Comparison of cerebral AVMs in patients undergoing surgical resection with and without prior endovascular embolization

Abstract Surgical resection is one option in the treatment of large high-grade brain arteriovenous malformations (AVMs). Resection of AVMs with skull-eroding components can be challenging due to the risk of excessive bleeding from these components during craniotomy and bone flap removal. We present a case of a 25-yr-old woman who presented with an acute onset right-sided frontal headache. She was found to have a large, frontal Spetzler-Martin grade IV AVM with an associated dural AVM. The AVM had caused focal erosions of the right frontal bone by a venous varix traversing the region of the calvarial defect. An elective staged endovascular embolization followed by surgical resection was recommended considering the patient's young age and the large size of the AVM located in a noneloquent area. Given the high risk of intraoperative hemorrhage during the craniotomy portion of the procedure, a “craniotomy within craniotomy” approach was planned. During this approach, a small rectangle of bone, including the portion eroded by the venous varix, was left in place, while the larger bone flap surrounding it was removed for an initial approach to the AVM. The small bony piece was safely removed at later stages of resection once the arterial feeders had been reasonably obliterated. Immediate postoperative catheter angiogram demonstrated good filling of the intracranial vascular territories with no residual AVM. The patient developed mild left facial and left hand weakness postoperatively, which resolved after 2 wk of follow-up. The patient remained neurologically intact on further follow-up.

Download Full-text

Endovascular Advances for Brain Arteriovenous Malformations

Neurosurgery ◽

10.1227/neu.0000000000000176 ◽

2014 ◽

Vol 74 (suppl_1) ◽

pp. S74-S82 ◽

Cited By ~ 57

Author(s):

R. Webster Crowley ◽

Andrew F. Ducruet ◽

Cameron G. McDougall ◽

Felipe C. Albuquerque

Keyword(s):

Endovascular Treatment ◽

Surgical Resection ◽

Arteriovenous Malformations ◽

Treatment Options ◽

Brain Arteriovenous Malformations ◽

Short Period ◽

Cerebral Avms ◽

Brain Avms ◽

The Brain ◽

The Way

Abstract Arteriovenous malformations (AVMs) of the brain represent unique challenges for treating physicians. Although these lesions have traditionally been treated with surgical resection alone, advancements in endovascular and radiosurgical therapies have greatly expanded the treatment options for patients harboring brain AVMs. Perhaps no subspecialty within neurosurgery has seen as many advancements over a relatively short period of time as the endovascular field. A number of these endovascular innovations have been designed primarily for cerebral AVMs, and even those advancements that are not particular to AVMs have resulted in substantial changes to the way cerebral AVMs are treated. These advancements have enabled the embolization of cerebral AVMs to be performed either as a stand-alone treatment, or in conjunction with surgery or radiosurgery. Perhaps nothing has impacted the treatment of brain AVMs as substantially as the development of liquid embolics, most notably Onyx and n-butyl cyanoacrylate. However, of near-equal impact has been the innovations seen in the catheters that help deliver the liquid embolics to the AVMs. These developments include flow-directed catheters, balloon-tipped catheters, detachable-tipped catheters, and distal access catheters. This article aims to review some of the more substantial advancements in the endovascular treatment of brain AVMs and to discuss the literature surrounding the expanding indications for endovascular treatment of these lesions.

Download Full-text

Endovascular embolization of cerebral AVMs prior to surgery or radiosurgery

Journal of Clinical Neuroscience ◽

10.1016/s0967-5868(98)90014-5 ◽

1998 ◽

Vol 5 ◽

pp. 58-60 ◽

Cited By ~ 8

Author(s):

Shigeru Miyachi ◽

Tatsuya Kobayashi ◽

Yoshihisa Kida ◽

Takayuki Tanaka

Keyword(s):

Endovascular Embolization ◽

Cerebral Avms

Download Full-text

Embolization of the choroidal artery in the treatment of cerebral arteriovenous malformations

Journal of Neurosurgery ◽

10.3171/2016.2.jns152370 ◽

2017 ◽

Vol 126 (4) ◽

pp. 1114-1122 ◽

Cited By ~ 7

Author(s):

Alaa Elkordy ◽

Hidenori Endo ◽

Kenichi Sato ◽

Yasushi Matsumoto ◽

Ryushi Kondo ◽

...

Keyword(s):

Arteriovenous Malformations ◽

Open Surgery ◽

Gamma Knife Radiosurgery ◽

Internal Capsule ◽

Endovascular Embolization ◽

Anterior Choroidal Artery ◽

Cerebral Avms ◽

Anterior Choroidal ◽

Choroidal Artery

OBJECTIVE The anterior and posterior choroidal arteries are often recruited to supply arteriovenous malformations (AVMs) involving important paraventricular structures, such as the basal ganglia, internal capsule, optic radiation, lateral geniculate body, and medial temporal lobe. Endovascular embolization through these arteries is theoretically dangerous because they supply eloquent territories, are of small caliber, and lack collaterals. This study aimed to investigate the safety and efficacy of embolization through these arteries. METHODS This study retrospectively reviewed 13 patients with cerebral AVMs who underwent endovascular embolization through the choroidal arteries between 2006 and 2014. Embolization was performed as a palliative procedure before open surgery or Gamma Knife radiosurgery. Computed tomography and MRI were performed the day after embolization to assess any surgical complications. The incidence and type of complications and their association with clinical outcomes were analyzed. RESULTS Decreased blood flow was achieved in all patients after embolization. Postoperative CT detected no hemorrhagic complications. In contrast, postoperative MRI detected that 4 of the 13 patients (30.7%) developed infarctions: 3 patients after embolization through the anterior choroidal artery, and 1 patient after embolization through the lateral posterior choroidal artery. Two of the 4 patients in whom embolization was from the cisternal segment of the anterior choroidal artery (proximal to the plexal point) developed symptomatic infarction of the posterior limb of the internal capsule, 1 of whom developed morbidity (7.7%). The treatment-related mortality rate was 0%. Additional treatment was performed in 12 patients: open surgery in 9 and Gamma Knife radiosurgery in 3 patients. Complete obliteration was confirmed by angiography at the last follow-up in 10 patients. Recurrent bleeding from the AVMs did not occur in any of the cases during the follow-up period. CONCLUSIONS Ischemic complications are possible following the embolization of cerebral AVMs through the choroidal artery, even with modern neurointerventional devices and techniques. Although further study is needed, embolization through the choroidal artery may be an appropriate treatment option when the risk of surgery or radiosurgery is considered to outweigh the risk of embolization.

Download Full-text

Superselective Endovascular Embolization as an Adjunct to Safe and Effective Surgical Resection of Cerebral and Spinal Tumors

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0034-1383809 ◽

2014 ◽

Vol 75 (S 02) ◽

Author(s):

D. Zumofen ◽

M. Potts ◽

O. Tanweer ◽

H. Riina

Keyword(s):

Surgical Resection ◽

Endovascular Embolization ◽

Spinal Tumors

Download Full-text

Outcome of Endovascular Treatment of Cerebral Arteriovenous Malformations with Ethylene Vinyl Alcohol Coploymer

QJM ◽

10.1093/qjmed/hcaa054.005 ◽

2020 ◽

Vol 113 (Supplement_1) ◽

Author(s):

H E Mohram ◽

M A Habib ◽

S H Mourad ◽

A H Abozeid ◽

A M M Salem

Keyword(s):

Arteriovenous Malformations ◽

Interventional Procedures ◽

Endovascular Embolization ◽

Vascular Territory ◽

Cure Rate ◽

Cerebral Arteriovenous Malformations ◽

University Hospitals ◽

Curative Intent ◽

Ethylene Vinyl Alcohol ◽

Cerebral Avms

Abstract Background Cerebral AVMs are very rare lesions, and this rarity contributes to the difficulty of treating them. There is no consensus concerning the method of treatment to be chosen among neurosurgery, radiosurgery or embolization. Onyx embolization could serve as a curative option with accepted morbidity and mortality. The introduction of Onyx and of catheters with detachable tips has no doubt increased the rate of endovascular occlusion, and decreased the risks associated with treatment in our experience. Objective The aim of the study was to assess the outcome of the use of Onyx in the treatment of intracranial AVMs as curative embolization or before neuro- or radiosurgery Patients and Methods This analytical prospective study was conducted on 25 patients who were diagnosed with cerebral arteriovenous malformations and underwent endovascular embolization with EVOH copolymer with curative intent during the study period. Interventional procedures were done in the neuro – endovascular unit, neurosurgery department Ain Shams University Hospitals and associate neuroendovascular unit in El Matarya Teaching Hospital in the period between September 2014 and April 2017. Results Actually comparing these results especially concerning the cure rate along with other studies was somewhat confusing and problematic owing to the diversity in results between studies across the last 15 years. Conclusion For the cases that are not fulfilling these criteria, embolization should be offered as preparing step for other modality of treatment. In our experience, for curative embolization, the AVM should be small sized (< 3 cm), supplied by one vascular territory, with feeders that can tolerate reflux up to 2–3 cm, with clear proximal parts of the draining veins, and not located in deep structures.

Download Full-text

Treatment of Pulmonary Sequestrations by Means of Endovascular Embolization: Future or Fashion?

Case Reports in Medicine ◽

10.1155/2011/173918 ◽

2011 ◽

Vol 2011 ◽

pp. 1-3 ◽

Cited By ~ 3

Author(s):

Jeroen Diks ◽

P. Ronald Schütte ◽

David Cheung ◽

J. Marco Schnater

Keyword(s):

Surgical Resection ◽

Arterial Embolization ◽

Primary Treatment ◽

Endovascular Embolization ◽

Endovascular Techniques ◽

Female Adult ◽

Unsuccessful Attempt ◽

Bronchopulmonary Sequestration ◽

Rare Malformation ◽

Methods Of Treatment

Bronchopulmonary sequestration is a rare malformation of the lower respiratory tract. Several methods of treatment have been described since the first publication. We present two cases of female adult patients with bronchopulmonary sequestration. In the first patient an unsuccessful attempt to treat the bronchopulmonary sequestration by means of arterial embolization is described. She was subsequently treated by means of surgical resection, which was the primary treatment for the second patient. Although endovascular techniques are becoming promising, in our opinion surgical resection remains the unique treatment for bronchopulmonary sequestration.

Download Full-text

Intraoperative Transpedicular Onyx Injection to Reduce Vascularity of a Thoracic Hemangiopericytoma After Unsuccessful Preoperative Endovascular Embolization: a Technical Report

Operative Neurosurgery ◽

10.1093/ons/opx102 ◽

2017 ◽

Vol 14 (2) ◽

pp. E17-E22

Author(s):

Hazem Mashaly ◽

Zoe Zhang ◽

Andrew Shaw ◽

Patrick Youssef ◽

Ehud Mendel

Keyword(s):

Central Nervous System ◽

Nervous System ◽

Blood Loss ◽

Surgical Resection ◽

Central Nervous System Involvement ◽

Vascular Tumor ◽

Massive Bleeding ◽

Endovascular Embolization ◽

Intraoperative Blood Loss ◽

Percutaneous Injection

Abstract BACKGROUND AND IMPORTANCE Hemangiopericytoma is a rare vascular tumor with central nervous system involvement representing only 1% of central nervous system tumors. They rarely affect the vertebral column. Complete surgical resection is the treatment of choice for hemangiopericytoma given their high rates of local recurrence. However, the high vascularity of such tumors with the risk of massive bleeding during surgery represents a significant challenge to surgeons. Therefore, preoperative endovascular embolization via the transarterial route has been advocated. CLINICAL PRESENTATION In the current study, we present a case of a T12 hemangiopericytoma that was managed by a 2-stage surgical resection, with the use of intraoperative transpedicular onyx injection to reduce intraoperative blood loss following an unsuccessful trial of preoperative endovascular embolization. CONCLUSION Preoperative endovascular embolization is not feasible in some cases due to the location of the segmental or radiculomedullary arteries in relation to tumor feeders and, rarely, small size of these arterial feeders. Percutaneous injection of onyx is an option. In this case report, we discuss direct intraoperative injection via a transpedicular route as a safe and effective method for decreasing the vascularity of some lesions and improving intraoperative blood loss.

Download Full-text

Urticarial reaction following endovascular embolization of an orbital arteriovenous malformation (AVM) with n-butyl cyanoacrylate (nBCA) glue

Interventional Neuroradiology ◽

10.1177/1591019917728400 ◽

2017 ◽

Vol 23 (6) ◽

pp. 666-668 ◽

Cited By ~ 4

Author(s):

Kunal R Sinha ◽

Gary Duckwiler ◽

Daniel B Rootman

Keyword(s):

Arteriovenous Malformation ◽

Surgical Resection ◽

Arteriovenous Malformations ◽

Vascular Inflammation ◽

Endovascular Embolization ◽

Vascular Lesions ◽

Hypersensitivity Reactions ◽

Potential Complication ◽

Skin Allergy ◽

Systemic Hypersensitivity

Orbital arteriovenous malformations (AVMs) are rare vascular lesions that may be managed with endovascular embolization followed by surgical resection. Embolization is often accomplished with n-butyl-2-cyanoacrylate (nBCA), which is considered to be a safe and effective liquid occlusive agent. Localized vascular inflammation has been associated with endovascular nBCA use in histopathologic studies, but reports of systemic hypersensitivity reactions following endovascular embolization with nBCA are rare. We present a case of a 26-year-old male who developed an intermittent systemic urticarial reaction without cardiopulmonary compromise beginning four weeks after nBCA embolization of an orbital AVM. Subsequent skin allergy testing performed by an allergist confirmed hypersensitivity to nBCA glue and the patient has since been successfully managed with daily oral antihistamines. Awareness of this rare potential complication of endovascular embolization with nBCA will aid in the counseling and management of patients with AVMs.

Download Full-text