Long term follow-up of endovascular management of spinal cord arteriovenous malformations with emphasis on particle embolization

2018 ◽  
Vol 10 (12) ◽  
pp. 1183-1186 ◽  
Author(s):  
Adrien Collin ◽  
Marc-Antoine Labeyrie ◽  
Stephanie Lenck ◽  
Akli Zetchi ◽  
Armand Aymard ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Endovascular Treatment ◽  
Arteriovenous Malformations ◽  
Median Number ◽  
Injection Technique ◽  
Imaging Data ◽  
Independent Observer ◽  
Neurological Improvement

ObjectiveTo determine long term safety and efficacy of endovascular treatment of spinal cord arteriovenous malformations (AVMs), with calibrated particle embolization as a firstline approach.MethodsWe reviewed clinical and imaging data of consecutive patients who underwent endovascular treatment for both nidal and fistulous type spinal cord AVMs in our center, from 1990 to 2015. Outcome at the last follow-up was assessed by an independent observer.ResultsEmbolization of spinal cord AVMs was performed in 61 patients, including 46 (75%) with particles (exclusively in 29 patients), 30 (49%) with cyanoacrylate, and 6 (10%) with combined surgical treatments. Particle embolizations were iterative in 33 patients (median number of sessions 5 (range 3–6)). Neurological deterioration after treatment occurred in 5 patients (cyanoacrylate=4, surgery=1, particles=0; P<0.001). At a median follow-up of 6 years (range 3–13 years), angiographic cure was obtained in 11/61 (18%) patients (nidal type=6/53 (11%), fistulous type=5/8 (63%)). In progressive forms, neurological improvement occurred in 16/28 (57%) patients, stabilized in 9/28 (31%), and worsened in 3/28 (12%). In hemorrhagic forms, the rebleeding rate was 4/14 patient years without standard treatment, 0/322 patient years in partial iterative treatment, and 0/15 patient years in angiographically cured lesions (P=0.001).ConclusionOur study suggests that particle embolization as a firstline therapy to treat spinal cord AVMs is safe and offers long term efficacy, especially for those with small, distal, and multiple shunts. Partial occlusion of the AVM may be sufficient to prevent rebleeding, without the potential risks of complete occlusion. Particle calibration and injection technique, ‘one by one’, are critical to safety. Cyanoacrylate embolization or surgery remains necessary if particle embolization fails to occlude large shunts.

Long-term Outcomes With Planned Multistage Reduced Dose Repeat Stereotactic Radiosurgery for Treatment of Inoperable High-Grade Arteriovenous Malformations: An Observational Retrospective Cohort Study

Neurosurgery ◽  
2017 ◽  
Vol 81 (1) ◽  
pp. 136-146 ◽  
Author(s):  
Ariel E. Marciscano ◽  
Judy Huang ◽  
Rafael J. Tamargo ◽  
Chen Hu ◽  
Mohamed H. Khattab ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Median Number ◽  
Treatment Session ◽  
High Grade ◽  
Obliteration Rate ◽  
Long Term Study ◽  
Complete Obliteration

Abstract BACKGROUND: There is no consensus regarding the optimal management of inoperable high-grade arteriovenous malformations (AVMs). This long-term study of 42 patients with high-grade AVMs reports obliteration and adverse event (AE) rates using planned multistage repeat stereotactic radiosurgery (SRS). OBJECTIVE: To evaluate the efficacy and safety of multistage SRS with treatment of the entire AVM nidus at each treatment session to achieve complete obliteration of high-grade AVMs. METHODS: Patients with high-grade Spetzler-Martin (S-M) III-V AVMs treated with at least 2 multistage SRS treatments from 1989 to 2013. Clinical outcomes of obliteration rate, minor/major AEs, and treatment characteristics were collected. RESULTS: Forty-two patients met inclusion criteria (n = 26, S-M III; n = 13, S-M IV; n = 3, S-M V) with a median follow-up was 9.5 yr after first SRS. Median number of SRS treatment stages was 2, and median interval between stages was 3.5 yr. Twenty-two patients underwent pre-SRS embolization. Complete AVM obliteration rate was 38%, and the median time to obliteration was 9.7 yr. On multivariate analysis, higher S-M grade was significantly associated (P = .04) failure to achieve obliteration. Twenty-seven post-SRS AEs were observed, and the post-SRS intracranial hemorrhage rate was 0.027 events per patient year. CONCLUSION: Treatment of high-grade AVMs with multistage SRS achieves AVM obliteration in a meaningful proportion of patients with acceptable AE rates. Lower obliteration rates were associated with higher S-M grade and pre-SRS embolization. This approach should be considered with caution, as partial obliteration does not protect from hemorrhage.

Presence of direct vertebrobasilar perforator feeders in posterior fossa arteriovenous malformations and association with poor outcomes after endovascular treatment

2020 ◽  
Vol 133 (6) ◽  
pp. 1802-1810
Author(s):  
Etienne Lefevre ◽  
Thomas Robert ◽  
Simon Escalard ◽  
Robert Fahed ◽  
Stanislas Smajda ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Neurological Deterioration ◽  
Complication Rates ◽  
Long Term Outcomes ◽  
Obliteration Rate ◽  
Brain Avms

OBJECTIVETreatment of posterior fossa arteriovenous malformations (PFAVMs) remains controversial as it is always challenging and may lead to major complications. Nonetheless, these lesions are more likely to bleed and generate poorer outcomes than other brain AVMs. The aim of this study was to evaluate the effect of endovascular treatment on long-term outcomes and identify the patient subgroups that might benefit from endovascular treatment.METHODSThe authors performed a retrospective analysis of all consecutive cases of PFAVM managed at the Fondation Rothschild Hospital between 1995 and 2018. Clinical, imaging, and treatment data were prospectively gathered; these data were analyzed with respect to long-term outcomes.RESULTSAmong the 1311 patients with brain AVMs, 114 (8.7%) had a PFAVM, and 88 (77.2%) of these patients had a history of bleeding. Of the 114 PFAVMs, 101 (88.6%) were treated (83 ruptured and 18 unruptured). The mean duration of follow-up was 47.6 months (range 0–240 months). Good neurological outcome at last follow-up was achieved in 79 cases (78.2%). Follow-up angiography showed obliteration of the PFAVM in 68.3% of treated cases. The presence of direct vertebrobasilar perforator feeders was associated with neurological deterioration (OR 5.63, 95% CI 11.15–30.76) and a lower obliteration rate (OR 15.69, 95% CI 2.52–304.03) after endovascular treatment. Other predictors of neurological deterioration and obliteration rate were consistent with the Spetzler-Martin grading system.CONCLUSIONSAdvances in endovascular techniques have enabled higher obliteration rates in the treatment of PFAVMs, but complication rates are still high. Subgroups of patients who might benefit from treatment must be carefully selected and the presence of direct vertebrobasilar perforator feeders must call into question the indication for endovascular treatment.

Endovascular treatment of brain arteriovenous malformations with prolonged intranidal Onyx injection technique: long-term results in 350 consecutive patients with completed endovascular treatment course

2011 ◽  
Vol 115 (1) ◽  
pp. 78-88 ◽  
Author(s):  
Isil Saatci ◽  
Serdar Geyik ◽  
Kivilcim Yavuz ◽  
H. Saruhan Cekirge
Keyword(s):  
Endovascular Treatment ◽  
Arteriovenous Malformations ◽  
Long Term Results ◽  
Morbidity Rate ◽  
Injection Technique ◽  
High Concentration ◽  
Cyanoacrylate Glue ◽  
Brain Arteriovenous Malformations ◽  
Control Angiography

Object The purpose of this study was to present the authors' clinical experience and long-term angiographic and clinical follow-up results in 350 patients with brain arteriovenous malformations (AVMs) treated using prolonged intranidal Onyx injection with a very slow “staged” reflux technique described by the authors. Methods Three hundred and fifty consecutive patients with brain AVMs treated using Onyx between 1999 and 2008 and in whom definitive status for endovascular treatment was reached are presented. There were 206 (59%) male and 144 (41%) female patients, with a mean age of 34 years. There were 607 endovascular sessions performed. Onyx was the only agent used for intranidal injections in all patients, but in 42 patients high-concentration N-butyl cyanoacrylate glue was used adjunctively to close high-flow direct arteriovenous intra- or perinidal fistulas, or when a feeding vessel or nidus perforation and/or dissection occurred. Results Angiographically confirmed obliteration was achieved in 179 patients (51%) with only endovascular treatment; 1 patient died due to intracranial hemorrhage after the treatment. Twenty-two patients underwent resection, and 136 patients were sent to radiosurgery after endovascular treatment. In 4 patients embolization therapy was discontinued, and 5 additional patients refused the suggested complementary surgery. In all 178 surviving patients who had angiographically confirmed AVM obliteration by embolization alone, 1–8 years of control angiography (mean 47 months) confirmed stable obliteration, except for 2 patients in whom a very small recruitment was noted in the 1st year on control angiography studies, despite initial apparent total obliteration (recanalization rate 1.1%). In the entire series, 5 patients died; the mortality rate was 1.4%. The permanent morbidity rate was 7.1%. Conclusions With the prolonged intranidal injection technique described herein, Onyx allows the practitioner to achieve higher rates of anatomical cures compared with the cure rates obtained previously with other embolic agents. More importantly, due to this technique's much more effective intranidal penetration, it allows high-grade AVMs to be made radiosurgically treatable in a group of patients for whom there has been no treatment alternative.

Microsurgical management of glomus spinal arteriovenous malformations: pial resection technique

2012 ◽  
Vol 16 (6) ◽  
pp. 523-531 ◽  
Author(s):  
Gregory J. Velat ◽  
Steve W. Chang ◽  
Adib A. Abla ◽  
Felipe C. Albuquerque ◽  
Cameron G. McDougall ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Arteriovenous Malformations ◽  
Signs And Symptoms ◽  
Vascular Lesions ◽  
Morbidity Rate ◽  
Surgical Morbidity ◽  
Surgical Interventions ◽  
Spinal Arteriovenous Malformations

Object Intramedullary, or glomus, spinal arteriovenous malformations (AVMs) are rare vascular lesions amenable to resection with or without adjuvant embolization. The authors retrospectively reviewed the senior author's (R.F.S.'s) surgical series of intramedullary spinal AVMs to evaluate clinical and radiographic outcomes. Methods Detailed chart and radiographic reviews were performed for all patients with intramedullary spinal AVMs who underwent surgical treatment between 1994 and 2011. Presenting and follow-up neurological examination results were obtained and graded using the modified Rankin Scale (mRS) and McCormick Scale. Surgical technique, outcomes, complications, and long-term angiographic studies were reviewed. Results During the study period, 20 patients (10 males and 10 females) underwent resection of glomus spinal AVMs. The mean age at presentation was 30 ± 17 years (range 7–62 years). The location of the AVMs was as follows: cervical spine (n = 10), thoracic spine (n = 9), and cervicothoracic junction (n = 1). The most common presenting signs and symptoms included paresis or paralysis (65%), paresthesias (40%), and myelopathy (40%). Perioperative embolization was performed in the majority (60%) of patients. Pial AVM resection was performed in 17 cases (85%). Angiographically verified AVM obliteration was achieved in 15 patients (75%). At a mean follow-up duration of 45.4 ± 52.4 months (range 2–176 months), 14 patients (70%) remained functionally independent (mRS and McCormick Scale scores ≤ 2). One perioperative complication occurred, yielding a surgical morbidity rate of 5%. Three symptomatic spinal cord tetherings occurred at a mean of 5.7 years after AVM resection. No neurological decline was observed after endovascular and surgical interventions. No deaths occurred. Long-term angiographic follow-up data were available for 9 patients (40%) at a mean of 67.6 ± 60.3 months (range 5–176 months) following AVM resection. Durable AVM obliteration was documented in 5 (83%) of 6 patients. Conclusions Intramedullary AVMs may be safely resected with satisfactory clinical and angiographic results. The pial resection technique, which provides subtotal AVM nidus resection, effectively devascularized these lesions, as confirmed on postoperative angiography, without violating the spinal cord parenchyma, thereby potentially reducing iatrogenic injury.

scholarly journals Metameric spinal AVM: Long-term symptomatic relief achieved by embolization of the extradural component

2019 ◽  
Vol 25 (4) ◽  
pp. 469-473
Author(s):  
B Drake ◽  
S Patro ◽  
A Quateen ◽  
EA Cora ◽  
S Finitsis ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Arteriovenous Malformations ◽  
Symptomatic Relief ◽  
Venous Drainage ◽  
Dramatic Improvement ◽  
Spinal Angiography ◽  
Case Presentation ◽  
Spinal Avm

Background Metameric spinal cord arteriovenous malformations (AVMs) are rare lesions characterized by an intradural and extradural component. They are difficult to treat surgically by the endovascular route. We report a case in which symptomatic relief was achieved by embolization of the extradural component only. Case presentation A 35-year-old woman presented with acute worsening of back pain, weakness in the left leg and urinary retention. Spinal angiography showed a metameric spinal cord AVM with partial common venous drainage of the extradural and intradural components. Conclusions Targeted embolization of the extradural component led to dramatic improvement of the patient’s symptoms, probably by achieving venous decongestion. She remains neurologically stable at two years’ follow-up.

scholarly journals Symptoms, Vascular Anatomy and Endovascular Treatment of Spinal Cord Arteriovenous Malformations

2000 ◽  
Vol 6 (1_suppl) ◽  
pp. 199-202 ◽  
Author(s):  
Y. Niimi ◽  
A. Berenstein ◽  
A. Setton ◽  
J. Pryor
Keyword(s):  
Spinal Cord ◽  
Endovascular Treatment ◽  
Retrospective Analysis ◽  
Arteriovenous Malformations ◽  
Vascular Anatomy ◽  
Provocative Test ◽  
First Choice ◽  
Complete Obliteration ◽  
Choice Of Treatment

The purpose of this study is to evaluate the symptoms, anatomy and efficacy of embolization of spinal cord AVMs (SCAVMs). We performed retrospective analysis of 108 SCAVMs consisting of 38 pediatric and 70 adult cases. They included 81 nidus (26 pediatric) and 27 fistulous (12 pediatric) AVMs. Hemorrhage occurred in 74% of pediatric and 62% of adult cases with multiple hemorrhages in 54% of pediatric and 42% of adult cases. Fistulous AVMs hemorrhaged more frequently in children than adults (75% vs. 13%). 75 cases were treated with embolization alone, 10 with surgery and embolization, 2 with embolization following radiation and 12 with surgery alone. 9 patients received no treatment. In 79 of 87 embolized patients, acrylic was utilized either alone (49) or in combination (30) with other materials. Embolization was attempted 156 times in 93 patients. Complete obliteration by embolization was obtained in 17 cases. If complete obliteration was not possible, partial targeted embolization was performed, aiming at dangerous anatomic structures such as aneurysms. During the follow-up period (mean: 34 months), hemorrhage was observed in only 2 cases. Although technical complications such as dissection or vasospasm occurred on 19 occasions, only 4 resulted in aggravation of neurological symptoms. Of the 21 sessions in which worsening of symptoms occurred after embolization, 10 resulted in permanent deficits and eight of these occurred prior to 1990. SCAVMs have a poor functional prognosis due to frequent hemorrhage if untreated. Embolization with acrylic is feasible as the first choice of treatment. Provocative test and electrophysiological monitoring have improved safety. Partial targeted embolization is effective in preventing hemorrhage.

scholarly journals Clinical and angiographic results of long-term follow-up of patients after endovascular treatment for spinal arteriovenous malformations

2020 ◽  
Vol 30 (4) ◽  
pp. 14-22
Author(s):  
D.V. Shchehlov ◽  
O.E. Svyrydiuk ◽  
A.V. Naida ◽  
Yu.M. Samonenko ◽  
O.V. Slobodian
Keyword(s):  
Spinal Cord ◽  
Endovascular Treatment ◽  
Neurological Deficit ◽  
Arteriovenous Malformations ◽  
Magnetic Resonance Tomography ◽  
Dynamic Monitoring ◽  
Long Term Results ◽  
Type I ◽  
Results Of Treatment

Objective – to evaluate long-term results of treatment of patients with arteriovenous malformations AVM of the spinal cord. Materials and methods. A retrospective analysis of clinical and angiographic data of the results of treatment of patients with spinal AVM for the period from 2005 to 2019 was conducted. In SO «Scientific-Practical Center of Endovascular Neuroradiology NAMS of Ukraine» 47 patients were operated on endovascular method. The age of patients ranged from 11 to 62 years (middle age is 45.3 years). There were 29 men (61.7 %), 18 women (38.3 %). Liquid cyanoacrylate embolizant was used for endovascular intervention. The operations were performed with transfemoral access. Accoding the classification proposed by Anson and Spetzler in 1992 patients with type I were 31 (65.9 %), with ІІ type – 8 (17.0 %), with ІIІ type – 5 (10.6 %), with IV type – 3 (6.4 %). Magnetic resonance tomography and spinal angiography were used for diagnostics AVM.Results. Total exclusion of AVM from the bloodstream was achieved in 22 (46.8 %) cases. Out of the 31 (65.9 %) patients with type I AVM, 17 (54.8 %) had an early transient deepening of the neurological deficit. In this group, complete dissection of arteriovenous fistula was achieved in 16 (51.6 %) patients. In 8 (17.0 %) patients with type II AVM, complete exclusion of AVM was achieved in 5 (62.5 %) cases. In this case, 6 (75.0 %) patients were observed early postoperative deepening of neurological symptoms. In 5 (10.6 %) patients with type III AVM, total exclusion was achieved in 1 (20.0 %) case. Transient deepening of neurological deficit was noted in 3 (60.0 %) patients. In 3 (75.0 %) patients with type IV AVM, total embolization was achieved in 1 (33.0 %) observation. Neurological impairment occurred in 1 (33.0 %) patient. In all groups there were no fatalities.Conclusions. Angiography is the gold standard of diagnosis and dynamic monitoring of patients with spinal cord AVM. The use of endovascular treatment of AVM can stop the further progression of neurological deficits, which, however, is not always associated with the total exclusion of AVM. The best neurological improvement and total exclusion were achieved in patients with type I AVM. Radicality, efficacy and deepening of neurological deficiency depend on angioarchitectonics of AVM. The main condition for carrying out embolization is to achieve a safe level of catheterization of the afferent.

Factors associated with progression-free survival and long-term neurological outcome after resection of intramedullary spinal cord tumors: analysis of 101 consecutive cases

2009 ◽  
Vol 11 (5) ◽  
pp. 591-599 ◽  
Author(s):  
Giannina L. Garcés-Ambrossi ◽  
Matthew J. McGirt ◽  
Vivek A. Mehta ◽  
Daniel M. Sciubba ◽  
Timothy F. Witham ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Progression Free Survival ◽  
Total Resection ◽  
Intramedullary Spinal Cord ◽  
Free Survival ◽  
Factors Associated ◽  
Neurological Improvement ◽  
Pathological Type

Object With the introduction of electrophysiological spinal cord monitoring, surgeons have been able to perform radical resection of intramedullary spinal cord tumors (IMSCTs). However, factors associated with tumor resectability, tumor recurrence, and long-term neurological outcome are poorly understood. Methods The authors retrospectively reviewed 101 consecutive cases of IMSCT resection in adults and children at a single institution. Neurological function and MR images were evaluated preoperatively, at discharge, 1 month after surgery, and every 6 months thereafter. Factors associated with gross-total resection (GTR), progression-free survival (PFS), and long-term neurological improvement were assessed using multivariate regression analysis. Results The mean age of the patients was 41 ± 18 years and 17 (17%) of the patients were pediatric. Pathological type included ependymoma in 51 cases, hemangioblastoma in 15, pilocytic astrocytoma in 16, WHO Grade II astrocytoma in 10, and malignant astrocytoma in 9. A GTR was achieved in 60 cases (59%). Independent of histological tumor type, an intraoperatively identifiable tumor plane (OR 25.3, p < 0.0001) and decreasing tumor size (OR 1.2, p = 0.05) were associated with GTR. Thirty-four patients (34%) experienced acute neurological decline after surgery (associated with increasing age [OR 1.04, p = 0.02] and with intraoperative change in motor evoked potentials [OR 7.4, p = 0.003]); in 14 (41%) of these patients the change returned to preoperative baseline within 1 month. In 31 patients (31%) tumor progression developed by last follow-up (mean 19 months). Tumor histology (p < 0.0001) and the presence of an intraoperatively identified tumor plane (hazard ratio [HR] 0.44, p = 0.027) correlated with improved PFS. A GTR resulted in improved PFS for hemangioblastoma (HR 0.004, p = 0.04) and ependymoma (HR 0.2, p = 0.02), but not astrocytoma. Fifty-five patients (55%) maintained overall neurological improvement by last follow-up. The presence of an identifiable tumor plane (HR 3.1, p = 0.0004) and improvement in neurological symptoms before discharge (HR 2.3, p = 0.004) were associated with overall neurological improvement by last follow-up (mean 19 months). Conclusions Gross-total resection can be safely achieved in the vast majority of IMSCTs when an intraoperative plane is identified, independent of pathological type. The incidence of acute perioperative neurological decline increases with patient age but will improve to baseline in nearly half of patients within 1 month. Long-term improvement in motor, sensory, and bladder dysfunction may be achieved in a slight majority of patients and occurs more frequently in patients in whom a surgical plane can be identified. A GTR should be attempted for ependymoma and hemangioblastoma, but it may not affect PFS for astrocytoma. For all tumors, the intraoperative finding of a clear tumor plane of resection carries positive prognostic significance across all pathological types.

Anticoagulation in addition to dual antiplatelet therapy has no impact on long-term follow-up after endovascular treatment of (sub)acute lower limb ischemia

VASA ◽  
2019 ◽  
Vol 48 (4) ◽  
pp. 321-329
Author(s):  
Mariya Kronlage ◽  
Erwin Blessing ◽  
Oliver J. Müller ◽  
Britta Heilmeier ◽  
Hugo A. Katus ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Limb Ischemia ◽  
Bleeding Complications ◽  
Severe Bleeding ◽  
Short Term ◽  
Long Term Follow Up

Summary. Background: To assess the impact of short- vs. long-term anticoagulation in addition to standard dual antiplatelet therapy (DAPT) upon endovascular treatment of (sub)acute thrombembolic occlusions of the lower extremity. Patient and methods: Retrospective analysis was conducted on 202 patients with a thrombembolic occlusion of lower extremities, followed by crirical limb ischemia that received endovascular treatment including thrombolysis, mechanical thrombectomy, or a combination of both between 2006 and 2015 at a single center. Following antithrombotic regimes were compared: 1) dual antiplatelet therapy, DAPT for 4 weeks (aspirin 100 mg/d and clopidogrel 75 mg/d) upon intervention, followed by a lifelong single antiplatelet therapy; 2) DAPT plus short term anticoagulation for 4 weeks, followed by a lifelong single antiplatelet therapy; 3) DAPT plus long term anticoagulation for > 4 weeks, followed by a lifelong anticoagulation. Results: Endovascular treatment was associated with high immediate revascularization (> 98 %), as well as overall and amputation-free survival rates (> 85 %), independent from the chosen anticoagulation regime in a two-year follow up, p > 0.05. Anticoagulation in addition to standard antiplatelet therapy had no significant effect on patency or freedom from target lesion revascularization (TLR) 24 months upon index procedure for both thrombotic and embolic occlusions. Severe bleeding complications occurred more often in the long-term anticoagulation group (9.3 % vs. 5.6 % (short-term group) and 6.5 % (DAPT group), p > 0.05). Conclusions: Our observational study demonstrates that the choice of an antithrombotic regime had no impact on the long-term follow-up after endovascular treatment of acute thrombembolic limb ischemia whereas prolonged anticoagulation was associated with a nominal increase in severe bleeding complications.

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