Single-stage planning for total cure of grade III–V brain arteriovenous malformations by embolization alone or in combination with microsurgical resection

2018 ◽  
Vol 61 (2) ◽  
pp. 195-205 ◽  
Author(s):  
Naci Kocer ◽  
Sedat Giray Kandemirli ◽  
Reza Dashti ◽  
Osman Kizilkilic ◽  
Hakan Hanimoglu ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Single Stage ◽  
Brain Arteriovenous Malformations ◽  
Microsurgical Resection ◽  
Grade Iii

Superior outcomes in children compared with adults after microsurgical resection of brain arteriovenous malformations

2006 ◽  
Vol 105 (2) ◽  
pp. 82-87 ◽  
Author(s):  
René O. Sanchez-Mejia ◽  
Sravana K. Chennupati ◽  
Nalin Gupta ◽  
Heather Fullerton ◽  
William L. Young ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Brain Arteriovenous Malformations ◽  
Microsurgical Resection

scholarly journals Microsurgery for cerebral arteriovenous malformations: subgroup outcomes in a consecutive series of 288 cases

2017 ◽  
Vol 126 (4) ◽  
pp. 1056-1063 ◽  
Author(s):  
Johannes Schramm ◽  
Karl Schaller ◽  
Jonas Esche ◽  
Azize Boström
Keyword(s):  
Arteriovenous Malformations ◽  
Consecutive Series ◽  
Cerebral Arteriovenous Malformations ◽  
Class A ◽  
Significant Deficit ◽  
Microsurgical Resection ◽  
Martin Grade ◽  
Grade Iii

OBJECTIVE The objective of this study was to review the outcomes after microsurgical resection of cerebral arteriovenous malformations (AVMs) from a consecutive single-surgeon series. Clinical and imaging data were analyzed to address the following questions concerning AVM treatment in the post-ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations) era. 1) Are the patients who present with unruptured or ruptured AVMs doing better at long-term follow-up? 2) Is the differentiation between Ponce Class A (Spetzler-Martin Grade I and II) patients versus Ponce Class B and C patients (Spetzler-Martin Grade III and IV) meaningful and applicable to surgical practice? 3) How did the ARUBA-eligible patients of this surgical series compare with the results reported in ARUBA? METHODS Two hundred eighty-eight patients with cerebral AVMs underwent microsurgical resection between 1983 and 2012 performed by the same surgeon (J.S.). This is a prospective case collection study that represents a consecutive series. The results are based on prospectively collected, early-outcome data that were supplemented by retrospectively collected, follow-up data for 94% of those cases. The analyzed data included the initial presentation, Spetzler-Martin grade, obliteration rates, surgical and neurological complications, and frequency of pretreatment with embolization or radiosurgery. The total cohort was compared using “small-AVM,” Spetzler-Martin Grade I and II, and ARUBA-eligible AVM subgroups. RESULTS The initial presentation was hemorrhage in 50.0% and seizures in 43.1% of patients. The series included 53 Spetzler-Martin Grade I (18.4%), 114 Spetzler-Martin Grade II (39.6%), 90 Spetzler-Martin Grade III (31.3%), 28 Spetzler-Martin Grade IV (9.7%), and 3 Spetzler-Martin Grade V (1.0%) AVMs. There were 144 unruptured and 104 ARUBA-eligible cases. Preembolization was used in 39 cases (13.5%). The occlusion rates for the total series and small AVM subgroup were 99% and 98.7%, respectively. The mean follow-up duration was 64 months. Early neurological deterioration was seen in 39.2% of patients, of which 12.2% had permanent and 5.6% had permanent significant deficits, and the mortality rate was 1.7% (n = 5). Outcome was better for patients with AVMs smaller than 3 cm (permanent deficit in 7.8% and permanent significant deficit in 3.2% of patients) and Ponce Class A status (permanent deficit in 7.8% and significant deficit in 3.2% of patients). Unruptured AVMs showed slightly higher new deficit rates (but 0 instances of mortality) among all cases, and in the small AVM and Ponce Class A subgroups. Unruptured Spetzler-Martin Grade I and II lesions had the best outcome (1.8% permanent significant deficit), and ARUBA-eligible Spetzler-Martin Grade I and II lesions had a slightly higher rate of permanent significant deficits (3.2%). CONCLUSIONS Microsurgery has a very high cure rate. Focusing microsurgical AVM resection on unruptured lesions smaller than 3 cm or on Spetzler-Martin Grade I and II lesions is a good strategy for minimizing long-term morbidity. Well-selected microsurgical cases lead to better outcomes than with multimodal interventions, as in the ARUBA treatment arm, or conservative treatment alone. Long-term prospective data collection is valuable.

Abstract 55: Selection and Outcomes of Multimodality Interventional Treatment for Unruptured Arteriovenous Malformations in a Single Institution

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Daisuke Maruyama ◽  
Hisae Mori ◽  
Tetsu Satow ◽  
Hiroharu Kataoka ◽  
Sei Sugata ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Primary Outcome ◽  
Intervention Group ◽  
Interventional Treatment ◽  
Single Institution ◽  
Conservative Group ◽  
Brain Arteriovenous Malformations ◽  
The Mean ◽  
Grade Iii

Objective: The present study aimed to evaluate the selection and outcomes of multimodal interventional treatment for unruptured brain arteriovenous malformations (AVMs) in A Randomised trial of Unruptured Brain Arteriovenous malformations (ARUBA)-eligible patients in a single institution. Methods: We retrospectively reviewed the data of 94 patients with unruptured and untreated AVMs, who had modified Rankin scale (mRS) scores of 0 or 1 at our institution between 2002 and 2014. The patients were divided into an intervention group and a conservative group, and the outcomes were compared. Similar to ARUBA, we defined the primary outcome as the composite endpoint of death or symptomatic stroke. The mRS was used to assess the functional outcome. Results: Of the 94 patients, 75 were included in the intervention group and 19 were included in the conservative group. Additionally, among the 94 patients, 58, 29, and 7 patients had Spetzler-Martin grade I/II, III, and IV/V AVMs, respectively. The number of male patients and the mean age of the patients were significantly lower in the intervention group than in the conservative group (58.6% vs. 84.2%, P=0.03 and 40.8±13.9 vs. 48.4±18.4 years, P=0.04, respectively). However, no significant difference in the proportion of patients with grade I/II AVMs was noted between the groups (65.3% vs. 47.3%). In the intervention and conservative groups, the mean follow-up periods were 59.2±41.6 and 72.8±39.2 months, respectively (P=0.20), and the primary outcome occurred in 9 (12.3%) and 3 (17.6%) patients, respectively (P=0.56). The proportion of patients with a mRS score ≥2 at last follow-up was not significantly different between the two groups (6.9% vs. 11.7%). In the intervention group, the incidence of death or stroke was lower and functional outcomes were better among patients with grade I/II AVMs than among patients with grade III AVMs (4.1% vs. 20%, P=0.003 and 2.0% vs. 15.7%, P=0.04, respectively). Conclusion: The present study found that for patients with unruptured AVMs, interventional treatment is not inferior to medical treatment alone. Multimodal interventional treatment is associated with good outcomes in patients with grade I/II AVMs. However, careful selection should be considered for patients with grade III AVMs.

Endovascular treatment as the main approach for Spetzler–Martin grade III brain arteriovenous malformations

2020 ◽  
pp. neurintsurg-2020-016450
Author(s):  
Humain Baharvahdat ◽  
Raphaël Blanc ◽  
Robert Fahed ◽  
Ashkan Pooyan ◽  
Ashkan Mowla ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Arteriovenous Malformations ◽  
Neurological Deficits ◽  
Treatment Modalities ◽  
Hemorrhagic Complication ◽  
Brain Arteriovenous Malformations ◽  
Poor Outcome ◽  
Complete Exclusion ◽  
Grade Iii

BackgroundBecause Spetzler–Martin (SM) grade III brain arteriovenous malformations (bAVMs) constitute a heterogeneous group of lesions with various combination of sizes, eloquence, and venous drainage patterns, their management is usually challenging. The aim of this study is to evaluate the clinical/imaging outcomes and the procedural safety of endovascular approach as the main treatment for the cure of SM grade III bAVMs.MethodsIn this retrospective study, prospectively collected data of SM grade III bAVMs treated by endovascular techniques between 2010 and 2018 at our hospital were reviewed. Patients older than 16 years with angiographic follow-up of at least 6 months after endovascular treatment were entered in the study. The patients had a mean follow-up of 12 months. The data were assessed for clinical outcome (modified Rankin Scale), permanent neurological deficit, post-operative complications, and optimal imaging outcome, defined by complete exclusion of AVM. The independent predictive variables of poor outcome or hemorrhagic complication were assessed using binary logistic regression.ResultsSixty-five patients with 65 AVMs were included in the study. Mean age of the patients was 40.0±14.4. Most common presentation was hemorrhage (61.5%). The patients underwent one to eight endovascular procedures (median=2). Mean nidus diameter was 30.2±13.0. A complete obliteration of AVM was achieved in 57 patients (87.7%). Post-procedure significant hemorrhagic and ischemic complications were seen in 13 (20%) and five (7.7%) patients respectively, leading to five (7.7%) transient and four (6.2%) permanent neurological deficits. Eight patients (12.3%) experienced worsening of mRS after embolization. Ten patients (15.4%) had poor outcome (mRS 3–5) at follow-up and two (3%) died.ConclusionsEndovascular treatment can achieve a high rate of complete exclusion of grade III AVM but may be associated (as in other treatment modalities) with significant important complications.Clinical trial registration numberNCT02879071.

scholarly journals Comparison of Endovascular Embolization Plus Simultaneous Microsurgical Resection vs. Primary Microsurgical Resection for High-Grade Brain Arteriovenous Malformations

2021 ◽  
Vol 12 ◽  
Author(s):  
Mingze Wang ◽  
Fa Lin ◽  
Hancheng Qiu ◽  
Yong Cao ◽  
Shuo Wang ◽  
...  
Keyword(s):  
Blood Loss ◽  
Arteriovenous Malformations ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
High Grade ◽  
Neurological Outcomes ◽  
Brain Arteriovenous Malformations ◽  
Hybrid Operation ◽  
Microsurgical Resection ◽  
The One

Aim: It remains a challenge in surgical treatments of brain arteriovenous malformations (AVMs) in Spetzler-Martin Grade (SMG) IV and V to achieve both optimal neurological outcomes and complete obliteration. The authors reported a series of patients with AVMs in SMG IV and V who underwent a surgical paradigm of endovascular embolization and simultaneous microsurgical resection based on the one-staged hybrid operation.Methods: Participants in the multicenter prospective clinical trial (NCT 03774017) between January 2016 and December 2019 were enrolled. Patients who received endovascular embolization plus microsurgical resection (EE+MRS) and those who received intraoperative digital subtraction angiography plus microsurgical resection (iDSA+MRS) were divided into two groups. Information on clinical features, operative details, and clinical outcomes were extracted from the database. Deterioration of neurological deficits (DNDs) was defined as the primary outcome, which represented neurological outcomes. The time of microsurgical operation and blood loss were defined as the secondary outcomes representing microsurgical risks and difficulties. Outcomes and technical details were compared between groups.Results: Thirty-eight cases (male: female = 23:15) were enrolled, with 24 cases in the EE+MRS group and 14 in the iDSA+MRS group. Five cases (13.2%) were in SMG V and 33 cases (86.8%) were in SMG IV. Fourteen cases (36.8%) underwent the paradigm of microsurgical resection plus intraoperative DSA. Twenty-four cases (63.2%, n = 24) underwent the paradigm of endovascular embolization plus simultaneous microsurgical resection. Degradations of SMG were achieved in 15 cases. Of the cases, two cases got the residual nidus detected via intraoperative DSA and resected. Deterioration of neurological deficits occurred in 23.7% of cases (n = 9) when discharged, and in 13.5, 13.5, 8.1% of cases at the follow-ups of 3, 6, and 12 months, respectively, without significant difference between groups (P > 0.05). Intracranial hemorrhagic complications were reported in three cases (7.9%) of the EE+MRS group only. The embolization did not significantly affect the surgical time and intraoperative blood loss. The subtotal embolization or the degradation of size by 2 points resulted in no DNDs.Conclusions: The paradigms based on the one-staged hybrid operation were practical and effective in treating high-grade AVMs. Appropriate intraoperative embolization could help decrease operative risks and difficulties and improve neurological outcomes.

Treatment of brain arteriovenous malformations by embolization and radiosurgery

1996 ◽  
Vol 85 (1) ◽  
pp. 19-28 ◽  
Author(s):  
Y. Pierre Gobin ◽  
Alexandre Laurent ◽  
Louis Merienne ◽  
Maurice Schlienger ◽  
Armand Aymard ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Morbidity Rate ◽  
Total Occlusion ◽  
Content Type ◽  
Brain Arteriovenous Malformations ◽  
History Of ◽  
Grade Ii ◽  
Risk Of Hemorrhage ◽  
Grade Iii

✓ Embolization was used to reduce the size of brain arteriovenous malformations (AVMs) prior to radiosurgical treatment in 125 patients who were poor surgical candidates or had refused surgery. Of these patients, 81% had suffered hemorrhage, and 22.4% had undergone treatment at another institution. According to the Spetzler—Martin scale, the AVMs were Grade II in 9.6%, Grade III in 31.2%, Grade IV in 30.4%, and Grades V to VI in 28.8% of the cases. Most embolizations were performed using cyanoacrylate delivered by flow-guided microcatheters. Radiosurgery was performed using a linear accelerator in 62 patients treated by the authors, and 34 patients were treated at other institutions using various methods. Embolization produced total occlusion in 11.2% of AVMs and reduced 76% of AVMs enough to allow radiosurgery. Radiosurgery produced total occlusion in 65% of the partially embolized AVMs (79% when the residual nidus was < 2 cm in diameter). Embolizations resulted in a mortality rate of 1.6% and a morbidity rate of 12.8%. No complications were associated with radiosurgery. The hemorrhage rate for partially embolized AVMs was 3% per year. No patient with a completely occluded AVM experienced rehemorrhage. Angiographic follow-up review of AVMs embolized with cyanoacrylate demonstrated a 11.8% revascularization rate, occurring within 1 year. It is concluded that after partial embolization with cyanoacrylate, the risk of hemorrhage from the residual nidus is comparable to the natural history of AVMs and that the residual nidus can be irradiated with results almost as good as for a native AVM of the same size.

scholarly journals RADIOSURGERY FACILITATES RESECTION OF BRAIN ARTERIOVENOUS MALFORMATIONS AND REDUCES SURGICAL MORBIDITY

Neurosurgery ◽  
2009 ◽  
Vol 64 (2) ◽  
pp. 231-240 ◽  
Author(s):  
Rene O. Sanchez-Mejia ◽  
Michael W. McDermott ◽  
Jeffery Tan ◽  
Helen Kim ◽  
William L. Young ◽  
...  
Keyword(s):  
San Francisco ◽  
Arteriovenous Malformations ◽  
Latency Period ◽  
Preoperative Embolization ◽  
Modified Rankin Scale ◽  
Surgical Morbidity ◽  
Operative Morbidity ◽  
Brain Arteriovenous Malformations ◽  
Asymptomatic Patients ◽  
Microsurgical Resection

Abstract OBJECTIVE Stereotactic radiosurgery makes brain arteriovenous malformations (AVM) more manageable during their microsurgical resection. To better characterize these effects, we compared results of microsurgical resection of radiated (RS+) and nonradiated (RS−) AVMs to demonstrate that previous radiosurgery facilitates surgery and decreases operative morbidity. METHODS From our series of 344 patients who underwent AVM resections at the University of California, San Francisco (1997–2007), 21 RS+ patients were matched with 21 RS+ patients based on pretreatment clinical and AVM characteristics. Matching was blinded to outcomes, which were assessed with the modified Rankin Scale. RESULTS Mean AVM volume was reduced by 78% (P &lt; 0.01), and Spetzler-Martin grades were reduced in 52% of RS+ patients (P &lt; 0.001). Preoperative embolization was used less in RS+ than in RS− patients (P &lt; 0.001). Mean operative time (P &lt; 0.01), blood loss (P &lt; 0.05), and length of hospital stay (P &lt; 0.05) were lower in the RS+ group. Surgical morbidity was 14% higher in RS− patients, and they demonstrated significant worsening in modified Rankin Scale scores after surgery, whereas RS+ patients did not (P &lt; 0.01). RS+ patients deteriorated between AVM diagnosis and surgery owing to hemorrhages during the latency period (P &lt; 0.05). CONCLUSION Previous radiosurgery facilitates AVM microsurgery and decreases operative morbidity. Radiosurgery is recommended for unruptured AVMs that are not favorable for microsurgical resection. Microsurgical resection is recommended for radiated AVMs that are not completely obliterated after the 3-year latency period but are altered favorably for surgery, even in asymptomatic patients. Prompt resection of persistent AVMs should be considered to avoid the risk of postlatency hemorrhage and to optimize patient outcomes.

Nidal embolization of brain arteriovenous malformations: rates of cure, partial embolization, and clinical outcome

2012 ◽  
Vol 117 (1) ◽  
pp. 65-77 ◽  
Author(s):  
Daniel H. Sahlein ◽  
Paloma Mora ◽  
Tibor Becske ◽  
Peter K. Nelson
Keyword(s):  
Treatment Strategy ◽  
Arteriovenous Malformations ◽  
Endovascular Embolization ◽  
Single Stage ◽  
Embolic Agent ◽  
Venous Aneurysm ◽  
Efficacy And Safety ◽  
Safety And Efficacy ◽  
Average Percentage ◽  
Brain Arteriovenous Malformations

Object Nidal embolization of brain arteriovenous malformations (bAVMs) has become an increasingly important component of bAVM treatment. However, controversy exists as to the relative efficacy and safety of single-stage versus multistage approaches to bAVM embolization, with recent literature favoring multistage strategies. The authors present a series of consecutive bAVMs embolized at their institution, demonstrating the safety and efficacy of a predominantly single-stage embolization strategy. The safety and efficacy of embolization are reported in the context of predetermined treatment strategies to provide more generalizable insight into treatment outcome. Methods One hundred thirty consecutive patients with 131 bAVMs underwent endovascular embolization at a single center. Diagnostic angiography with superselective microcatheterizations was performed in all patients. Postembolization angiograms were reviewed by 3 neuroradiologists for degree of occlusion and angiographic evidence of procedural complications. Patients were divided into cohorts based on the prospectively determined treatment strategy, which included the following: global devascularization of the bAVM (Devasc); targeting of a focal angioarchitectural weakness (Target), typically as an adjunct to surgery or Gamma Knife treatment; and primary occlusion of the bAVM by embolization alone (Occlude). Safety and efficacy were evaluated in the context of these treatment groups. Results The 131 bAVMs were treated over an average of 1.28 embolization sessions per bAVM; 105 bAVMs (80%) were treated in a single stage. The average percentage devascularization in the Devasc arm was 85.3%, which was statistically significantly greater than the 72% aggregate devascularization reported in 8 modern N-butyl cyanoacrylate and Onyx papers based on 1-sample Wilcoxon rank-sum testing (p < 0.001). Focal angioarchitectural weaknesses were successfully embolized for all 24 bAVMs in the Target group, directly with the embolic agent in 23 bAVMs and indirectly in 1 bAVM with a venous aneurysm/pseudoaneurysm by reducing arterial inflow and inducing venous thrombosis. Lesions in all patients in the Occlude arm were 100% occluded with embolization alone. Overall, the bAVMs in the Occlude arm were significantly smaller and required embolization of fewer pedicles than those in the Devasc group. One patient (0.8%) experienced significant morbidity following embolization, and 1 patient in the cohort died (0.8%). Conclusions This research communicates the authors' experience in developing a largely single-stage strategy for embolization of bAVMs. The results suggest that an aggressive, single-stage embolization may be implemented with a margin of safety and effectiveness similar to the multistage approaches more commonly reported in the literature. This work additionally introduces the importance of prospective assignment to a treatment strategy in assessing procedural outcome in bAVM embolization, thereby improving generalizability of the results and allowing for more rigorous interpretation of efficacy and safety.

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