Clinical Features of Superficially Located Brain Arteriovenous Malformations with Transdural Arterial Communication

Background: Contrary to deeply located brain arteriovenous malformations (AVMs), superficially located AVMs are more likely to have transdural arterial communications (TACs). However, the clinical and radiologic characteristics of patients presenting with AVMs and TACs are poorly understood. The purpose of this study is to determine whether clinicoradiological features of cerebral AVMs differ according to TAC. Methods: Between 2002 and 2012, 438 consecutive patients with a brain AVM were treated in our hospital. Among them were 124 patients with superficially located brain AVMs who met the inclusion and exclusion criteria of our study. We retrospectively reviewed the clinicoradiological features of their TACs to explore the variation in characteristics. Results: Thirty-two of the 124 patients with a superficially located AVM (25.8%) had TAC. Radiologic findings of brain AVM images with TAC showed that TAC occurred significantly more frequently among larger AVMs (with vs. without TAC, 11.2 vs. 4.0 ml) and among diffuse AVMs (56.3 vs. 28.3%, p = 0.004). Clinical findings indicate that TAC was associated with chronic headache (43.8 vs. 12.0%, p < 0.001) and older age (43.1 vs. 36.6 years, p = 0.037). Conclusions: Brain AVM with TAC seems to be accompanied by distinctive clinical features, such as chronic headache and older age. Larger size and diffuseness of the AVM were also associated with TAC. Findings from this study and the prognostic significance of TAC should be further explored in a large prospective study.

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Abstract 179: Brain Avm Embolization With Onyx: Clinical And Anatomical Results In A Prospective, Multicenter, European Study (BRAVO)

Stroke ◽

10.1161/str.43.suppl_1.a179 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Laurent Pierot ◽

Keyword(s):

Arteriovenous Malformations ◽

Multidisciplinary Approach ◽

Interventional Neuroradiology ◽

High Rate ◽

First Line ◽

Complete Occlusion ◽

Brain Arteriovenous Malformations ◽

Brain Avm ◽

Long Time ◽

Brain Avms

Purpose: The treatment of brain arteriovenous malformations (AVMs) is challenging based on a multidisciplinary approach involving neurosurgery, radiosurgery, and interventional neuroradiology. The embolization of brain AVMS was for a long time performed using particles and glue. Onyx has been recently introduced in the armamentarium for AVM embolization, but large, multicenter evaluation is lacking. BRAVO study was conducted to evaluate the clinical and anatomical results of brain AVM embolization with Onyx. Materials and Methods: BRAVO (Brain ArterioVenous malformations embolization with Onyx) was a multicentric, prospective, consecutive study conducted in 11 neurointerventional centers in Europe. 117 patients harbouring brain AVMs embolized with Onyx were included. Clinical presentation was mostly hemorrhage (30.8%) and epilepsy (27.4%). AVM size was less than 3cm in 52.1% of cases and more than 3cm in 47.9% of cases. A mean number of 2.05 embolization sessions / patient were performed with injection of a mean of 2.4 ml Onyx / session. Results: Complete occlusion was obtained with Onyx embolization alone in a high percentage of cases (23.5% of all cases and 36.7% of AVM smaller than 3cm). Intra and post-operative bleeding related to the treatment was observed in 9.4% leading to death in 3.4% and neurologic worsening in 1.7%. Non-hemorrhagic permanent deficits were observed in 6.0% of cases. Treatment related morbidity (mRS>2) and mortality were respectively 5.1% and 4.3%. Conclusion: Embolization of brain AVMs with Onyx is associated with a high rate of complete occlusion with acceptable morbidity and mortality. Onyx has to be used as the first line embolization agent for the treatment of brain AVMs.

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Clinical Features and Outcomes of Community-Acquired Pneumonia Caused by Haemophilus Influenza

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa622 ◽

2021 ◽

Vol 8 (4) ◽

Author(s):

Saeed Shoar ◽

Fernando H Centeno ◽

Daniel M Musher

Keyword(s):

Clinical Features ◽

Alcohol Use Disorder ◽

Pneumococcal Pneumonia ◽

Severe Infection ◽

Clinical Findings ◽

Community Acquired Pneumonia ◽

Equal Frequency ◽

Haemophilus Influenza ◽

Radiologic Findings ◽

Viral Coinfection

Abstract Background Long regarded as the second most common cause of community-acquired pneumonia (CAP), Haemophilus influenzae has recently been identified with almost equal frequency as pneumococcus in patients hospitalized for CAP. The literature lacks a detailed description of the presentation, clinical features, laboratory and radiologic findings, and outcomes in Haemophilus pneumonia. Methods During 2 prospective studies of patients hospitalized for CAP, we identified 33 patients with Haemophilus pneumonia. In order to provide context, we compared clinical findings in these patients with findings in 36 patients with pneumococcal pneumonia identified during the same period. We included and analyzed separately data from patients with viral coinfection. Patients with coinfection by other bacteria were excluded. Results Haemophilus pneumonia occurred in older adults who had underlying chronic lung disease, cardiac conditions, and alcohol use disorder, the same population at risk for pneumococcal pneumonia. However, in contrast to pneumococcal pneumonia, patients with Haemophilus pneumonia had less severe infection as shown by absence of septic shock on admission, less confusion, fewer cases of leukopenia or extreme leukocytosis, and no deaths at 30 days. Viral coinfection greatly increased the severity of Haemophilus, but not pneumococcal pneumonia. Conclusions We present the first thorough description of Haemophilus pneumonia, show that it is less severe than pneumococcal pneumonia, and document that viral coinfection greatly increases its severity. These distinctions are lost when the label CAP is liberally applied to all patients who come to the hospital from the community for pneumonia.

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Prevalence and characteristics of brain arteriovenous malformations in hereditary hemorrhagic telangiectasia: a systematic review and meta-analysis

Journal of Neurosurgery ◽

10.3171/2016.7.jns16847 ◽

2017 ◽

Vol 127 (2) ◽

pp. 302-310 ◽

Cited By ~ 20

Author(s):

Waleed Brinjikji ◽

Vivek N. Iyer ◽

Christopher P. Wood ◽

Giuseppe Lanzino

Keyword(s):

Systematic Review ◽

Hereditary Hemorrhagic Telangiectasia ◽

Arteriovenous Malformations ◽

Clinical Presentation ◽

Meta Analysis ◽

Prevalence Rates ◽

Brain Avm ◽

Martin Grade ◽

Cerebral Avms ◽

Brain Avms

OBJECTIVEPatients with hereditary hemorrhagic telangiectasia (HHT) are known to suffer from high rates of cerebral arteriovenous malformations (AVMs). The authors performed a systematic review and meta-analysis of the literature examining prevalence rates, characteristics, and clinical presentation of cerebral AVMs in the HHT population.METHODSTo identify studies on AVM prevalence and characteristics in the HHT population, 4 databases (MEDLINE, EMBASE, Scopus and Web of Science) were searched by a reference librarian with over 30 years experience in systematic reviews and meta-analysis. The search period was January 1, 1990–March 2016. The following search terms were used: hereditary hemorrhagic telangiectasia, Osler-Weber-Rendu syndrome, AVM, brain AVM, arteriovenous malformation, arteriovenous fistula, prevalence, and epidemiology. The authors identified studies that examined the prevalence rates, characteristics, and clinical presentation of cerebral AVMs in patients with HHT. They assessed overall AVM prevalence rates as well as prevalence rates by age, sex, HHT type, and country/region. They also systematically reviewed the characteristics of AVMs, including rupture status, location, clinical presentation, angioarchitecture, and Spetzler-Martin grade. Data were analyzed using a random-effects meta-analysis model.RESULTSThirty-nine studies were included in this meta-analysis. Thirty studies examined brain AVM prevalence rates in various HHT patient populations, and 18 studies examined AVM clinical and angiographic characteristics (9 studies examined both prevalence rates and AVM characteristics). The prevalence of brain AVMs in HHT patients was 10.4% (95% CI 7.9%–13.0%) with no significant difference between males (8.5%, 95% CI 4.9%–12.0%) and females (11.0%, 95% CI 5.9%–16.1%). Patients with HHT Type 1 (HHT1) had a significantly higher brain AVM prevalence (13.4%, 95% CI 9.5%–17.4%) compared with those with HHT Type 2 (HHT2) (2.4%, 95% CI 1.0%–3.8%) (p < 0.0001). In 55.2% (95% CI 38.3%–72.1%) of cases, the AVMs were symptomatic. Spetzler-Martin grade was 2 or less in 86.9% (95% CI 67.5%–95.2%) of patients.CONCLUSIONSThe prevalence of brain AVMs in the HHT population is about 10%. HHT1 patients are significantly more likely to have brain AVMs than HHT2 patients. Most AVMs in the HHT population are symptomatic. The Spetzler-Martin grade for these lesions is 2 or less in nearly 90% of patients.

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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.

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Abstract 50: Evaluation of Candidate Polymorphisms for Association With Brain Arteriovenous Malformations and Intracranial Hemorrhage in Hereditary Hemorrhagic Telangiectasia

Stroke ◽

10.1161/str.47.suppl_1.50 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Ludmila Pawlikowska ◽

Jeffrey Nelson ◽

Diana E Guo ◽

Charles E McCulloch ◽

Michael T Lawton ◽

...

Keyword(s):

Intracranial Hemorrhage ◽

Hereditary Hemorrhagic Telangiectasia ◽

Arteriovenous Malformations ◽

Nucleotide Polymorphisms ◽

Genetic Modifiers ◽

Association Analyses ◽

Brain Arteriovenous Malformations ◽

Significance Threshold ◽

Common Genetic Variants ◽

Brain Avm

Introduction: Brain arteriovenous malformations (AVM) are an important cause of intracranial hemorrhage (ICH) in young adults. Most are sporadic, but also occur in inherited diseases such as hereditary hemorrhagic telangiectasia (HHT). ICH presentation of brain AVM in both sporadic and HHT cases is a marker of high ICH risk. In order to investigate whether the same genetic modifiers influence sporadic and HHT brain AVM, we evaluated candidate genetic polymorphisms reported as associated with sporadic brain AVM, with ICH presentation or ICH during clinical course, in HHT patients. Methods: We genotyped 8 polymorphisms ( APOE E2/3/4 [rs7412, rs429358], ANGPTL rs116724, EPHB4 rs314308, IL6 -174G>C [rs1800795], IL1B -31T>C [rs1143627], ITGB8 rs10486391, TNF -238G>A[rs361525]) in 753 Caucasian HHT patients enrolled by the Brian Vascular Malformation Consortium (BVMC). Genotypes were collapsed into risk allele carriers vs. other for analysis, as published for sporadic AVM. APOE E2/3/4 haplotypes were assigned based on genotypes of the 2 APOE polymorphisms. Association of genotype with phenotype was evaluated by multivariable logistic regression adjusted for age, gender and accounting for family clustering. We used a nominal significance threshold of p=0.05, requiring the same direction of effect as in sporadic brain AVM (odds ratio for risk genotype [OR]>1). Results: Among 753 HHT patients, 155 (21%) had brain AVM, of whom 26 (17%) presented with ICH. Two additional brain AVM patients had ICH during follow-up. None of the 7 variants (6 single nucleotide polymorphisms and APOE haplotype) were significantly associated with brain AVM (OR=0.6-1.3), with ICH presentation of brain AVM (OR=0.4-1.9), or with any brain AVM ICH in HHT patients (OR=0.5-2.1). Conclusions: Common genetic variants previously reported to be associated with sporadic brain AVM were not associated with brain AVM nor with ICH in the BVMC HHT cohort, suggesting different genetic modifiers may influence sporadic and HHT brain AVM. However, the number of ICH cases in the cohort is small, so the confidence intervals are wide and we cannot rule out clinically important associations. The BVMC is enrolling additional HHT patients to expand the cohort and increase power for association analyses.

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Brain arteriovenous malformations

Neurology ◽

10.1212/wnl.0000000000010968 ◽

2020 ◽

Vol 95 (20) ◽

pp. 917-927 ◽

Cited By ~ 1

Author(s):

Ching-Jen Chen ◽

Dale Ding ◽

Colin P. Derdeyn ◽

Giuseppe Lanzino ◽

Robert M. Friedlander ◽

...

Keyword(s):

Natural History ◽

Minimally Invasive ◽

Arteriovenous Malformations ◽

Cerebral Arteries ◽

Treatment Strategies ◽

Latency Period ◽

Management Options ◽

Brain Arteriovenous Malformations ◽

Risk Of Hemorrhage ◽

Brain Avms

Brain arteriovenous malformations (AVMs) are anomalous direct shunts between cerebral arteries and veins that convalesce into a vascular nidus. The treatment strategies for AVMs are challenging and variable. Intracranial hemorrhage and seizures comprise the most common presentations of AVMs. However, incidental AVMs are being diagnosed with increasing frequency due to widespread use of noninvasive neuroimaging. The balance between the estimated cumulative lifetime hemorrhage risk vs the risk of intervention is often the major determinant for treatment. Current management options include surgical resection, embolization, stereotactic radiosurgery (SRS), and observation. Complete nidal obliteration is the goal of AVM intervention. The risks and benefits of interventions vary and can be used in a combinatorial fashion. Resection of the AVM nidus affords high rates of immediate obliteration, but it is invasive and carries a moderate risk of neurologic morbidity. AVM embolization is minimally invasive, but cure can only be achieved in a minority of lesions. SRS is also minimally invasive and has little immediate morbidity, but AVM obliteration occurs in a delayed fashion, so the patient remains at risk of hemorrhage during the latency period. Whether obliteration can be achieved in unruptured AVMs with a lower risk of stroke or death compared with the natural history of AVMs remains controversial. Over the past 5 years, multicenter prospective and retrospective studies describing AVM natural history and treatment outcomes have been published. This review provides a contemporary and comprehensive discussion of the natural history, pathobiology, and interventions for brain AVMs.

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Complication Analysis of 469 Brain Arteriovenous Malformations Treated with N-Butyl Cyanoacrylate

Interventional Neuroradiology ◽

10.1177/159101990501100204 ◽

2005 ◽

Vol 11 (2) ◽

pp. 141-148 ◽

Cited By ~ 14

Author(s):

T. L. Li ◽

B. Fang ◽

X. Y. He ◽

C. Z. Duan ◽

Q. J. Wang ◽

...

Keyword(s):

Arteriovenous Malformations ◽

Endovascular Procedures ◽

Endovascular Embolization ◽

Neurological Deficits ◽

Embolization Therapy ◽

Brain Arteriovenous Malformations ◽

Ischemic Complications ◽

Brain Avms ◽

Special Strategy ◽

Low Rate

We independently assessed the frequency, severity and determinants of neurological deficits after endovascular embolization with NBCA of brain arteriovenous malformations (BAVMs) to have a better basis for making treatment decisions. All the charts of 469 BAVMs patients who underwent embolization with NBCA were reviewed. We analyzed the complications and their relation to angiographic features. The 469 patients were treated with 1108 endovascular procedures. Each met one to eight times, average 2.3 times. Eleven patients showed treatment-related complications, including four haemorrhagic and seven ischemic complications. Of these 11 cases, two died, two had persistent disabling deficits, and another seven suffered transient neurological deficits. Our finding suggests a low rate of disabling treatment complications for embolization of brain AVMs with NBCA in this center. The management of AVM patients who have high risk of embolization therapy should be treated by special strategy.

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Detectability of Brain Arteriovenous Malformations with CT Angiography in the Chuvash Republic

Journal of radiology and nuclear medicine ◽

10.20862/0042-4676-2020-101-3-163-169 ◽

2020 ◽

Vol 101 (3) ◽

pp. 163-169

Author(s):

M. N. Mikhaylova ◽

O. Yu. Kostrova ◽

L. M. Merkulova ◽

G. Yu. Struchko ◽

A. Yu. Semenov

Keyword(s):

High Risk ◽

Arteriovenous Malformations ◽

Detection Rate ◽

Carotid Arteries ◽

Internal Carotid ◽

Brain Arteriovenous Malformations ◽

Hemorrhagic Complications ◽

Chuvash Republic ◽

Brain Avms ◽

Internal Carotid Arteries

Objective. To estimate the detection rate of brain arteriovenous malformations (AVMs) in the Chuvash Republic and their characteristics.Material and methods. The results of CT angiographies performed at the Unit of Radiation Diagnosis in 2014–2017 were retrospectively analyzed.Results. Over 4 years, brain AVMs were first detected in 29 patients (5–9 cases per year); of them 59% were men and 41% were women. The peak detectability occurred at the age of 31–40 years. AVMs were more frequently localized in the frontal and temporal regions. The high risk of surgery for AVMs according to the grading scheme by R. Spetzler and N. Martin (1986) occurred in 10% of cases. Besides AVMs, cerebral vascular aneurysms were detected in 14% of patients.Conclusion. Small AVMs with a low risk of surgery are more common; however, there is a higher risk of hemorrhagic complications. The risk of cerebral hemorrhage is higher when AVMs are fed by the internal carotid arteries and drained into the deep veins. The likelihood of strokes in AVMs is 27% higher in patients with the open circle of Willis.

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Safety and Feasibility of Balloon-Assisted Embolization with Onyx of Brain Arteriovenous Malformations Revisited: Personal Experience with the Scepter XC Balloon Microcatheter

Interventional Neurology ◽

10.1159/000490579 ◽

2018 ◽

Vol 7 (6) ◽

pp. 439-444 ◽

Cited By ~ 6

Author(s):

Bharathi D. Jagadeesan ◽

Andrew W. Grande ◽

Ramachandra P. Tummala

Keyword(s):

Retrospective Study ◽

Vinyl Alcohol ◽

Personal Experience ◽

Arteriovenous Malformations ◽

Pial Arteries ◽

Ethylene Vinyl Alcohol ◽

Brain Arteriovenous Malformations ◽

Pial Vessel ◽

Brain Avms ◽

Vessel Rupture

Background/Objective: Compliant dual-lumen balloon microcatheters have been used to perform balloon-assisted embolization (BAE) of brain arteriovenous malformations (AVMs) with ethylene vinyl alcohol copolymer (Onyx). However, vessel rupture and microcatheter retention have been reported from BAE using these microcatheters. Using an extra-compliant balloon microcatheter (Scepter XC; Microvention, Tustin, CA, USA) could help avoid pial vessel rupture during BAE. We herein report our experience using this balloon microcatheter for BAE. Methods: This retrospective study included patients who underwent BAE of brain AVMs at our institution between June 2012 and March 2017. Results: The extra-compliant Scepter XC balloon microcatheter was used for BAE of brain AVMs in 23 patients aged 44.3 ± 16.7 years (range 0–65 years). A total of 40 intracranial vessels (39 pial arteries and 1 pial vein) were catheterized and embolized during 30 separate sessions. In all instances, the balloon microcatheter could be successfully advanced to the AVM nidus. A mean volume of 2.4 ± 1.7 mL (range 0.65–4.6 mL) of Onyx was injected per session. There were no instances of vessel rupture, microcatheter retention, or stroke. Conclusion: Utilization of the extra-compliant balloon microcatheter results in safe and effective BAE, which adds to the growing experience with BAE for AVM treatment.

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Treatment of brain arteriovenous malformations with high-flow arteriovenous fistulas: risk and complications associated with endovascular embolization in multimodality treatment

Journal of Neurosurgery ◽

10.3171/2009.9.jns081588 ◽

2010 ◽

Vol 113 (4) ◽

pp. 715-722 ◽

Cited By ~ 45

Author(s):

Ichiro Yuki ◽

Robert H. Kim ◽

Gary Duckwiler ◽

Reza Jahan ◽

Satoshi Tateshima ◽

...

Keyword(s):

Arteriovenous Malformations ◽

Multimodality Treatment ◽

Endovascular Embolization ◽

High Flow ◽

Special Focus ◽

Arteriovenous Fistulas ◽

Brain Arteriovenous Malformations ◽

Superselective Angiography ◽

Fistula Treatment ◽

Brain Avms

Object High-flow fistulas associated with brain arteriovenous malformations (AVMs) pose a significant challenge to both stereotactic radiosurgery (SRS) and surgical treatment. The purpose of this study was to examine the outcomes of multimodality treatment of AVMs in association with a large arteriovenous fistula (AVF), with a special focus on endovascular embolization and its associated complications. Methods One hundred ninety-two patients harboring cerebral AVMs underwent endovascular treatment in the authors' department between 1997 and 2003. Of these, the authors selected 74 patients presenting with an AVM associated with high-flow AVF(s) for a retrospective analysis based on the findings of superselective angiography. After endovascular embolization, 32 patients underwent resection, 33 underwent either SRS or hypofractionated stereotactic radiotherapy (HSRT), and 3 underwent both surgery and SRS. Six patients underwent embolization only. Immediate and midterm treatment outcomes were analyzed. Results Fifty-seven (77%) of the 74 patients had AVMs that were Spetzler-Martin Grade III or higher. A complete resection was achieved in all 32 patients. Of patients who underwent SRS/HSRT, 13 patients (39.3%) had either complete or > 90% obliteration of the AVM, and 2 patients (6.1%) had incomplete obliteration. Fourteen patients (42.4%) with residual AVM underwent repeated radiotherapy (and remain under observation). Of the 3 patients who underwent both SRS and resection, resection was complete in 2 and incomplete in one. No follow-up was obtained in 6 patients (8.1%). An endovascular complication was observed in 4 patients (5.4%). Fistula embolization was safely performed in every patient, whereas every endovascular complication was associated with other procedures such as nidus embolization. Conclusions Endovascular occlusion of the fistulous component was successfully achieved in every patient; every endovascular complication in this series was related to other procedures such as nidus embolization. The importance of the fistula treatment should be emphasized to minimize the endovascular complications and to maximize the treatment effect when a multimodality therapy is used to treat brain AVMs with large AVF.

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