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Pinheiro LCP, Wolak Junior M, Ferreira MY, Magalhaes RB, Fernandes AY, Paiva WS, Zanini MA, Marchesan Rodrigues MA. Unruptured Brain Arteriovenous Malformations: A Systematic Review and Meta-Analysis of Mortality and Morbidity in Aruba-Eligible Studies. World Neurosurg 2024:S1878-8750(24)00322-X. [PMID: 38423455 DOI: 10.1016/j.wneu.2024.02.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Treating unruptured brain arteriovenous malformations (bAVMs) represent significant challenges, with numerous uncertainties still in debate. The ARUBA trial induced further investigation into optimal management strategies for these lesions. Here, we present a systematic-review and meta-analysis focusing on ARUBA-eligible studies, aiming to correlate patient data with outcomes and discuss key aspects of these studies. METHODS Following PRISMA guidelines, we conducted a systematic-review. Variables analyzed included bAVM Spetzler-Martin (SM) grade, treatment modalities, and outcomes such as mortality and neurological deficits. We compared studies with a minimum of 50% cases classified as SM 1-2 lesions and those with less than 50% in this category. Similarly, a comparison between studies with at least 50% microsurgery-cases and those with less than 50% was performed. We examined correlations between mortality incidence, SM distribution, and treatment modalities. RESULTS Our analysis included 16 studies with 2.417 patients. The frequency of bAVMs SM-grade 1-2 ranged from 44% to 76%, SM-grade 3 from 19% to 48%, and SM 4-5 from 5 to 23%. Notably, studies with more than 50% cases presenting lesions SM-grade 1-2 presented significantly lower mortality rates than those with less than 50% cases of SM 1-2 lesions (P < 0.001). No significant difference in mortality rates or neurological deficits was identified between studies with more than 50% of microsurgery-cases and those with less than 50%. CONCLUSIONS The analysis revealed that studies with a higher proportion of bAVMs presenting SM 1-2 lesions were associated with lower mortality rates. Mortality did not show a significant association with treatment modalities.
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Figueroa-Sanchez JA, Martinez HR, Avalos-Montes PJ, Arreola-Aldape CA, Guerrero JAM, Caro-Osorio E. A simple but effective solution for proximal mark absence on some microcatheters in intracranial aneurysm embolization: Technical note. Surg Neurol Int 2023; 14:257. [PMID: 37560566 PMCID: PMC10408614 DOI: 10.25259/sni_381_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/08/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Endovascular coil embolization is increasingly being used for the treatment of intracranial aneurysms and other pathologies such as arteriovenous (AV) malformations and AV fistulas. Appropriate embolization technique requires a microcatheter with two radiopaque marks, one proximal and one distal. We present an alternative coils deployment technique for intracranial aneurysms, using a microcatheter without a proximal radiopaque mark. METHODS We describe the technique for embolization that was used in a 36-year-old female patient, in which we used a microcatheter without a proximal radiopaque mark for coil embolization of an intracranial aneurysm. RESULTS We used a Headway Duo flow directed microcatheter for a coiling embolization of an intracranial aneurysm, solving the absence of the proximal radiopaque mark by cannulating the microcatheter with a Traxcess 0.014 microguidewire, and placing an external mark on the screen in the proximal portion of the microguidewire 30 mm radiopaque tip to indirectly mark the proximal mark of the microcatheter. CONCLUSION There is scarce evidence supporting the use of microcatheters with no proximal radiopaque mark for coil embolization. This report attempts to disclose how an easy and simple technique can be used as a rescue method to solve the proximal radiopaque mark absence during endovascular coil release procedures. To the best of our knowledge, this technique has not been previously described; therefore, its use is not widespread among neurointerventionists.
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Affiliation(s)
- Jose A. Figueroa-Sanchez
- Department of Medicine, Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Mexico
- Neuroscience and Neurorestoration Research Group, Instituto de Neurología y Neurocirugía, Centro Médico Zambrano Hellion TecSalud, San Pedro Garza García, Mexico
| | - Hector R. Martinez
- Department of Medicine, Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Mexico
- Neuroscience and Neurorestoration Research Group, Instituto de Neurología y Neurocirugía, Centro Médico Zambrano Hellion TecSalud, San Pedro Garza García, Mexico
| | - Pablo J. Avalos-Montes
- Neuroscience and Neurorestoration Research Group, Instituto de Neurología y Neurocirugía, Centro Médico Zambrano Hellion TecSalud, San Pedro Garza García, Mexico
| | - Carlos A. Arreola-Aldape
- Department of Medicine, Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Mexico
- Neuroscience and Neurorestoration Research Group, Instituto de Neurología y Neurocirugía, Centro Médico Zambrano Hellion TecSalud, San Pedro Garza García, Mexico
| | - Jose Alberto Moran Guerrero
- Department of Medicine, Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Mexico
- Neuroscience and Neurorestoration Research Group, Instituto de Neurología y Neurocirugía, Centro Médico Zambrano Hellion TecSalud, San Pedro Garza García, Mexico
| | - Enrique Caro-Osorio
- Department of Medicine, Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Mexico
- Neuroscience and Neurorestoration Research Group, Instituto de Neurología y Neurocirugía, Centro Médico Zambrano Hellion TecSalud, San Pedro Garza García, Mexico
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Su H, Yu J. Brain arteriovenous malformations of the middle cerebral artery region: image characteristics and endovascular treatment based on a new classification system. BMC Neurol 2023; 23:41. [PMID: 36698107 PMCID: PMC9875394 DOI: 10.1186/s12883-023-03084-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/23/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND To date, few studies have investigated the use of endovascular treatment (EVT) for brain arteriovenous malformations (BAVMs) in the supplying area of the middle cerebral artery (MCA). Moreover, no suitable classification was aimed at EVT for MCA-BAVMs. Therefore, this study proposed a new classification. METHODS This study retrospectively collected 135 MCA‑BAVMs. They were classified into four types: Type I BAVMs located above the M1 segment; Type II BAVMs located in the region around the Sylvian fissure; and Type III BAVMs located in the supplying region of the M4 segment and subdivided into types IIIa and IIIb. The relevance of various types of MCA-BAVMs and their imaging characteristics and EVT outcomes was analyzed by ordinary one-way ANOVA, Tukey's multiple comparisons test and the chi-square test. RESULTS The 135 patients averaged 33.8 ± 14.7 years and included 75 females (55.6%, 75/135). Among them, 15 (11.1%, 15/135), 16 (11.9%, 16/135), 54 (40%, 54/135), and 50 (37%, 50/135) MCA-BAVMs were type I, II, IIIa and IIIb, respectively. After EVT, a good outcome was achieved in 97% of patients. Statistical analysis showed that type I BAVMs were smaller than type II and IIIb BAVMs (P value < 0.05), and type IIIb BAVMs were larger than type I and IIIa BAVMs (P value < 0.05). Deep vein involvement in type I and IIIb BAVMs was more common than in other types (P value < 0.05), and intraventricular hemorrhage (IVH) was also more common (P value < 0.05). The normal morphology in type IIIb was less than that in the other types (P value < 0.05). Type IIIa BAVMs had a higher degree than other types (P value < 0.05). CONCLUSION The present study demonstrated that the new classification of MCA-BAVMs can be used to evaluate imaging characteristics and EVT outcomes in different types. In addition, EVT may be a safe treatment modality for MCA‑BAVMs.
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Affiliation(s)
- Han Su
- grid.430605.40000 0004 1758 4110Department of Neurosurgery, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021 China
| | - Jinlu Yu
- grid.430605.40000 0004 1758 4110Department of Neurosurgery, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021 China
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Singh A, Saini N, Behl G, Aggarwal S, Kolar G. Recurrent Vein of Galen Aneurysmal Malformation as a Presentation of Hereditary Hemorrhagic Telangiectasia. Mol Syndromol 2022; 13:440-446. [PMID: 36588762 PMCID: PMC9801315 DOI: 10.1159/000522352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/26/2022] [Indexed: 01/04/2023] Open
Abstract
Introduction Vein of Galen malformation (VGM) results from an aneurysmal aberration with an arteriovenous shunting of blood and is the most frequent arteriovenous malformation in infants and fetuses. The congenital malformation develops during weeks 6-11 of fetal development. Infants often die from high-output congestive heart failure. VGM is mostly considered as a sporadic condition with minimal recurrence risk in subsequent pregnancies. Mendelian forms of VGM have rarely been described as infrequent phenotypic presentations of 2 disorders: capillary malformation-arteriovenous malformation syndrome (RASA1, EPHB4) and hereditary hemorrhagic telangiectasia (ENG, ACVRL1, and SMAD4), both showing autosomal dominant inheritance. Case Presentation Here, we report on a consanguineous couple with recurrent VGM in 2 pregnancies. Both partners were found to be affected by hereditary hemorrhagic telangiectasia due to a known pathogenic heterozygous c.790G>A (p.Asp264Asn) variant in ENG. Fetal DNA was unavailable, however in view of the mild phenotype in the couple, along with the severe prenatal presentation in 2 pregnancies, the fetus was presumed to be homozygous for the ENG variant. A subsequent pregnancy revealed a fetus heterozygous for the variant, which had an uneventful perinatal course. Conclusion This report highlights a severe perinatal lethal phenotype due to biallelic variants in a gene hitherto known to cause an autosomal dominant disorder.
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Affiliation(s)
- Arati Singh
- Department of Fetal Medicine, Fernandez Foundation, Hyderabad, India
| | - Neelam Saini
- Department of Medical Genetics, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Geetanjli Behl
- Department of Fetal Medicine, Fernandez Foundation, Hyderabad, India
| | - Shagun Aggarwal
- Department of Medical Genetics, Nizam's Institute of Medical Sciences, Hyderabad, India,Diagnostics Division, Centre for DNA Fingerprinting and Diagnostics, Hyderabad, India,*Shagun Aggarwal,
| | - Geeta Kolar
- Department of Fetal Medicine, Fernandez Foundation, Hyderabad, India
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Vetiska S, Wälchli T, Radovanovic I, Berhouma M. Molecular and genetic mechanisms in brain arteriovenous malformations: new insights and future perspectives. Neurosurg Rev 2022; 45:3573-3593. [PMID: 36219361 DOI: 10.1007/s10143-022-01883-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/30/2022] [Accepted: 10/05/2022] [Indexed: 10/17/2022]
Abstract
Brain arteriovenous malformations (bAVMs) are rare vascular lesions made of shunts between cerebral arteries and veins without the interposition of a capillary bed. The majority of bAVMs are asymptomatic, but some may be revealed by seizures and potentially life-threatening brain hemorrhage. The management of unruptured bAVMs remains a matter of debate. Significant progress in the understanding of their pathogenesis has been made during the last decade, particularly using genome sequencing and biomolecular analysis. Herein, we comprehensively review the recent molecular and genetic advances in the study of bAVMs that not only allow a better understanding of the genesis and growth of bAVMs, but also open new insights in medical treatment perspectives.
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Affiliation(s)
- Sandra Vetiska
- Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada
| | - Thomas Wälchli
- Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.,Group of CNS Angiogenesis and Neurovascular Link, Neuroscience Center Zurich, and Division of Neurosurgery, University and University Hospital Zurich, and Swiss Federal Institute of Technology (ETH) Zurich, Zurich, Switzerland.,Division of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Ivan Radovanovic
- Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada.,Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Moncef Berhouma
- Department of Neurosurgery, University Hospital of Dijon Bourgogne, Dijon, France. .,CREATIS Lab, CNRS UMR 5220, INSERM U1294, Lyon 1, University, Lyon, France.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Iampreechakul P, Wangtanaphat K, Hangsapruek S, Wattanasen Y, Lertbutsayanukul P, Siriwimonmas S. Acquired Chiari malformation Type I and holocord syringomyelia associated with a high-flow supratentorial fistulous arteriovenous malformations: A case report and literature review. Surg Neurol Int 2022; 13:217. [PMID: 35673663 PMCID: PMC9168309 DOI: 10.25259/sni_11_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/30/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Chiari malformation Type I (CMI) is generally considered a congenital lesion and typically associated with syringomyelia. Acquired CMI or adult Chiari malformation caused by intracranial mass is extremely rare. Brain arteriovenous malformations (AVMs) are characteristically symptomatic due to seizure, intracranial hemorrhage, or neurological deficit. We report an extremely rare case of an acquired CMI and extensive syringomyelia associated with a large supratentorial AVM. Case Description: A 35-year-old woman was referred to our institute after a diagnosis of CMI and extensive syringomyelia from whole-spine magnetic resonance imaging (MRI) due to complaining of low back pain radiating to the right leg for the past 1 month. She had intermittent headache for 2 years. The patient underwent suboccipital decompression and C1 laminectomy followed by duraplasty. Two months later, she developed severe right-sided sciatic pain and complete right foot drop. Follow-up MRI revealed progressive enlargement of a syrinx cavity at the lower spinal cord and a large right parieto-occipital AVM with markedly dilated cortical draining veins and diffuse engorgement of dural venous sinuses was detected. This AVM supplied mainly by enlarged cortical branches of the right middle cerebral artery and posterior cerebral artery with multiple dural supplies. Endovascular treatment of a high-flow fistulous AVM was successfully performed with N-butyl cyanoacrylate (NBCA) through the hypertrophic branches of the right middle cerebral artery. Four months after embolization, the patient had recovered completely from the right foot drop. Further staged embolization was planned to reduce the size and flow of the AVM before stereotactic radiosurgery. However, the patient was lost to follow-up due to financial reason. One year later, she developed sudden severe headache followed by alteration of conscious due to intraventricular hemorrhage from the AVM, leading to obstructive hydrocephalus requiring cerebrospinal fluid diversion. During a period of 2 years, the patient underwent several staged embolization with NBCA and Onyx. Final cerebral angiography after embolization demonstrated a significant reduction in size and flow of the brain AVM. A control whole-spine MRI revealed a significant reduction in syrinx size. At the end of embolization, the patient had no neurological deficit. However, she had suffered from persistent central neuropathic pain at the right lower extremity. The AVM remnant was further treated by stereotactic radiosurgery. Conclusion: Increased cerebral venous hypertension secondary to a high-flow supratentorial AVM leading to posterior fossa venous hypertension may play a major role in the pathogenesis of CMI, induced the formation of syringomyelia. Endovascular treatment of brain AVM, the underlying cause of CMI, resulted in a significant reduction of the size of the syrinx. The need for cranial imaging in initial evaluation of cases with adult Chiari malformation is important.
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Affiliation(s)
| | | | - Sunisa Hangsapruek
- Department of Neuroradiology, Prasat Neurological Institute, Bangkok, Thailand
| | - Yodkhwan Wattanasen
- Department of Neuroradiology, Prasat Neurological Institute, Bangkok, Thailand
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Azma R, Dmytriw AA, Biswas A, Pollak M, Ratjen F, Amirabadi A, Branson HM, Kulkarni AV, Dirks P, Muthusami P. Neurovascular Manifestations in Pediatric Patients With Hereditary Haemorrhagic Telangiectasia. Pediatr Neurol 2022; 129:24-30. [PMID: 35176532 DOI: 10.1016/j.pediatrneurol.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/06/2021] [Accepted: 12/09/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hereditary hemorrhagic telangiectasia (HHT) is a multiorgan vascular dysplasia with limited data regarding its neurovascular manifestations and genotype-phenotype correlation in children. The objective of this study was to describe the neurovascular findings in a large cohort of children with HHT and correlate between phenotype and genotype. METHODS This retrospective study was conducted on 221 children (<18 years) with a definite or possible diagnosis of HHT based on Curacao criteria, or with positive genetics for the mutated genes of ENG, ACVRL-1, and SMAD-4, who also underwent brain MRI and/or conventional angiography. Demographic and clinical information, imaging findings, and follow up information were gathered. RESULTS Two hundred twenty-one children with HHT (70.6% genetically confirmed, and 99.5% positive family history) were included, with a median age of 7 years (interquartile range: 3 to 11 years) and 58.8% male predominance. Neurovascular lesions were found in 64 of 221 (28.9%), with 3.1% prevalence of intracranial hemorrhage. The most commonly observed vascular malformations were developmental venous anomalies (48.5%) and brain arteriovenous malformations (AVMs) (31.2%), followed by capillary malformations (14.1%). Multiple AVMs were seen in 10.0% of the cohort. We found no instances of de novo AVM (1281.8 patient-years).A significantly higher proportion of patients with ENG mutations (19.7%) had brain AVM than those with ACVRL-1 (4.9%) and SMAD-4 (0%) mutations (P < 0.01). There was no significant difference in the hemorrhagic risk of shunting lesions associated with ENG (35.3%) or ACVRL-1 (33.3%) positivity (P = 0.9). CONCLUSIONS We describe the neurovascular imaging and genetic findings from a large pediatric cohort of HHT, to enhance clinical awareness and guide management of patients with HHT.
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Meng X, Gao D, He H, Sun S, Liu A, Jin H, Li Y. A Machine Learning Model Predicts the Outcome of SRS for Residual Arteriovenous malformations after partial embolization- A Real-World Clinical Obstacle. World Neurosurg 2022; 163:e73-e82. [PMID: 35276397 DOI: 10.1016/j.wneu.2022.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To propose a machine learning (ML) model predicting the favorable outcome of stereotactic radiosurgery (SRS) for residual brain arteriovenous malformation (bAVM) after partial embolization. MATERIALS AND METHODS One hundred and thirty bAVM patients who underwent partial embolization followed by SRS were retrospectively reviewed. Patients were randomly split into training datasets (n=100) and testing datasets (n=30). Radiomics and dosimetric features were extracted from pre-SRS treatment images. Feature selection was performed to select appropriate radiomics and dosimetric features. Three ML algorithms were applied to construct models using selected features respectively. A total of 9 models were trained to predict favorable outcomes (obliteration without complication) of bAVMs. The efficacy of these models was evaluated on the testing dataset using mean accuracy (ACC) and area under the receiver operating characteristic curve (AUROC). RESULTS The obliteration rate of this cohort was 70.77% (92/130) with a mean follow-up period of 43.8 (Range 12-108 months) months. Favorable outcomes were achieved in 89 (68.46%) patients. Four radiomics features and 7 dosimetric features were selected for ML model construction. The dosimetric SVM showed the best performance on the training dataset, with an ACC and AUC of 0.74 and 0.78 respectively. The dosimetric SVM model also showed the best performance on the testing dataset where the ACC and AUC were 0.83 and 0.77 respectively. CONCLUSION Dosimetric features are good predictors of prognosis for patients with partially embolized bAVM followed by SRS therapy. The use of ML models is an innovative method for predicting favorable outcomes of partially embolized bAVM followed by SRS therapy.
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Affiliation(s)
- Xiangyu Meng
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dezhi Gao
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongwei He
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shibin Sun
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ali Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Beijing Engineering Research Center, Beijing, China.
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Pérez-Alfayate R, Grasso G. State of the Art and Future Direction in Diagnosis, Molecular Biology, Genetics, and Treatment of Brain Arteriovenous Malformations. World Neurosurg 2022; 159:362-372. [PMID: 35255635 DOI: 10.1016/j.wneu.2021.08.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022]
Abstract
Brain arteriovenous malformations (bAVMs) are uncommon and represent a heterogeneous group of lesions. Although these 2 facts have delayed research on this topic, knowledge about the pathophysiology, diagnosis, and treatment of bAVMs has evolved in recent years. We conducted a review of the literature to update the knowledge about diagnosis, molecular biology, genetic, pathology, and treatment by searching for the following terms: "Epidemiology AND Natural History," "risk of hemorrhage," "intracranial hemorrhage," "diagnosis," "angiogenesis," "molecular genetics," "VEGF," "KRAS," "radiosurgery," "endovascular," "microsurgery," or "surgical resection." Our understanding of bAVMs has significantly evolved in recent years. The latest investigations have helped in defining some molecular pathways involved in the pathology of bAVM. Although there is still more to learn and discover, describing these pathways will allow the creation of targeted treatments that could improve the prognosis of patients with bAVMs.
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Affiliation(s)
- Rebeca Pérez-Alfayate
- Department of Neurosurgery, Neuroscience Institute, Hospital Clínico San Carlos, Madrid, Spain.
| | - Giovanni Grasso
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
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Jiao Y, Zhang JZ, Zhao Q, Liu JQ, Wu ZZ, Li Y, Li H, Fu WL, Weng JC, Huo R, Zhao SZ, Wang S, Cao Y, Zhao JZ. Machine Learning-Enabled Determination of Diffuseness of Brain Arteriovenous Malformations from Magnetic Resonance Angiography. Transl Stroke Res 2021; 13:939-948. [PMID: 34383209 DOI: 10.1007/s12975-021-00933-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/04/2021] [Accepted: 07/25/2021] [Indexed: 11/25/2022]
Abstract
The diffuseness of brain arteriovenous malformations (bAVMs) is a significant factor in surgical outcome evaluation and hemorrhagic risk prediction. However, there are still predicaments in identifying diffuseness, such as the judging variety resulting from different experience and difficulties in quantification. The purpose of this study was to develop a machine learning (ML) model to automatically identify the diffuseness of bAVM niduses using three-dimensional (3D) time-of-flight magnetic resonance angiography (TOF-MRA) images. A total of 635 patients with bAVMs who underwent TOF-MRA imaging were enrolled. Three experienced neuroradiologists delineated the bAVM lesions and identified the diffuseness on TOF-MRA images, which were considered the ground-truth reference. The U-Net-based segmentation model was trained to segment lesion areas. Eight mainstream ML models were trained through the radiomic features of segmented lesions to identify diffuseness, based on which an integrated model was built and yielded the best performance. In the test set, the Dice score, F2 score, precision, and recall for the segmentation model were 0.80 [0.72-0.84], 0.80 [0.71-0.86], 0.84 [0.77-0.93], and 0.82 [0.69-0.89], respectively. For the diffuseness identification model, the ensemble-based model was applied with an area under the Receiver-operating characteristic curves (AUC) of 0.93 (95% CI 0.87-0.99) in the training set. The AUC, accuracy, precision, recall, and F1 score for the diffuseness identification model were 0.95, 0.90, 0.81, 0.84, and 0.83, respectively, in the test set. The ML models showed good performance in automatically detecting bAVM lesions and identifying diffuseness. The method may help to judge the diffuseness of bAVMs objectively, quantificationally, and efficiently.
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Affiliation(s)
- Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, People's Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
| | - Jun-Ze Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, People's Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
| | - Qi Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Jia-Qi Liu
- China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Zhen-Zhou Wu
- China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Yan Li
- China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Hao Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, People's Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
| | - Wei-Lun Fu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, People's Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
| | - Jian-Cong Weng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, People's Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
| | - Ran Huo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, People's Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
| | - Shao-Zhi Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, People's Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, People's Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, People's Republic of China.
- China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China.
| | - Ji-Zong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, 119 South Fourth Ring Road West, Fengtai District, Beijing, People's Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China
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Luzzi S, Del Maestro M, Galzio R. The Preoperative Functional Downgrading of Brain AVMs. Acta Neurochir Suppl 2021; 132:107-12. [PMID: 33973037 DOI: 10.1007/978-3-030-63453-7_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
The actual role of preoperative embolization of brain arteriovenous malformations (AVMs) is undervalued.The present study aims to describe the effectiveness, safety, technics, and results of the endovascular-based functional downgrading of brain AVMs.Data regarding 31 Spetzler-Martin (SM) grade III AVMs that consecutively underwent a combined endovascular-surgical treatment were reviewed. Clinical and radiological outcomes were evaluated according to modified Ranking Scale score (mRS) and postoperative angiography, respectively.Low-density Onyx was used in all cases, and the timeframe between the embolizations was 10-15 days. Procedures were 1.6 (±0.6) on average. Superselective nidal catheterization was essential to reach the deepest parts of the AVMs, which were the targets. Onyx made the nidus compact and easier to dissect. The Average obliteration rate was 29.6%, with negligible morbidity. Surgery was performed after 3.7 days on average and the AVM exclusion was complete in 83.4% of cases. An mRS score between 0 and 2 was reported in 77.5% of patients, while the best outcome was achieved in small and medium-deep malformations.An effective and safe functional downgrading of brain AVMs must be based upon specific technical key aspects, which make surgery easier and, ultimately, allow for the achievement of the best outcome.
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Kaya I, Çakır V, Cingoz ID, Atar M, Gurkan G, Sahin MC, Saygili SK, Yuceer N. Comparison of cerebral AVMs in patients undergoing surgical resection with and without prior endovascular embolization. Int J Neurosci 2021; 132:735-743. [PMID: 33866943 DOI: 10.1080/00207454.2021.1918689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM Brain arteriovenous malformations (AVMs) are congenital anomalies that present as intracranial hemorrhage or epilepsy. AVMs often remain clinically silent for extended periods. Although AVM treatment methods are controversial, three treatment strategies are usually combined or applied alone: surgical removal, embolization and stereotactic radiosurgery. We compared clinical and radiological outcomes in intracranial AVM patients treated via surgical resection with and without prior embolization. MATERIALS AND METHODS Patients who did (30 patients) and did not (30 patients) undergo endovascular embolization before surgical resection at the İzmir Katip Çelebi University Atatürk Training and Research Hospital Neurosurgery Clinic from 2011 to 2019 were included in this retrospective, cohort study. Symptoms at diagnosis, comorbidities and clinical (AVM and Spetzler-Martin grade) and morphological characteristics were assessed. RESULTS A mean one-year follow-up assessed outcomes using the modified Rankin score, and imaging studies assessed AVM obliteration post-procedure. Mean operation times for surgical resection with and without embolization were 166.50 ± 32.02 and 204.47 ± 26.66 min, respectively. Mean patient hospitalization periods for surgical resection with and without embolization were 8.43 ± 3.60 and 12.00 ± 5.51 days, respectively. CONCLUSION Among patients who underwent surgical resection, significant operation time and hospitalization time differences were observed in favor of patients who underwent embolization, indicating that preoperative embolization is a safe and beneficial method for treating ruptured and non-ruptured AVMs.
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Affiliation(s)
- Ismail Kaya
- Medical Faculty, Department of Neurosurgery, Usak University, Usak, Turkey
| | - Volkan Çakır
- Medical Faculty, Department of Interventional Radiology, Tınaztepe University, Izmir, Turkey
| | - Ilker Deniz Cingoz
- Medical Faculty, Department of Neurosurgery, Usak University, Usak, Turkey
| | - Murat Atar
- Department of Neurosurgery, Sultan 2.Abdulhamid Han Sample Training And Research Hospital, Istanbul, Turkey
| | - Gokhan Gurkan
- Medical Faculty, Department of Neurosurgery, Katip Çelebi University, Izmir, Turkey
| | - Meryem Cansu Sahin
- Training and Research Center, Kutahya Health Sciences University, Kutahya, Turkey
| | - Suna Karadeniz Saygili
- Medical Faculty, Department of Histology and Embryology, Kutahya Health Sciences University, Kutahya, Turkey
| | - Nurullah Yuceer
- Medical Faculty, Department of Neurosurgery, Katip Çelebi University, Izmir, Turkey
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Mehta T, Hassan A, Masood K, Tekle W, Grande A, Tummala R, Jagadeesan BD. The next step in balloon assisted endovascular neurosurgical procedures: A case series of initial experience with the Scepter Mini balloon microcatheter. Interv Neuroradiol 2021; 27:298-306. [PMID: 33164616 PMCID: PMC8050521 DOI: 10.1177/1591019920972884] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/25/2020] [Accepted: 10/13/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The use of compliant dual lumen balloon microcatheters (CDLB) for the endovascular treatment of vascular malformations, wide neck aneurysms, and intracranial angioplasty (for vasospasm) is well documented. Navigation of 4 mm or larger CDLB within tortuous and small distal intracranial vessels can be challenging. Recently, the lower profile Scepter Mini balloon microcatheter (SMB) has been approved for use, with potential for improved intracranial navigation. OBJECTIVE Discuss operative experience of Scepter Mini (Microvention, Aliso Viejo, CA). METHODS We describe our initial experience with the SMB in a series of nine patients. RESULTS The balloon microcatheter was used for delivery of liquid embolic in six patients (Case 1, 2, 6-9), adjunct support for delivery or positioning of the Woven Endobridge (WEB) device in two (Case 3,4), and gentle post-deployment repositioning of a WEB device in the last one (Case 5). We were able to successfully navigate the SMB over a 0.008 "micro wire to the target lesion in all the patients. We experienced initial difficulty with injecting liquid embolic in Case 2. We postulate that the SMB was in a tortuous segment of a dural vessel in this patient, and that it kinked on inflation with occlusion of the liquid embolic delivery lumen; this was overcome with slightly proximal repositioning and reinflation of the SMB. CONCLUSION Our initial experience shows that the SMB has potential to be useful in endovascular neurosurgical procedures requiring balloon assistance within smaller diameter blood vessels.
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Affiliation(s)
- Tapan Mehta
- Department of Neurology, Neurosurgery and Radiology, University of Minnesota, Minneapolis, MN, USA
- Ayer Neuroscience Institute, Hartford Healthcare, Hartford, CT, USA
| | - Ameer Hassan
- Department of Neuroscience, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Kamran Masood
- Department of Neurology, Neurosurgery and Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Wondwossen Tekle
- Department of Neuroscience, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Andrew Grande
- Department of Neurology, Neurosurgery and Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Ramachandra Tummala
- Department of Neurology, Neurosurgery and Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Bharathi D Jagadeesan
- Department of Neurology, Neurosurgery and Radiology, University of Minnesota, Minneapolis, MN, USA
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Cai H, Chen L, Zhang N, Tang W, Yang F, Li Z. Long-term efficacy and safety of curative embolization of brain arteriovenous malformations using the dual microcatheter technique: A single-institution case series and literature review. Clin Neurol Neurosurg 2020; 201:106417. [PMID: 33370624 DOI: 10.1016/j.clineuro.2020.106417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/28/2020] [Accepted: 11/28/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Brain arteriovenous malformations (bAVMs) are among the most common causes of cerebral hemorrhage in adolescents. For multiple-feeder bAVMs, complete exclusion of the nidus by endovascular embolization is challenging. This case series and literature review examined the long-term efficacy and safety of bAVM embolization using the dual microcatheter technique (DMCT). METHODS A total of 38 consecutive patients who underwent endovascular treatment for bAVMs with the DMCT along with all cases reported in the literature were retrospectively reviewed. Patient demographics, clinical presentation, bAVM angioarchitecture, treatment, complications, and long-term outcome were independently assessed. RESULTS Patients with bAVM (24 male and 14 female, mean age: 33.87 ± 13.70 years) treated at our institution were followed up for 97.76 ± 14.51 months. Angiographic obliteration was achieved in a single embolization session in 27/38 (71.05 %) cases; 4/38 (10.53 %) required multiple sessions, and 7/38 (18.42 %) underwent embolization combined with microsurgery or radiotherapy. Neurologic improvement at 90 days was observed in 29/38 patients (76.32 %). At the final follow-up, 34/38 patients (89.47 %) had a favorable clinical outcome. Two patients experienced recurrence during the follow-up period. In total, 55 patients were ultimately analyzed in our literature review. Complete exclusion of bAVMs was achieved in 35 patients (63.63 %), including in 54.54 % after a single endovascular treatment session. One patient died of hemorrhagic complication after endovascular treatment for an overall mortality rate of 1.82 %. CONCLUSIONS DMCT is safe for bAVM embolization and shows long-term efficacy, especially for multiple-feeder bAVMs.
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Affiliation(s)
- Heng Cai
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang 110004, People's Republic of China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang 110004, People's Republic of China
| | - Liangyu Chen
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang 110004, People's Republic of China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang 110004, People's Republic of China
| | - Nan Zhang
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang 110004, People's Republic of China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang 110004, People's Republic of China
| | - Wei Tang
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang 110004, People's Republic of China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang 110004, People's Republic of China
| | - Fangyu Yang
- Department of Neurosurgery, PLA North Military Command Region General Hospital, Shenyang 110004, People's Republic of China
| | - Zhiqing Li
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang 110004, People's Republic of China; Liaoning Clinical Medical Research Center in Nervous System Disease, Shenyang 110004, People's Republic of China.
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Gorgan RM, Petrescu GED, Brehar FM. Microsurgical approach for symptomatic brain AVMs - single center experience. Neurol Res 2020; 42:1080-1084. [PMID: 32892720 DOI: 10.1080/01616412.2020.1803604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objectives: Brain arteriovenous malformations (AVMs) represent high-flow vascular lesions made up of a complex network of feeding arteries and draining veins interposed by a nidus and without a capillary bed. The management of the AVMs represents a challenge, and the optimal treatment should be considered based on the particularities of each AVM. This paper aims to provide outcome data for the cohort of patients with AVMs that underwent surgical treatment. Methods: A retrospective review of patients who presented with AVMs between 2001 and 2019 was conducted. Patients were included if they underwent surgery, preoperative and postoperative angiographic studies were available. Results: 91 patients were included. The SM grade was 1 in 16 cases (17,6%), 2 in 27 patients (29.7%), 3 in 29 patients (31,9%), 4 in 12 cases (13.2%) and grade 5 in 7 cases (7.7%). In 58 (63.7%) cases the AVMs were ruptured. Complete microsurgical resection was achieved in 82 cases (90.1%). Unruptured AVM (87.9% vs. 63.8% for ruptured AVMs; p = 0.015), low-grade AVM (86% vs. 60.4% for grade III-V AVMs; p = 0.006) and cortical location (79.5% vs. 30.8% for deep AVM; p < 0.0001) were the factors associated with a good outcome on mRS scale. Conclusions: Microsurgical resection is the curative treatment for AVMs and offers a good functional outcome if selection criteria are met.
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Affiliation(s)
- Radu M Gorgan
- Department of Neurosurgery, University of Medicine and Pharmacy "Carol Davila" , Bucahrest, Romania.,Department of Neurosurgery, "Bagdasar-Arseni" Clinical Emergency Hospital , Bucharest, Romania
| | - George E D Petrescu
- Department of Neurosurgery, University of Medicine and Pharmacy "Carol Davila" , Bucahrest, Romania.,Department of Neurosurgery, "Bagdasar-Arseni" Clinical Emergency Hospital , Bucharest, Romania
| | - Felix M Brehar
- Department of Neurosurgery, University of Medicine and Pharmacy "Carol Davila" , Bucahrest, Romania.,Department of Neurosurgery, "Bagdasar-Arseni" Clinical Emergency Hospital , Bucharest, Romania
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Panni P, Gallotti AL, Gigliotti CR, Shehata AB, Albano L, da Passano CF, Barzaghi RLA, Capitanio JF, Righi C, Simionato F, Scomazzoni F, Del Vecchio A, Falini A, Mortini P. Impact of flow and angioarchitecture on brain arteriovenous malformation outcome after gamma knife radiosurgery: the role of hemodynamics and morphology in obliteration. Acta Neurochir (Wien) 2020; 162:1749-57. [PMID: 32335814 DOI: 10.1007/s00701-020-04351-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/14/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Few studies have evaluated the relationship between brain arteriovenous malformations (bAVMs) angioarchitecture and the response to Gamma Knife Stereotactic Radiosurgery (GKSR). METHODS A prospectively enrolled single-center cohort of patients with bAVMs treated by GKSR has been studied to define independent predictors of obliteration with particular attention to angioarchitectural variables. Only patients older than 18 years old (y.o.), who underwent baseline digital subtraction angiography (DSA) and clinico-radiological follow-up of at least 36 months, were included in the study. RESULTS Data of 191 patients were evaluated. After a mean follow-up of 80 months (range 37-173), total obliteration rate after first GKSR treatment was 66%. Mean dose higher than 22 Gy (P = .019, OR = 2.39, 95% CI 1.15-4.97) and flow rate dichotomized into high vs non-high (P < .001, OR = 0.23, 95% CI 0.11-0.51) resulted to be independent predictors of obliteration. Flow-surrogate angioarchitectural features did not emerge as independent outcome predictors. CONCLUSIONS Flow rate seems to be associated in predicting outcome after GKSR conferring high-flow AVM a lower occlusion rate. Its role should be considered when planning radiosurgical treatment of bAVM, and it could be added to other parameters used in GKRS outcome predicting scales.
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Winkler EA, Lu AY, Raygor KP, Linzey JR, Jonzzon S, Lien BV, Rutledge WC, Abla AA. Defective vascular signaling & prospective therapeutic targets in brain arteriovenous malformations. Neurochem Int 2019; 126:126-138. [PMID: 30858016 DOI: 10.1016/j.neuint.2019.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/01/2019] [Accepted: 03/04/2019] [Indexed: 02/08/2023]
Abstract
The neurovascular unit is composed of endothelial cells, vascular smooth muscle cells, pericytes, astrocytes and neurons. Through tightly regulated multi-directional cell signaling, the neurovascular unit is responsible for the numerous functionalities of the cerebrovasculature - including the regulation of molecular and cellular transport across the blood-brain barrier, angiogenesis, blood flow responses to brain activation and neuroinflammation. Historically, the study of the brain vasculature focused on endothelial cells; however, recent work has demonstrated that pericytes and vascular smooth muscle cells - collectively known as mural cells - play critical roles in many of these functions. Given this emerging data, a more complete mechanistic understanding of the cellular basis of brain vascular malformations is needed. In this review, we examine the integrated functions and signaling within the neurovascular unit necessary for normal cerebrovascular structure and function. We then describe the role of aberrant cell signaling within the neurovascular unit in brain arteriovenous malformations and identify how these pathways may be targeted therapeutically to eradicate or stabilize these lesions.
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Affiliation(s)
- Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.
| | - Alex Y Lu
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Joseph R Linzey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Soren Jonzzon
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Brian V Lien
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
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Lo Presti A, Rogers JM, Assaad NNA, Rodriguez ML, Stoodley MA, Morgan MK. De novo brain arteriovenous malformation after tumor resection: case report and literature review. Acta Neurochir (Wien) 2018; 160:2191-7. [PMID: 30206686 DOI: 10.1007/s00701-018-3668-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 08/31/2018] [Indexed: 02/03/2023]
Abstract
The congenital origin of brain arteriovenous malformations (bAVMs) has been increasingly challenged by reports of de novo bAVMs in patients previously confirmed to have no vascular malformation. We describe the oldest patient reported in the English language literature harboring a de novo bAVM. An uneventful frontal convexity meningioma resection was performed for a 60-year-old woman, and at 67 years of age, a bAVM was detected by MRI and confirmed by digital subtraction angiography at the site of the previous meningioma resection. This case adds to the growing literature that the etiology of bAVMs is most likely multifactorial.
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20
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Shah KJ, Cohen-Gadol AA. The Application of FLOW 800 ICG Videoangiography Color Maps for Neurovascular Surgery and Intraoperative Decision Making. World Neurosurg 2018; 122:e186-e197. [PMID: 30292668 DOI: 10.1016/j.wneu.2018.09.195] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/23/2018] [Accepted: 09/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Indocyanine green (ICG) videoangiography can assess cerebral blood flow, but results are primarily qualitative. FLOW 800 software measures fluorescence dynamics and creates a semiquantitative color delay map for assessment of relative sequence of blood flow within the vasculature. METHODS We retrospectively reviewed 23 consecutive patients for whom FLOW 800 ICG videoangiography was used. They harbored aneurysms, arteriovenous malformations (AVMs), dural arteriovenous fistula (dAVF), or hemangioblastoma. Patients' characteristics, FLOW 800 data, and clinical findings were recorded. Color map data were readily available intraoperatively and guided surgery. RESULTS The cohort included 10 patients with AVMs, 11 with aneurysms, 1 with dAVF, and 1 with hemangioblastoma. Approximately two thirds of patients underwent intraoperative angiography. FLOW 800 data provided semiquantitative data regarding localization, flow status in major feeding arteries, and dominance of the arterialized draining veins for AVMs, more than data from ICG videoangiography alone. For complex aneurysms, color maps confirmed relative adequate flow in parent and branching vessels. For the foramen magnum dAVF, the location of the dominant transdural connection was appreciated only via flow analysis. Flow analysis created the blood flow map of a large complex solid brainstem hemangioblastoma and guided devascularization. All FLOW 800 findings agreed with intraoperative and postoperative angiography. CONCLUSIONS ICG videoangiography with FLOW 800 analysis can provide semiquantitative and relative flow magnitude data that are efficient and noninvasive. This process helps identify early arterialized veins and their flow status during AVM and dAVF surgery and can confirm adequate relative flow within branching vessels during aneurysm surgery when clip-induced stenosis is suspected.
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Affiliation(s)
- Kushal J Shah
- Department of Neurosurgery, University of Kansas, Kansas City, Kansas, USA
| | - Aaron A Cohen-Gadol
- Department of Neurological Surgery, Goodman Campbell Brain and Spine and Indiana University, Indianapolis, Indiana, USA.
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21
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Chen Y, Li Z, Shi Y, Huang G, Chen L, Tan H, Wang Z, Yin C, Hu J. Deep Sequencing of Small RNAs in Blood of Patients with Brain Arteriovenous Malformations. World Neurosurg 2018; 115:e570-e579. [PMID: 29689389 DOI: 10.1016/j.wneu.2018.04.097] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 04/11/2018] [Accepted: 04/13/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Deregulation of circulating microRNAs (miRNAs) is always associated with development and progression of human diseases. We aimed to assess whether patients with brain arteriovenous malformations (BAVMs) possess a distinct miRNA signature compared with healthy subjects. METHODS Three patients with unruptured BAVMs and 3 normal control subjects were recruited as case and control groups. Peripheral blood was collected, and miRNA signature was obtained by next-generation sequencing, followed by comparative, functional, and network analyses. Quantitative reverse transcription polymerase chain reaction was performed to validate expression of specific miRNAs. RESULTS Deep sequencing detected 246 differentially expressed miRNAs in blood samples of patients with BAVMs compared with normal control subjects. For the top 5 miRNAs, 946 target genes were predicted, and a BAVM-specific miRNA-target gene regulatory network was constructed. Functional annotation suggested that 15 of the predicted miRNA-targeted genes were involved in vascular endothelial growth factor signaling, in which 3 critical miRNAs were involved: miR-7-5p, miR-199a-5p, and miR-200b-3p. CONCLUSIONS We explored the miRNA expression signature of BAVMs, which will provide an important foundation for future studies on the regulation of miRNAs involved in BAVMs.
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Affiliation(s)
- Yong Chen
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Sichuan, China
| | - Zhili Li
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Sichuan, China.
| | - Yi Shi
- Key Laboratory of SiChuan Province in Human Disease Gene Study, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Sichuan, China
| | - Guangfu Huang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Sichuan, China
| | - Longyi Chen
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Sichuan, China
| | - Haibin Tan
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Sichuan, China
| | - Zhenyu Wang
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Sichuan, China
| | - Cheng Yin
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Sichuan, China
| | - Junting Hu
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Sichuan, China
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Jin H, Jiang Y, Ge H, Luo J, Li C, Wu H, Li Y. Comparison of Grading Scales Regarding Perioperative Complications and Clinical Outcomes of Brain Arteriovenous Malformations After Endovascular Therapy-Multicenter Study. World Neurosurg 2017; 106:394-401. [PMID: 28712909 DOI: 10.1016/j.wneu.2017.07.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/04/2017] [Accepted: 07/06/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Several scales have been proposed for risk assessment and outcome determination in brain arteriovenous malformations treated by endovascular therapy. We aim to validate and compare the efficacy of these scales in predicting perioperative complications and clinical outcomes. METHODS We retrospectively reviewed brain arteriovenous malformations patients who underwent endovascular therapy at 4 centers in China from January 2012 to December 2015. The primary outcomes were complications, unfavorable outcome (mRS ≥ 3), and complete obliteration. Each patient was assessed using the Spetzler-Martin grading system (SM), Puerto Rico scale, Buffalo score, and arteriovenous malformation embocure score (AVMES). Correlation analysis was performed between primary outcomes incidence rate and the grades of each scale. The area under the receiver operating characteristic curve of these scales was calculated. Pairwise comparison of receiver operating characteristic curves was performed to compare the efficacy of the scales. RESULTS A total of 270 patients were included. Correlation analysis demonstrated that the complication rate increased with increasing grade in SM (P = 0.002), Puerto Rico scale (P = 0.014), and Buffalo score (P = 0.001); complete obliteration rate decreased with increasing grade in AVMES (P = 0.017); unfavorable outcome rate increased with increasing grade in the Puerto Rico scale (P = 0.005). The area under the receiver operating characteristic curve analysis showed statistical differences between the Puerto Rico score and SM (P = 0.047) in predicting complications and between the Puerto Rico score and SM (P = 0.008) in predicting unfavorable outcomes. The area under the curve of the AVMES in predicting complete obliteration was 0.757. CONCLUSIONS The Puerto Rico score predicts complications and unfavorable outcomes better than the SM. The AVMES scale has medium efficacy in predicting complete obliteration.
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Jiang YY, Jo YE, Woo JM, Lim OK, Hwang C, Maeng JY, Kim J, Kim N, Lee DH. In Vitro Quantification of the Radiopacity of Onyx during Embolization. Neurointervention 2017; 12:3-10. [PMID: 28316864 PMCID: PMC5355458 DOI: 10.5469/neuroint.2017.12.1.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 01/23/2017] [Indexed: 11/29/2022] Open
Abstract
Purpose Onyx has been successfully applied in the treatment of various neurovascular lesions. However, some experience is required to get accustomed to its unpredictable fluoroscopic visibility during injection. This in vitro study aimed to evaluate the characteristics of radiopacity change in a simulated embolization procedure. Materials and Methods Using a bench-top Onyx injection experiment simulating a typical brain arteriovenous malformation embolization, nine cycles of casting modes (continuous injection) and plugging modes (injection with intermittent pauses) were performed. Radiodensity of Onyx droplets collected from the microcatheter tip and the distal head portion of the microcatheter were measured as time lapsed. Distribution of droplet radiodensity (radiodensity) and distribution of radiographic grade (grade) were analyzed and compared by repeated measurements. Results Within-group analysis revealed no significant radiodensity change with time (P>0.05). The radiodensity was significantly higher in the casting mode than in the plugging mode (P<0.01). The lateral radiograph of the microcatheter showed higher radiopacity (P<0.01) and better evenness (P<0.01) in the casting mode than in the plugging mode. A significant difference in microcatheter attenuation (both radiographic grade mean and SD; P<0.01) was noted between the two modes. Radiodensity had a significant influence on the radiopacity and radiopacity evenness of the microcatheter. Conclusion The radiopacity of the Onyx can vary significantly over time because of early precipitation of tantalum powder. Radiopacity decreased significantly during plugging modes, characterized by pauses between injections.
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Affiliation(s)
- Yuan Yuan Jiang
- Department of Medical Biotechnology, Dongguk University, Ilsan, Korea
| | - Ye-Eun Jo
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Min Woo
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ok Kyun Lim
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Changmo Hwang
- Biomedical R&D Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | - Jun Young Maeng
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jieun Kim
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.; Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Namkug Kim
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.; Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok Hee Lee
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Cagnazzo F, Brinjikji W, Lanzino G. Arterial aneurysms associated with arteriovenous malformations of the brain: classification, incidence, risk of hemorrhage, and treatment-a systematic review. Acta Neurochir (Wien) 2016; 158:2095-104. [PMID: 27644700 DOI: 10.1007/s00701-016-2957-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/05/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Aneurysms associated with brain arteriovenous malformations (bAVMs) influence the natural history of these lesions and pose important therapeutic challenges. However, the epidemiology, natural history, and appropriate management of the aneurysms associated with bAVMs are not completely understood due to the paucity of large and uniform studies. We performed a systematic review of published series examining the association between aneurysms and bAVMs with the purpose of clarifying the prevalence, risk of hemorrhage, and appropriate management of these lesions. METHOD PRISMA/MOOSE guidelines were followed. We conducted a comprehensive literature search of three databases (PubMed, Ovid MEDLINE, and Ovid EMBASE) on aneurysms associated with bAVMs. Only studies examining consecutive case series of aneurysms associated with bAVMs were included. From the collected studies, we extracted data regarding prevalence of bAVM-associated aneurysms, risk of aneurysm rupture in relation to bAVM location and aneurysm characteristics, and treatment-related outcomes. RESULTS Our systematic review included 44 articles with a total of 10,093 bAVMs. The proportion of bAVMs with an associated aneurysm was 20.2 % (95 % CI = 19.4-20.9 %). Among ruptured bAVMs with associated aneurysms, the aneurysm was the source of hemorrhage in 49.2 % (95 % CI = 43.7-54.7 %) of cases. Flow-related aneurysms were the most common source of aneurysm rupture (78.5 %, 95 % CI = 70.6-84.9 %). Infratentorial bAVM-associated aneurysms presented a higher risk of rupture (60 %, 95 % CI = 47.4-71.9 %) when compared with supratentorial lesions (29 %, 95 % CI = 21.4-38.5 %). Endovascular treatment of aneurysms associated with bAVMs had a cure rate of 80.0 % (95 % CI = 73.3-85.3 %), complication rate of 8.7 % (95 % CI = 5.5-13.1 %), and a good neurological outcome rate of 78.8 % (95 % CI = 72.5-83.9 %). CONCLUSIONS Twenty percent of bAVMs harbored arterial aneurysms. The presence of aneurysm increases the risk of bleeding of the bAVM, especially when flow-related or infratentorially located. Aneurysms associated with bAVMs should be treated promptly. Selective endovascular treatment of bAVM-associated aneurysms appears safe and effective.
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Ma L, Shen F, Jun K, Bao C, Kuo R, Young WL, Nishimura SL, Su H. Integrin β8 Deletion Enhances Vascular Dysplasia and Hemorrhage in the Brain of Adult Alk1 Heterozygous Mice. Transl Stroke Res 2016; 7:488-96. [PMID: 27352867 DOI: 10.1007/s12975-016-0478-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 06/13/2016] [Accepted: 06/16/2016] [Indexed: 10/21/2022]
Abstract
Brain arteriovenous malformation (bAVM), characterized by tangled dysplastic vessels, is an important cause of intracranial hemorrhage in young adults, and its pathogenesis and progression are not fully understood. Patients with haploinsufficiency of transforming growth factor-β (TGF-β) receptors, activin receptor-like kinase 1 (ALK1) or endoglin (ENG) have a higher incidence of bAVM than the general population. However, bAVM does not develop effectively in mice with the same haploinsufficiency. The expression of integrin β8 subunit (ITGB8), another member in the TGF-β superfamily, is reduced in sporadic human bAVM. Brain angiogenic stimulation results at the capillary level of vascular malformation in adult Alk1 haploinsufficient (Alk1 +/- ) mice. We hypothesized that deletion of Itgb8 enhances bAVM development in adult Alk1 +/- mice. An adenoviral vector expressing Cre recombinase (Ad-Cre) was co-injected with an adeno-associated viral vector expressing vascular endothelial growth factor (AAV-VEGF) into the brain of Alk1 +/-;Itgb8-floxed mice to induce focal Itgb8 gene deletion and angiogenesis. We showed that compared with Alk +/- mice (4.75 ± 1.38/mm2), the Alk1 +/-;Itgb8-deficient mice had more dysplastic vessels in the angiogenic foci (7.14 ± 0.68/mm2, P = 0.003). More severe hemorrhage was associated with dysplastic vessels in the brain of Itgb8-deleted Alk1 +/- , as evidenced by larger Prussian blue-positive areas (1278 ± 373 pixels/mm2 vs. Alk1 +/- : 320 ± 104 pixels/mm2; P = 0.028). These data indicate that both Itgb8 and Alk1 are important in maintaining normal cerebral angiogenesis in response to VEGF. Itgb8 deficiency enhances the formation of dysplastic vessels and hemorrhage in Alk1 +/- mice.
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Magro E, Gentric JC, Darsaut TE, Batista AL, Chaalala C, Roberge D, Weill A, Roy D, Bojanowski MW, Raymond J. [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: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Neyazi B, Herz A, Stein KP, Gawish I, Hartmann C, Wilkens L, Erguen S, Dumitru CA, Sandalcioglu IE. Brain arteriovenous malformations: implications of CEACAM1-positive inflammatory cells and sex on hemorrhage. Neurosurg Rev 2016; 40:129-134. [PMID: 27215911 DOI: 10.1007/s10143-016-0744-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 04/11/2016] [Accepted: 05/05/2016] [Indexed: 11/29/2022]
Abstract
Brain arteriovenous malformations (bAVMs) are severe conditions which, upon rupture, cause debilitating neurological deficits and even death. The exact cellular and molecular mechanisms associated with bAVM rupture are currently unclear. The objective of this study was to explore the potential role of CEA-related cell adhesion molecule-1 (CEACAM1) in bAVM pathophysiology. Expression and localization of CEACAM1 were assessed immunohistochemically in tissue microarrays from bAVM patients (n = 60). The association of CEACAM1 with clinical parameters was analyzed with Spearman's rank correlation coefficient and chi-square test. The predictive value of CEACAM1 was tested using logistic regression analysis. CEACAM1 was highly expressed in tissue-infiltrating neutrophil granulocytes. High levels of CEACAM1-positive cells were associated with bAVM rupture (hemorrhage), but not with arteriovenous malformation (AVM) size, preoperative embolization, or seizure. This association was significant (p = 0.029, chi-square) in male but not in female patients, and high CEACAM1-positive immune infiltration showed predictive significance for hemorrhage in male bAVM patients only (OR = 6.50, 95 % CI 1.09-38.63, p = 0.040). Within the ruptured bAVM group, patients with a short hemorrhage to surgery (HTS) time interval had higher levels of CEACAM1 immune infiltration than patients with long HTS. This decrease in the levels of CEACAM1 immune infiltration between the HTS short and HTS long groups was, however, significant only in female patients (p = 0.022, chi-square). Our findings substantiate the role of inflammation in the pathophysiology of bAVM and suggest the presence of sexual dimorphism in this disease.
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Affiliation(s)
- Belal Neyazi
- Department of Neurosurgery, Nordstadt Hospital Hannover, Haltenhoffstrasse 41, 30167, Hannover, Germany
| | - Angelika Herz
- Department of Neurosurgery, Nordstadt Hospital Hannover, Haltenhoffstrasse 41, 30167, Hannover, Germany
| | - Klaus-Peter Stein
- Department of Neurosurgery, Nordstadt Hospital Hannover, Haltenhoffstrasse 41, 30167, Hannover, Germany
| | - Islam Gawish
- Department of Neurosurgery, Nordstadt Hospital Hannover, Haltenhoffstrasse 41, 30167, Hannover, Germany
| | - Christian Hartmann
- Department of Neuropathology, Institute of Pathology, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Ludwig Wilkens
- Department of Pathology, Nordstadt Hospital Hannover, Haltenhoffstrasse 41, 30167, Hannover, Germany
| | - Sueleyman Erguen
- Institute of Anatomy and Cell Biology, University of Wuerzburg, Koellikerstrasse 6, 97070, Wuerzburg, Germany
| | - Claudia A Dumitru
- Department of Neurosurgery, Nordstadt Hospital Hannover, Haltenhoffstrasse 41, 30167, Hannover, Germany
| | - I Erol Sandalcioglu
- Department of Neurosurgery, Nordstadt Hospital Hannover, Haltenhoffstrasse 41, 30167, Hannover, Germany.
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Abstract
Brain arteriovenous malformation (bAVM) is an important cause of intracranial hemorrhage (ICH), particularly in the young population. ICH is the first clinical symptom in about 50 % of bAVM patients. The vessels in bAVM are fragile and prone to rupture, causing bleeding into the brain. About 30 % of unruptured and non-hemorrhagic bAVMs demonstrate microscopic evidence of hemosiderin in the vascular wall. In bAVM mouse models, vascular mural cell coverage is reduced in the AVM lesion, accompanied by vascular leakage and microhemorrhage. In this review, we discuss possible signaling pathways involved in abnormal vascular development in bAVM.
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Affiliation(s)
- Rui Zhang
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, 1001 Potrero Avenue, 1363, San Francisco, CA, 94110, USA
| | - Wan Zhu
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, 1001 Potrero Avenue, 1363, San Francisco, CA, 94110, USA
| | - Hua Su
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California, San Francisco, 1001 Potrero Avenue, 1363, San Francisco, CA, 94110, USA.
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Abstract
Brain arteriovenous malformations (BAVM) are some of the most complex lesions treated by clinical neuroscientists. The recent publication of the ARUBA trial, showing higher complication rates with treatment compared with the natural history over a short period of follow-up, puts even more pressure on the physician to achieve complete BAVM eradication without complication. These lesions are often treated by multimodality therapy with some combination of endovascular embolization, radiosurgery, and microsurgical resection; however, multimodality therapy involves the additive risk of procedural complication with each procedure. While surgical resection has long been accepted as monotherapy with good cure rates, staged pre-operative endovascular embolization has facilitated microsurgical resection with lower blood loss. Endovascular embolization is more often utilized in conjunction with surgical resection, and often the portions of the AVM and feeders that are completely embolized with Onyx or glue may not be surgically resected since they have been "internally obliterated." We present a case where the AVM was preoperatively embolized with Onyx and subsequently partially surgically resected. Post-operative angiography showed complete obliteration or "cure" of the AVM with no filling of the nidus or early venous drainage. The patient presented 12 months later with seizures and imaging showed volume loss in the residual Onyx cast and recanalization of the AVM nidus. The patient subsequently underwent repeat resection with complete removal of the residual AVM and Onyx cast. To our knowledge this is the first published report of volume loss within the Onyx cast leading to recanalization of the AVM nidus. This suggests that extreme care should be taken with partial resection of the AVM nidus or with embolization for cure, as late recanalization may occur.
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Affiliation(s)
- Andrew M Bauer
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mark D Bain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Peter A Rasmussen
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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