Interactive Use of Cerebral Angiography and Magnetoencephalography in Arteriovenous Malformations: Technical Note

Neurosurgery ◽  
2002 ◽  
Vol 50 (4) ◽  
pp. 903-911 ◽  
Author(s):  
Toshifumi Kamiryo ◽  
Joshua Cappell ◽  
Eugene Kronberg ◽  
Henry H. Woo ◽  
Jafar J. Jafar ◽  
...  
Keyword(s):  
Cerebral Angiography ◽  
Arteriovenous Malformations ◽  
Three Dimensional ◽  
Technical Note ◽  
Distortion Correction ◽  
Custom Made ◽  
Selective Targeting ◽  
Coordinate Transfer ◽  
Feeding Vessels ◽  
Digital Subtraction Angiogram

Abstract OBJECTIVE: To minimize the risks associated with treating cortical cerebral arteriovenous malformations (AVMs), we developed a technique combining functional imaging and cerebral angiography. The functional loci obtained by performing magnetoencephalography (MEG) are projected onto stereoscopic pairs of a stereotactically derived digital subtraction angiogram. The result is a simultaneous three-dimensional perspective of the angioarchitecture of an AVM and its relationship to the sensorimotor cortex. METHODS: Eight patients underwent multimodality brain imaging, including magnetic resonance imaging, functional mapping via MEG, and stereotactic angiography using a modified Compass fiducial system (Compass International, Rochester, MN). The coordinates derived by performing MEG were superimposed onto stereotactic, stereoscopic, angiographic pairs using custom-made distortion correction and coordinate transfer software. RESULTS: The magnetoencephalographic angiogram allowed simultaneous viewing of the angioarchitecture of the AVM nidus, the feeding vessels, and the draining veins and their relationship to the normal cerebral vasculature and functional cortex. This imaging technique was particularly valuable in identifying en passant vessels that supplied functional cortex and was used during the treatment of these lesions. CONCLUSION: The techniques of MEG and cerebral angiography were combined to provide simultaneous viewing of both modalities in a three-dimensional perspective. This technique can aid in risk stratification in the management of patients with cerebral AVMs. In addition, this technique can facilitate the selective targeting of vessels, thus potentially reducing the risks associated with embolization of these formidable lesions.

scholarly journals The Use of Detachable Flanges on Customized Titanium Orbital Implants: A Technical Note

2011 ◽  
Vol 4 (4) ◽  
pp. 201-202 ◽  
Author(s):  
Shakir F. Mustafa ◽  
A. Bocca ◽  
Adrian W. Sugar ◽  
Steven J. Key
Keyword(s):  
Rapid Prototyping ◽  
Three Dimensional ◽  
Titanium Implant ◽  
Technical Note ◽  
Implant Surface ◽  
Orbital Implants ◽  
Combined Use ◽  
Custom Made ◽  
Orbital Rim ◽  
Stereolithographic Models

The combined use of three-dimensional reformatted images, stereolithographic models, and rapid prototyping allows the construction of an accurate, individually made titanium implant for the reconstruction of orbital floor defects. Despite the perfect fit of the custom-made plate to the model, there might be several locations on the bone where the plate may reside intraoperatively. Most titanium orbital plates therefore contain extensions over the inferior orbital rim to help locate and stabilize the plate in its position on the bone. Such over-the-rim extensions may be palpable and can cause discomfort postoperatively. We describe the use of two small detachable flanges that help to accurately locate the orbital plate in place and allow its fixation. The locating flanges are then detached and discarded, leaving a smooth implant surface within the confines of the bony orbit.

An innovative prone positioning system for advanced deformity and frailty in complex spine surgery

2020 ◽  
Vol 32 (2) ◽  
pp. 229-234
Author(s):  
Benjamin Kolb ◽  
John Large ◽  
Stuart Watson ◽  
Glyn Smurthwaite
Keyword(s):  
Ankylosing Spondylitis ◽  
Three Dimensional ◽  
Technical Note ◽  
Positioning System ◽  
Prone Positioning ◽  
Economic Implications ◽  
Potential Safety ◽  
Chest Deformity ◽  
Positioning Device ◽  
Skin Quality

The authors present a technical note for a prone positioning system developed to facilitate cervical extension osteotomy for ankylosing spondylitis in the presence of severe deformity and frailty. Chin-on-chest deformity represents one of the most debilitating changes of ankylosing spondylitis. Where the chin-brow angle approaches or exceeds 90°, prone positioning becomes problematic due to the fixed position of the head. Furthermore, the challenge is compounded where physiological deconditioning leads to frailty, and the side effects of medical therapies decrease muscle mass and skin quality. Conventional prone positioning equipment is not able to cater to all patients. A versatile system was developed using a 3D reconstruction to enable a positioning simulation and verification tool. The tool was used to comprehensively plan the perioperative episode, including spatial orientation and associated equipment. Three-dimensional printing was used to manufacture a bespoke positioning device that precisely matched the contours of the patient, reducing contact pressure and risk of skin injury. The authors were able to safely facilitate surgery for a patient whose deformity and frailty may otherwise have precluded this possibility. The system has potential safety and economic implications that may be of significant utility to other institutions engaging in complex spinal surgery.

Fractionated Stereotactic Radiotherapy For the Treatment of Large Arteriovenous Malformations with or without Previous Partial Embolization

Neurosurgery ◽  
2004 ◽  
Vol 55 (3) ◽  
pp. 519-531 ◽  
Author(s):  
Erol Veznedaroglu ◽  
David W. Andrews ◽  
Ronald P. Benitez ◽  
M. Beverly Downes ◽  
Maria Werner-Wasik ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Stereotactic Radiotherapy ◽  
Arteriovenous Malformations ◽  
Three Dimensional ◽  
Late Complications ◽  
Fractionated Stereotactic Radiotherapy ◽  
Medical Systems ◽  
Significant Treatment ◽  
Lost To Follow Up

Abstract OBJECTIVE: Despite the success of stereotactic radiosurgery, large inoperable arteriovenous malformations (AVMs) of 14 cm3 or more have remained largely refractory to stereotactic radiosurgery, with much lower obliteration rates. We review treatment of large AVMs either previously untreated or partially obliterated by embolization with fractionated stereotactic radiotherapy (FSR) regimens using a dedicated linear accelerator (LINAC). METHODS: Before treatment, all patients were discussed at a multidisciplinary radiosurgery board and found to be suitable for FSR. All patients were evaluated for pre-embolization. Those who had feeding pedicles amenable to glue embolization were treated. LINAC technique involved acquisition of a stereotactic angiogram in a relocatable frame that was also used for head localization during treatment. The FSR technique involved the use of six 7-Gy fractions delivered on alternate days over a 2-week period, and this was subsequently dropped to 5-Gy fractions after late complications in one of seven patients treated with 7-Gy fractions. Treatments were based exclusively on digitized biplanar stereotactic angiographic data. We used a Varian 600SR LINAC (Varian Medical Systems, Inc., Palo Alto, CA) and XKnife treatment planning software (Radionics, Inc., Burlington, MA). In most cases, one isocenter was used, and conformality was established by non-coplanar arc beam shaping and differential beam weighting. RESULTS: Thirty patients with large AVMs were treated between January 1995 and August 1998. Seven patients were treated with 42-Gy/7-Gy fractions, with one patient lost to follow-up and the remaining six with previous partial embolization. Twenty-three patients were treated with 30-Gy/5-Gy fractions, with two patients lost to follow-up and three who died as a result of unrelated causes. Of 18 evaluable patients, 8 had previous partial embolization. Mean AVM volumes at FSR treatment were 23.8 and 14.5 cm3, respectively, for the 42-Gy/7-Gy fraction and 30-Gy/5-Gy fraction groups. After embolization, 18 patients still had AVM niduses of 14 cm3 or more: 6 in the 7-Gy cohort and 12 in the 5-Gy cohort. For patients with at least 5-year follow-up, angiographically documented AVM obliteration rates were 83% for the 42-Gy/7-Gy fraction group, with a mean latency of 108 weeks (5 of 6 evaluable patients), and 22% for the 30-Gy/5-Gy fraction group, with an average latency of 191 weeks (4 of 18 evaluable patients) (P = 0.018). For AVMs that remained at 14 cm3 or more after embolization (5 of 6 patients), the obliteration rate remained 80% (4 of 5 patients) for the 7-Gy cohort and dropped to 9% for the 5-Gy cohort. A cumulative hazard plot revealed a 7.2-fold greater likelihood of obliteration with the 42-Gy/7-Gy fraction protocol (P = 0.0001), which increased to a 17-fold greater likelihood for postembolization AVMs of 14 cm3 or more (P = 0.003). CONCLUSION: FSR achieves obliteration for AVMs at a threshold dose, including large residual niduses after embolization. With significant treatment-related morbidities, further investigation warrants a need for better three-dimensional target definition with higher dose conformality.

scholarly journals Techniques of Onyx Embolization of Arteriovenous Malformation: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Kathryn M Wagner ◽  
Visish M Srinivasan ◽  
Peter Kan
Keyword(s):  
Informed Consent ◽  
Surgical Resection ◽  
Arteriovenous Malformations ◽  
Preoperative Embolization ◽  
Great Care ◽  
Endovascular Techniques ◽  
Definitive Therapy ◽  
Feeding Vessels ◽  
Multiple Feeding ◽  
Staged Treatment

Abstract Advances in endovascular techniques and tools have allowed for treatment of complex arteriovenous malformations (AVMs), which historically may have posed unacceptable risk for open surgical resection. Endovascular treatment may be employed as an adjunct to surgical resection or as definitive therapy. Improvements in embolization materials have made endovascular AVM treatment safer for patients and useful across a variety of lesions. While many techniques are employed for transarterial AVM embolization, the essential tenets apply to all procedures: (1) great care should be taken to cannulate only vessels directly supplying the lesion, and not en passage vessels, prior to injecting embolisate; (2) embolisate should travel into the nidus, but not into the draining veins; (3) embolistate reflux proximal to the microcatheter should be avoided. There are several techniques that accomplish these goals, including the plug and push method, or using a balloon to prevent embolisate reflux. We use controlled injection of liquid Onyx (Medtronic), with increasing pressure over multiple injections pushing the embolisate forward into the AVM. This is repeated in multiple feeding vessels to decrease or eliminate supply to the AVM. Here, we present a 36-yr-old female with a right parietal AVM discovered on workup of headaches. After informed consent was obtained, she underwent preoperative embolization using this technique prior to uncomplicated surgical resection. The video shows the endovascular Onyx embolization of multiple feeding vessels over staged treatment.

scholarly journals Recurrent contracted sockets treated with personalized, three-dimensionally printed conformers and buccal grafts

2021 ◽  
pp. 112067212110000
Author(s):  
Annabel LW Groot ◽  
Jelmer S Remmers ◽  
Roel JHM Kloos ◽  
Peerooz Saeed ◽  
Dyonne T Hartong
Keyword(s):  
Three Dimensional ◽  
Case Series ◽  
Secondary Outcome ◽  
Retrospective Case ◽  
Upper Eyelid ◽  
Ocular Prosthesis ◽  
Buccal Mucosal Graft ◽  
Custom Made ◽  
3D Printed

Purpose: Recurrent contracted sockets are complex situations where previous surgeries have failed, disabling the wear of an ocular prosthesis. A combined method of surgery and long-term fixation using custom-made, three-dimensional (3D) printed conformers is evaluated. Methods: Retrospective case series of nine patients with recurrent excessive socket contraction and inability to wear a prosthesis, caused by chemical burns ( n = 3), fireworks ( n = 3), trauma ( n = 2) and enucleation and radiotherapy at childhood due to optic nerve glioma ( n = 1) with three average previous socket surgeries (range 2–6). Treatment consisted of a buccal mucosal graft and personalized 3D-printed conformer designed to be fixated to the periosteum and tarsal plates for minimal 2 months. Primary outcome was the retention of an ocular prosthesis. Secondary outcome was the need for additional surgeries. Results: Outcomes were measured at final follow-up between 7 and 36 months postoperatively (mean 20 months). Eight cases were able to wear an ocular prosthesis after 2 months. Three cases initially treated for only the upper or only the lower fornix needed subsequent surgery for the opposite fornix for functional reasons. Two cases had later surgery for cosmetic improvement of upper eyelid position. Despite pre-existing lid abnormalities (scar, entropion, lash deficiency), cosmetic outcome was judged highly acceptable in six cases because of symmetric contour and volume, and reasonably acceptable in the remaining two. Conclusions: Buccal mucosal transplant fixated with a personalized 3D-designed conformer enables retention of a well-fitted ocular prosthesis in previously failed socket surgeries. Initial treatment of both upper and lower fornices is recommended to avoid subsequent surgeries for functional reasons.

scholarly journals Preoperative silk suture embolization of cerebral and dural arteriovenous malformations

2001 ◽  
Vol 11 (5) ◽  
pp. 1-6 ◽  
Author(s):  
Amir R. Dehdashti ◽  
Michel Muster ◽  
Alain Reverdin ◽  
Nicolas De Tribolet ◽  
Daniel A. Ruefenacht
Keyword(s):  
Arteriovenous Malformations ◽  
Histopathological Examination ◽  
Adverse Outcomes ◽  
Neurological Deficits ◽  
Grading System ◽  
Silk Suture ◽  
Long Term Follow Up ◽  
Feeding Vessels ◽  
A Minor ◽  
Proximal Occlusion

Object The aim of this study was to evaluate the use of silk sutures as a medical implant when applied for the embolization of cerebral and dural arteriovenous malformations (AVMs). The facility of surgery and the clinical significance of complications related to preoperative silk suture embolization were evaluated immediately after surgery and at long-term follow up. Methods Thirty-four patients harboring 29 cerebral and five dural AVMs underwent embolization in which silk alone or in association with other agents was used. Medical and radiological records obtained in these 34 patients were reviewed retrospectively. The cerebral AVMs were classified according to the Spetzler–Martin grading system and the dural AVMs to the Djindjian grading system. The facility of the resection and the adverse outcomes, including new neurological deficits, hemorrhage, and fever, as well as histopathological evidence of vessel inflammatory changes, were determined in each case. In all 23 surgical cases, the AVM could be easily manipulated and excised. New temporary neurological deficits occurred in three patients. A high Spetzler–Martin grade was not associated with a higher incidence of new neurological deficits. One delayed-onset hemorrhage was detected after embolization. Fever was present in 24% of the patients. No sign of significant vasculitis or perivascular inflammation was found on radiological or histopathological examination. Conclusions Silk sutures are safe embolic agents especially for proximal occlusion of AVM feeding vessels. New permanent neurological deficits were not encountered in this series. Fever was considered to be a minor, temporary side effect of silk suture embolization.

Cerebral angiography during operation for intracranial aneurysms and arteriovenous malformations

1971 ◽  
Vol 34 (5) ◽  
pp. 706-708 ◽  
Author(s):  
Martin L. Lazar ◽  
Clark C. Watts ◽  
Bassett Kilgore ◽  
Kemp Clark
Keyword(s):  
Cerebral Angiography ◽  
Arteriovenous Malformations ◽  
Intracranial Aneurysms ◽  
Operative Procedure ◽  
Superficial Temporal Artery ◽  
Technical Problem ◽  
Temporal Artery ◽  
Content Type ◽  
Actual Operation ◽  
Fine Print

✓ Angiography during the operative procedure is desirable, but is often difficult because of the problem of maintaining a needle or cannula in an artery for long periods of time. Cannulation of the superficial temporal artery avoids this technical problem. The artery is easily found, cannulation is simple, and obliteration of the artery is of no consequence. Cerebral angiography then provides a means for prompt evaluation of the surgical procedure at any time during the actual operation.

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