Comparison of embolization strategies for mixed plexiform and fistulous brain arteriovenous malformations: a computational model analysis of theoretical risks of nidus rupture

2021 ◽  
pp. neurintsurg-2021-018067
Author(s):  
Mika S Jain ◽  
Nicholas A Telischak ◽  
Jeremy J Heit ◽  
Huy M Do ◽  
Tarik F Massoud
Keyword(s):  
Flow Rate ◽  
Arteriovenous Malformations ◽  
Monte Carlo Analysis ◽  
Electrical Circuit ◽  
Hemodynamic Forces ◽  
Brain Arteriovenous Malformations ◽  
Risk Of Rupture ◽  
Large Brain ◽  
Flow Through ◽  
Intravascular Pressure

BackgroundHigh-flow fistulas related to plexiform nidi are found in 40% of large brain arteriovenous malformations (AVMs). Endovascular occlusion of intranidal fistulas before plexiform components is empirically considered safe, but potential ensuing dangerous re-routing of flow through plexiform vessels may in theory raise their rupture risk. It remains unclear whether it is safer to embolize plexiform or fistulous vessels initially. We used a novel biomathematical AVM model to compare theoretical hemodynamic changes and rupture risks on sequential embolizations of both types of nidus vessels.MethodsWe computationally modeled a theoretical AVM as an electrical circuit containing a nidus consisting of a massive stochastic network ensemble comprising 1000 vessels. We sampled and individually simulated 10 000 different nidus morphologies with a fistula angioarchitecturally isolated from its adjacent plexiform nidus. We used network analysis to calculate mean intravascular pressure (Pmean) and flow rate within each nidus vessel; and Monte Carlo analysis to assess overall risks of nidus rupture when simulating sequential occlusions of vessel types in all 10 000 nidi.ResultsWe consistently observed lower nidus rupture risks with initial fistula occlusion in different network morphologies. Intranidal fistula occlusion simultaneously reduced Pmean and flow rate within draining veins.ConclusionsInitial occlusion of AVM fistulas theoretically reduces downstream draining vessel hypertension and lowers the risk of rupture of an adjoining plexiform nidus component. This mitigates the theoretical concern that fistula occlusion may cause dangerous redistribution of hemodynamic forces into plexiform nidus vessels, and supports a clinical strategy favoring AVM fistula occlusion before plexiform nidus embolization.

Intravascular pressure measurements in feeding pedicles of brain arteriovenous malformations

2005 ◽  
Vol 48 (3) ◽  
pp. 182-189 ◽  
Author(s):  
H. Henkes ◽  
T. F. Gotwald ◽  
S. Brew ◽  
E. Miloslavski ◽  
F. Kämmerer ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Pressure Measurements ◽  
Brain Arteriovenous Malformations ◽  
Intravascular Pressure

Volume-staged versus dose-staged stereotactic radiosurgery outcomes for large brain arteriovenous malformations: a systematic review

2018 ◽  
Vol 128 (1) ◽  
pp. 154-164 ◽  
Author(s):  
Adeel Ilyas ◽  
Ching-Jen Chen ◽  
Dale Ding ◽  
Davis G. Taylor ◽  
Shayan Moosa ◽  
...  
Keyword(s):  
Systematic Review ◽  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Management Strategy ◽  
Individual Patient Data ◽  
Brain Arteriovenous Malformations ◽  
Large Brain ◽  
Radiation Induced ◽  
The Mean ◽  
Induced Changes

OBJECTIVESeveral recent studies have improved our understanding of the outcomes of volume-staged (VS) and dose-staged (DS) stereotactic radiosurgery (SRS) for the treatment of large (volume > 10 cm3) brain arteriovenous malformations (AVMs). In light of these recent additions to the literature, the aim of this systematic review is to provide an updated comparison of VS-SRS and DS-SRS for large AVMs.METHODSA systematic review of the literature was performed using PubMed to identify cohorts of 5 or more patients with large AVMs who had been treated with VS-SRS or DS-SRS. Baseline data and post-SRS outcomes were extracted for analysis.RESULTSA total of 11 VS-SRS and 10 DS-SRS studies comprising 299 and 219 eligible patients, respectively, were included for analysis. The mean obliteration rates for VS-SRS and DS-SRS were 41.2% (95% CI 31.4%–50.9%) and 32.3% (95% CI 15.9%–48.8%), respectively. Based on pooled individual patient data, the outcomes for patients treated with VS-SRS were obliteration in 40.3% (110/273), symptomatic radiation-induced changes (RICs) in 13.7% (44/322), post-SRS hemorrhage in 19.5% (50/256), and death in 7.4% (24/323); whereas the outcomes for patients treated with DS-SRS were obliteration in 32.7% (72/220), symptomatic RICs in 12.2% (31/254), post-SRS hemorrhage in 10.6% (30/282), and death in 4.6% (13/281).CONCLUSIONSVolume-staged SRS appears to afford higher obliteration rates than those achieved with DS-SRS, although with a less favorable complication profile. Therefore, VS-SRS or DS-SRS may be a reasonable treatment approach for large AVMs, either as stand-alone therapy or as a component of a multimodality management strategy.

scholarly journals Natural history of brain arteriovenous malformations: a systematic review

2014 ◽  
Vol 37 (3) ◽  
pp. E7 ◽  
Author(s):  
Isaac Josh Abecassis ◽  
David S. Xu ◽  
H. Hunt Batjer ◽  
Bernard R. Bendok
Keyword(s):  
Natural History ◽  
Arteriovenous Malformations ◽  
Venous Drainage ◽  
Cerebral Arteriovenous Malformations ◽  
Brain Arteriovenous Malformations ◽  
Increased Risk ◽  
Risk Of Rupture ◽  
History Of ◽  
Arterial Aneurysms

Object The authors aimed to systematically review the literature to clarify the natural history of brain arteriovenous malformations (BAVMs). Methods The authors searched PubMed for one or more of the following terms: natural history, brain arteriovenous malformations, cerebral arteriovenous malformations, and risk of rupture. They included studies that reported annual rates of hemorrhage and that included either 100 patients or 5 years of treatment-free follow-up. Results The incidence of BAVMs is 1.12–1.42 cases per 100,000 person-years; 38%–68% of new cases are first-ever hemorrhage. The overall annual rates of hemorrhage for patients with untreated BAVMs range from 2.10% to 4.12%. Consistently implicated in subsequent hemorrhage are initial hemorrhagic presentation, exclusively deep venous drainage, and deep and infrantentorial brain location. The risk for rupture seems to be increased by large nidus size and concurrent arterial aneurysms, although these factors have not been studied as thoroughly. Venous stenosis has not been implicated in increased risk for rupture. Conclusions For patients with BAVMs, although the overall risk for hemorrhage seems to be 2.10%–4.12% per year, calculating an accurate risk profile for decision making involves clinical attention and accounting for specific features of the malformation.

scholarly journals The Natural History of Brain Arteriovenous Malformations

2017 ◽  
Vol 36 (03) ◽  
pp. 153-159
Author(s):  
Carlos Peres ◽  
Vitor Yamaki ◽  
Eberval Figueiredo
Keyword(s):  
Natural History ◽  
Arteriovenous Malformations ◽  
Functional Performance ◽  
Brain Infarction ◽  
Treatment Decision ◽  
Venous Drainage ◽  
Brain Arteriovenous Malformations ◽  
Risk Of Rupture ◽  
Choice Of Treatment ◽  
History Of

AbstractBrain arteriovenous malformations (AVMs) are relatively rare lesions with irreversible consequences in the context of hemorrhage. They are characterized by direct connections between arteries and veins without an intervening capillary network. The natural history of brain AVMs is controversial in the literature, with low evidence level gathered in the papers published, and with large divergence of results among them. A detailed understanding of the natural history is critical for treatment decision. The risk of development of deleterious outcomes such as hemorrhage or brain infarction should always be considered when submitting a patient to the risks of treatment. Several factors related to the patient and to the AVMs are determinants in the natural history of this disease. The topography, size, morphology and angioarchitecture of AVMs determine the risk of rupture. Large AVMs, those located in the posterior fossa and with deep venous drainage, have higher risk of rupture. Due to divergence in the literature regarding the natural history of AVMs, the choice of treatment should also consider experiences acquired over the years from reference centers with a high number of AVMs treated per year. We determined 7 variables that should be considered during the decision to treat an AVM: 1) previous hemorrhage; 2) aneurysm associated to the AVM; 3) direct arteriovenous fistula; 4) factors related to the nidus; 5) age and habits (smoking, sedentary lifestyle, diet quality); 6) the functional performance of the patient; 7) psychological factors.

scholarly journals Homocysteine Level and Risk of Hemorrhage in Brain Arteriovenous Malformations

2021 ◽  
Vol 2021 ◽  
pp. 1-9
Author(s):  
Chaofan Zeng ◽  
Fa Lin ◽  
Peicong Ge ◽  
Dong Zhang ◽  
Shuo Wang ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Regression Analysis ◽  
Logistic Regression Analysis ◽  
Lower Risk ◽  
Arteriovenous Malformations ◽  
Maximum Diameter ◽  
Brain Arteriovenous Malformations ◽  
Risk Of Rupture ◽  
Laboratory Variables ◽  
Risk Of Hemorrhage

Objective. We aimed to investigate the risk factors associated with hemorrhage and clarify the relation of homocysteine (Hcy) with brain arteriovenous malformations (bAVMs). Method. We retrospectively reviewed bAVM patients from Beijing Tiantan Hospital between January 2019 and December 2019. Clinical and laboratory variables were analyzed in enrolled patients with bAVMs. Potential predictors associated with hemorrhage were evaluated by logistic regression analysis. Results. A total of 143 bAVM patients were identified in the study, including 69 unruptured and 74 ruptured cases. Patients with hemorrhage were less likely to have hyperhomocysteinemia ( P = 0.023 ). Logistic regression analysis showed that increased maximum diameter of bAVM lesions (odds ratio (OR) 0.634, 95% confidence intervals (CI) 0.479-0.839; P = 0.001 ) and serum Hcy level (OR 0.956, 95% CI 0.920-0.993; P = 0.021 ) were associated with lower risk of hemorrhage in bAVMs. Conclusion. The present study provided evidence regarding the association between serum Hcy and hemorrhage in patients with bAVMs. Higher Hcy level was correlated with a lower risk of rupture. Detection of factors for subsequent hemorrhage is necessary to develop therapeutic strategies for bAVMs preferably.

scholarly journals Risk of Rupture and Risks of Endovascular Management of Unruptured Brain Arteriovenous Malformations

2014 ◽  
Vol 20 (4) ◽  
pp. 495-501 ◽  
Author(s):  
Xun Shen ◽  
Jie Liu ◽  
Xianli Lv ◽  
Youxiang Li
Keyword(s):  
Natural History ◽  
Arteriovenous Malformations ◽  
Morbidity And Mortality ◽  
Endovascular Management ◽  
Brain Arteriovenous Malformations ◽  
Risk Of Rupture ◽  
Cumulative Rate ◽  
History Of ◽  
Group 2 ◽  
Group 1

This study reports the natural history of unruptured brain arteriovenous malformations (AVMs) and the risks involved in their endovascular management. A total of 242 patients at our center were enrolled in the study, which had retrospective and prospective components. We retrospectively assessed the morbidity and mortality related to endovascular management in 125 patients with unruptured AVMs. We prospectively assessed the natural history of unruptured AVMs in 117 patients with newly diagnosed unruptured AVMs; 48 of the patients had no history of seizure (Group 1), whereas 69 had a history of seizure from the lesion (Group 2). The retrospective group was also divided into patients with and without seizures. The cumulative rate of rupture of AVMs in Group 2 was less than 0.8% per year, while the rate was approximately sixfold higher (5.1% per year) in Group 1. The overall cumulative rate of rupture of AVMs was less than 3.0% per year. The overall rate of endovascular management-related morbidity and mortality was 10.6% in Group 2 and 11.9% in Group 1 at 30 days and was 25.9% and 13.6%, respectively, at one year. There was no independent predictor of a poor endovascular outcome. The likelihood of rupture of unruptured AVMs was exceedingly low among patients in Group 2 and was substantially higher among those in Group 1. The risk of morbidity and mortality related to endovascular management greatly exceeded the six-year risk of rupture among patients in Group 2. Endovascular management of an AVM should not be performed to eliminate or to improve seizure frequency.

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