) was designed to assess curative treatments in the management of AVMs. The purpose of our study is to provide a care trial context to brain AVM patients. METHODS TOBAS is a pragmatic, prospective study including 2 randomized controlled trials and a registry. All AVM patients can be recruited. The preferred management modality will be predetermined prior to randomization by the team based on clinical judgment. Patients eligible for both conservative and interventional management will be randomly allocated conservative or curative treatment. Randomization will be stratified by a treatment modality (surgery, radiosurgery or embolization) and minimized according to a history of previous rupture and Spetzler-Martin grade. A second randomization will allocate eligible patients to embolization/no embolization prior to surgery or radiosurgery. The primary outcome of the study is death (any cause) or disabling stroke (mRS>2) at 10 years. All patients managed according to clinical judgment alone will be included in the registry. The study is registered under: wwwTrials.gov, ID: NCT02098252. EXPECTED RESULTS A minimum recruitment of 540 patients is required to show that treatment can reduce the primary outcome by 10 % (from 25 to 15 %); 440 patients will be needed to show a 10 % increase in angiographic occlusion for a good clinical outcome with pre-embolization. CONCLUSION The trial is designed to offer optimal and verifiable care to patients with brain AVMs in spite of the uncertainty. We are currently seeking the participation of multiple centers.
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Darsaut TE, Magro E, Gentric JC, Batista AL, Chaalala C, Roberge D, Bojanowski MW, Weill A, Roy D, Raymond J. Treatment of Brain AVMs (TOBAS): study protocol for a pragmatic randomized controlled trial. Trials 2015; 16:497. [PMID: 26530856 PMCID: PMC4632683 DOI: 10.1186/s13063-015-1019-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 10/20/2015] [Indexed: 12/13/2022] Open
Abstract
Background The management of unruptured brain arteriovenous malformation (AVM) patients remains controversial. Furthermore, curative attempts to treat ruptured AVM patients have not been questioned so far, and there is a lack of prospective data on clinical results according to treatment modality. Endovascular treatment is often used aiming to improve the safety or efficacy of surgery or radiation therapy, but benefits have never been documented in a trial. A care trial context is needed to evaluate interventions at the same time they are practised. Methods/Trial design TOBAS is a pragmatic, prospective, multicenter, randomized, controlled trial and registry which offers a care trial context for brain AVM patients, including surgical resection, radiosurgery or endovascular embolization, alone or combined. The study includes two RCTs and a multimodality prospective registry. The objectives of the proposed study are to assess whether preventive interventions (surgery, embolization, radiation therapy, alone or combined), selected by the local treatment team and performed as locally practiced, randomly allocated and compared with conservative management, in unruptured brain AVM patients eligible for active or conservative management, can improve the proportion of patients having an independent outcome (modified Rankin Scale (mRS) < 3, as assessed by a standardized questionnaire administered by non-masked care personnel) at 10 years. All patients judged ineligible for randomized allocation are to be entered in a multimodal registry. The objective of a nested trial in patients with ruptured or unruptured AVMs to be treated by surgery or radiation therapy, is to assess whether pre-surgical or pre-radiation embolization, randomly allocated and compared with no embolization, can improve the proportion of patients with complete eradication of the AVM, as locally adjudicated, combined with a good clinical outcome (mRS < 3). The study will require up to 2000 patients in approximately 30 centers or more, followed for 10 years. TOBAS is registered at clinicaltrials.gov: NCT02098252 as of 25 March 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1019-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tim E Darsaut
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Center, Edmonton, AB, Canada.
| | - Elsa Magro
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, QC, Canada. .,Service de Neurochirurgie, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest, France.
| | - Jean-Christophe Gentric
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada. .,Service de Radiologie, CHU Cavale Blanche, EA 3878 GETBO, Brest, France.
| | - André Lima Batista
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada.
| | - Chiraz Chaalala
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, QC, Canada.
| | - David Roberge
- Department of Radio-Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, QC, Canada.
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, QC, Canada.
| | - Alain Weill
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada.
| | - Daniel Roy
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada.
| | - Jean Raymond
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada.
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Abstract
An arteriovenous malformation is a tangle of dysplastic vessels (nidus) fed by arteries and drained by veins without intervening capillaries, forming a high-flow, low-resistance shunt between the arterial and venous systems. Arteriovenous malformations in the brain have a low estimated prevalence but are an important cause of intracerebral haemorrhage in young adults. For previously unruptured malformations, bleeding rates are approximately 1% per year. Once ruptured, the subsequent risk increases fivefold, depending on associated aneurysms, deep locations, deep drainage and increasing age. Recent findings from novel animal models and genetic studies suggest that arteriovenous malformations, which were long considered congenital, arise from aberrant vasculogenesis, genetic mutations and/or angiogenesis after injury. The phenotypical characteristics of arteriovenous malformations differ among age groups, with fistulous lesions in children and nidal lesions in adults. Diagnosis mainly involves imaging techniques, including CT, MRI and angiography. Management includes observation, microsurgical resection, endovascular embolization and stereotactic radiosurgery, alone or in any combination. There is little consensus on how to manage patients with unruptured malformations; recent studies have shown that patients managed medically fared better than those with intervention at short-term follow-up. By contrast, interventional treatment is preferred following a ruptured malformation to prevent rehaemorrhage. Management continues to evolve as new mechanistic discoveries and reliable animal models raise the possibility of developing drugs that might prevent the formation of arteriovenous malformations, induce obliteration and/or stabilize vessels to reduce rupture risk. For an illustrated summary of this Primer, visit: http://go.nature.com/TMoAdn.
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Labby ZE, Chaudhary N, Gemmete JJ, Pandey AS, Roberts DA. Dosimetric measurements of an n
-butyl cyanoacrylate embolization material for arteriovenous malformations. Med Phys 2015; 42:1739-44. [DOI: 10.1118/1.4915080] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Brain AVMs: an endovascular, surgical, and radiosurgical update. ScientificWorldJournal 2014; 2014:834931. [PMID: 25401156 PMCID: PMC4221901 DOI: 10.1155/2014/834931] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 08/01/2014] [Indexed: 11/17/2022] Open
Abstract
Brain arteriovenous malformations (bAVMs) are complex vascular lesions. Despite multiple studies, several classifications, and a great interest of the scientific community, case selection in AVM patients remains challenging. During the last few years, tremendous advancements widened therapeutic options and improved outcomes spreading indications for patients harboring lesions deemed inoperable in the past. Anatomical and biological case specific features, and natural history with a focus on presenting symptoms should be evaluated case by case and always kept in mind while planning a therapeutic management for a bAVMs. A multidisciplinary approach is strongly recommended when dealing with bAVMs and should involve physicians expertise in this kind of challenging lesions. The goal of this paper is to provide a focused review of the most recent acquisitions and therapeutic strategies regarding surgical, endovascular, and radiosurgical treatment.
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Potts MB, Zumofen DW, Raz E, Nelson PK, Riina HA. Curing arteriovenous malformations using embolization. Neurosurg Focus 2014; 37:E19. [DOI: 10.3171/2014.6.focus14228] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endovascular embolization is typically reserved as an adjuvant therapy in the management of cerebral arteriovenous malformations (AVMs), either for preoperative devascularization or preradiosurgical volume reduction. Curative embolization plays a limited role in AVM treatment but several studies have shown that it is possible, especially with later-generation liquid embolic agents. Given the complexity of AVM anatomy and the recent controversies over the role of any intervention in AVM management, it is critical that the cerebrovascular community better define the indications of each treatment modality to provide quality AVM management. In this review, the authors evaluate the role of curative AVM embolization. Important considerations in the feasibility of curative AVM embolization include whether it can be performed reliably and safely, and whether it is a durable cure. Studies over the past 20 years have begun to define the anatomical factors that are amenable to complete endovascular occlusion, including size, feeding artery anatomy, AVM morphology, and endovascular accessibility. More recent studies have shown that highly selected patients with AVMs can be treated with curative intent, leading to occlusion rates as high as 100% of such prospectively identified lesions with minimal morbidity. Advances in endovascular technology and techniques that support the efficacy and safety of curative embolization are discussed, as is the importance of superselective diagnostic angiography. Finally, the durability of curative embolization is analyzed. Overall, while still unproven, endovascular embolization has the potential to be a safe, effective, and durable curative treatment for select AVMs, broadening the armamentarium with which one can treat this disease.
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Affiliation(s)
- Matthew B. Potts
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Daniel W. Zumofen
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Eytan Raz
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Peter K. Nelson
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
| | - Howard A. Riina
- 1 Departments of Neurological Surgery, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
- 2 Departments of Radiology, New York University School of Medicine, and Bernard and Irene Schwartz Neurointerventional Radiology Section, NYU Langone Medical Center, New York, New York
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Jordan JA, Llibre JC, Vazquez F, Rodríguez RM. Predictors of total obliteration in endovascular treatment of cerebral arteriovenous malformations. Neuroradiol J 2014; 27:108-14. [PMID: 24571841 DOI: 10.15274/nrj-2014-10013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 01/14/2013] [Indexed: 11/12/2022] Open
Abstract
Endovascular therapy is a therapeutic option that can achieve total obliteration of cerebral arteriovenous malformations (AVMs). The objective of this study was to determine the predictive factors of total obliteration in the endovascular treatment of AVMs. A prospective study was carried out in 71 patients with cerebral AVMs having undergone 147 embolization sessions with n-BCA, performed between 2006 and 2011. A univariate analysis was carried out, followed by a logistic regression analysis to determine the predictive factors of total obliteration. Total obliteration was achieved in 18.3% of the patients and angiographic control after 12 months showed the permanency of total occlusion in 100% of the AVMs with initial total obliteration. Angiographic characteristics found favorable for total eradication were: AVM size under 3 cm and the presence of a single arterial pedicle. Predictive factors of total obliteration were an AVM diameter smaller than 3 cm (OR: 50.9; IC: 7.41 - 349, 0; P = 0.000), and opposing factors, a 3-6 cm diameter (OR: 11.7; IC: 2.49 - 55, 4; P = 0.002) and afferences of more than two vessels of the Willis polygon (OR: 7.0; IC: 1.12-43.9; P = 0.038). An AVM diameter smaller than 3 cm is a predictive factor of total obliteration. Total postembolization obliteration persisted in 100% of the cases after 12 months.
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Affiliation(s)
- José Antonio Jordan
- Interventional Neuroradiology Unit, Stroke Unit, Institute of Neurology and Neurosurgery, CIMEQ; La Habana, Cuba -
| | - Juan Carlos Llibre
- Interventional Neuroradiology Unit, Stroke Unit, Institute of Neurology and Neurosurgery, CIMEQ; La Habana, Cuba
| | - Frank Vazquez
- Interventional Neuroradiology Unit, Stroke Unit, Institute of Neurology and Neurosurgery, CIMEQ; La Habana, Cuba
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Rubin BA, Brunswick A, Riina H, Kondziolka D. Advances in Radiosurgery for Arteriovenous Malformations of the Brain. Neurosurgery 2014; 74 Suppl 1:S50-9. [DOI: 10.1227/neu.0000000000000219] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Arteriovenous malformations of the brain are a considerable source of morbidity and mortality for patients who harbor them. Although our understanding of this disease has improved, it remains in evolution. Advances in our ability to treat these malformations and the modes by which we address them have also improved substantially. However, the variety of patient clinical and disease scenarios often leads us into challenging and complex management algorithms as we balance the risks of treatment against the natural history of the disease. The goal of this article is to provide a focused review of the natural history of cerebral arteriovenous malformations, to examine the role of stereotactic radiosurgery, to discuss the role of endovascular therapy as it relates to stereotactic radiosurgery, and to look toward future advances.
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Danielson L, Anderson J, Nykamp M, Remund T, Kelly P. Treatment of a massive left femoral arteriovenous malformation using an innovative modular hybrid bifurcated stent graft system. Ann Vasc Surg 2013; 28:1031.e15-20. [PMID: 24184461 DOI: 10.1016/j.avsg.2013.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 07/28/2013] [Accepted: 07/31/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Arteriovenous malformations (AVMs) are difficult to treat and manage because of their high recurrence and complication rates. In particular, peripheral AVMs pose multiple clinical challenges because of their high flow rates and the frequent presence of multifocal nidi. METHODS A 37-year-old man with a massive AVM involving the left common, deep, and superficial femoral arteries and veins is discussed herein. After initially being treated at another facility with coil embolization in 2005, he went untreated until he presented to us in April 2012 with swelling, tissue breakdown, leg ulcers, pain, and difficulty walking. When our extensive packed coil embolization proved ineffective, we knew that other standard treatments would be impractical, given the size of the AVM. Because the patient was in significant danger of bleeding, we treated him endovascularly with a system of modified stent grafts to exclude the arterial branches feeding multiple nidi. RESULTS Postoperative computed tomography angiography scans revealed exclusion of the AVM and excellent flow to the deep and superficial femoral arteries. At 6 months postoperatively, the patient had no complications, and the leg continued to decompress. At 8 months postoperatively, we started additional treatment using percutaneous sclerotherapy to treat residual areas. CONCLUSION A modular hybrid bifurcated stent graft system is a viable option to treat or manage complex peripheral arteriovenous malformations.
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