scholarly journals Maternal and Fetal Outcomes in Women with Brain Arteriovenous Malformation Rupture during Pregnancy

2021 ◽  
pp. 1-7
Author(s):  
Kimberly L. Yan ◽  
Nerissa U. Ko ◽  
Steven W. Hetts ◽  
Shantel Weinsheimer ◽  
Adib A. Abla ◽  
...  
Keyword(s):  
San Francisco ◽  
Treatment Strategies ◽  
First Trimester ◽  
Interventional Treatment ◽  
Maternal Outcomes ◽  
Fetal Outcomes ◽  
Brain Avm ◽  
Risk Of Hemorrhage ◽  
The University

Background: Sporadic brain arteriovenous malformations (BAVM) are a major cause of hemorrhagic stroke in younger persons. Prior studies have reported contradictory results regarding the risk of hemorrhage during pregnancy, and there are no standard guidelines for the management of pregnant women who present with BAVM rupture. The purpose of this study is to describe maternal and fetal outcomes and treatment strategies in patients with BAVM hemorrhage during pregnancy. Methods: We performed a retrospective review of the University of California, San Francisco Brain AVM Project database for female patients who were pregnant at the time of BAVM hemorrhage between 2000 and 2017. Clinical and angiographic characteristics at presentation, BAVM treatment, and maternal outcomes using modified Rankin scale (mRS) score at presentation and 2-year follow-up were recorded. Fetal outcomes were abstracted from medical records and maternal reports. Results: Sixteen patients presented with BAVM hemorrhage during pregnancy, 81% (n = 13) of whom were in their second or third trimester. Three patients (19%) who were in their first trimester terminated or miscarried pregnancy prior to BAVM intervention. Of the remaining 13 patients, 77% (n = 10) received emergent BAVM treatment at time of hemorrhage prior to delivery, and 85% of patients achieved BAVM obliteration and good maternal outcomes (mRS 0–2) at 2-year follow-up. All patients had uncomplicated deliveries (69% cesarean and 23% vaginal) with no reports of postnatal cognitive or developmental delays in infants at 2-year follow-up. Conclusions: Our study shows good long-term maternal and fetal outcomes in ruptured BAVM patients presenting during pregnancy, the majority who received BAVM interventional treatment prior to delivery.

Treatment strategies for protein-losing enteropathy in Fontan-palliated patients

2020 ◽  
Vol 30 (5) ◽  
pp. 698-709
Author(s):  
Anastasia Schleiger ◽  
Stanislav Ovroutski ◽  
Björn Peters ◽  
Stephan Schubert ◽  
Joachim Photiadis ◽  
...  
Keyword(s):  
Cardiac Transplantation ◽  
Fontan Procedure ◽  
Disease Onset ◽  
Treatment Strategies ◽  
Individual Treatment ◽  
Interventional Treatment ◽  
Vasodilator Therapy ◽  
Protein Losing Enteropathy ◽  
Pulmonary Vasodilator

AbstractObjective:Protein-losing enteropathy is an infrequent but severe condition occurring after Fontan procedure. The multifactorial pathogenesis remains unclear and no single proposed treatment strategy has proven universally successful. Therefore, we sought to describe different treatment strategies and their effect on clinical outcome and mortality.Material and Methods:We performed a retrospective observational study. From the total cohort of 439 Fontan patients treated in our institution during the study period 1986–2019, 30 patients (6.8%) with protein-losing enteropathy were identified. Perioperative, clinical, echocardiographic, laboratory, and invasive haemodynamic findings and treatment details were analysed.Results:Median follow-up after disease onset was 13.1 years [interquartile range 10.6]. Twenty-five patients received surgical or interventional treatment for haemodynamic restrictions. Medical treatment, predominantly pulmonary vasodilator and/or systemic anti-inflammatory therapy with budesonide, was initiated in 28 patients. In 15 patients, a stable remission could be achieved by medical or surgical procedures (n = 3 each), by combined multimodal therapy (n = 8), or ultimately by cardiac transplantation (n = 1). Phrenic palsy, bradyarrhythmia, Fontan pathway stenosis, and absence of a fenestration were significantly associated with development of protein-losing enteropathy (p = 0.001–0.48). Ten patients (33.3%) died during follow-up; 5-year survival estimate was 96.1%. In unadjusted analysis, medical therapy with budesonide and pulmonary vasodilator therapy in combination was associated with improved survival.Conclusions:Protein-losing enteropathy is a serious condition limiting survival after the Fontan procedure. Comprehensive assessment and individual treatment strategies are mandatory to achieve best possible outcome. Nevertheless, relapse is frequent and long-term mortality substantial. Cardiac transplantation should be considered early as treatment option.

Prospective Staged Volume Radiosurgery for Large Arteriovenous Malformations: Indications and Outcomes in Otherwise Untreatable Patients

Neurosurgery ◽  
2006 ◽  
Vol 58 (1) ◽  
pp. 17-27 ◽  
Author(s):  
Sait Sirin ◽  
Douglas Kondziolka ◽  
Ajay Niranjan ◽  
John C. Flickinger ◽  
Ann H. Maitz ◽  
...  
Keyword(s):  
Target Volume ◽  
Neurological Deficits ◽  
University Of Pittsburgh ◽  
Brain Avm ◽  
Last Stage ◽  
Two Stages ◽  
The University ◽  
Median Margin ◽  
Median Interval

Abstract OBJECTIVE: The obliteration response of an arteriovenous malformation (AVM) to radiosurgery is strongly dependent on dose and volume. For larger volumes, the dose must be reduced for safety, but this compromises obliteration. In 1992, we prospectively began to stage anatomic components in order to deliver higher single doses to symptomatic AVMs >15 ml in volume. METHODS: During a 17-year interval at the University of Pittsburgh, 1040 patients underwent radiosurgery for a brain AVM. Out of 135 patients who had multiple procedures, 37 patients underwent prospectively staged volume radiosurgery for symptomatic otherwise unmanageable larger malformations. Twenty-eight patients who were managed before 2002 were included in this study to achieve sufficient follow-up in assessing the outcomes. The median age was 37 years (range, 13–57 yr). Thirteen patients had previous hemorrhages and 13 patients had attempted embolization. Separate anatomic volumes were irradiated at 3 to 8 months (median, 5 mo) intervals. The median initial AVM volume was 24.9 ml (range, 10.2–57.7 ml). Twenty-six patients had two stages and two had three-stage radiosurgery. Seven patients had repeat radiosurgery after a median interval of 63 months. The median target volume was 12.3 ml. (range, 4.2–20.8 ml.) at Stage I and 11.5 ml. (range, 2.8–22 ml.) at Stage II. The median margin dose was 16 Gy at both stages. Median follow-up after the last stage of radiosurgery was 50 months (range, 3–159 mo). RESULTS: Four patients (14%) sustained a hemorrhage after radiosurgery; two died and two patients recovered with mild permanent neurological deficits. Worsened neurological deficits developed in one patient. Seizure control was improved in three patients, was stable in eight patients and worsened in two. Magnetic resonance imaging showed T2 prolongation in four patients (14%). Out of 28 patients, 21 had follow-up more than 36 months. Out of 21 patients, seven underwent repeat radiosurgery and none of them had enough follow- up. Of 14 patients followed for more than 36 months, seven (50%) had total, four (29%) near total, and three (21%) had moderate AVM obliteration. CONCLUSIONS: Prospective staged volume radiosurgery provided imaging defined volumetric reduction or closure in a series of large AVMs unsuitable for any other therapy. After 5 years, this early experience suggests that AVM related symptoms can be stabilized and anticipated bleed rates can be reduced.

scholarly journals Prospective comparison of long-term pain relief rates after first-time microvascular decompression and stereotactic radiosurgery for trigeminal neuralgia

2018 ◽  
Vol 128 (1) ◽  
pp. 68-77 ◽  
Author(s):  
Doris D. Wang ◽  
Kunal P. Raygor ◽  
Tene A. Cage ◽  
Mariann M. Ward ◽  
Sarah Westcott ◽  
...  
Keyword(s):  
San Francisco ◽  
Pain Control ◽  
Favorable Outcome ◽  
Pain Intensity Score ◽  
Intensity Score ◽  
Surgical Treatments ◽  
The University ◽  
First Time

OBJECTIVECommon surgical treatments for trigeminal neuralgia (TN) include microvascular decompression (MVD), stereotactic radiosurgery (SRS), and radiofrequency ablation (RFA). Although the efficacy of each procedure has been described, few studies have directly compared these treatment modalities on pain control for TN. Using a large prospective longitudinal database, the authors aimed to 1) directly compare long-term pain control rates for first-time surgical treatments for idiopathic TN, and 2) identify predictors of pain control.METHODSThe authors reviewed a prospectively collected database for all patients who underwent treatment for TN between 1997 and 2014 at the University of California, San Francisco. Standardized collection of data on preoperative clinical characteristics, surgical procedure, and postoperative outcomes was performed. Data analyses were limited to those patients who received a first-time procedure for treatment of idiopathic TN with > 1 year of follow-up.RESULTSOf 764 surgical procedures performed at the University of California, San Francisco, for TN (364 SRS, 316 MVD, and 84 RFA), 340 patients underwent first-time treatment for idiopathic TN (164 MVD, 168 SRS, and 8 RFA) and had > 1 year of follow-up. The analysis was restricted to patients who underwent MVD or SRS. Patients who received MVD were younger than those who underwent SRS (median age 63 vs 72 years, respectively; p < 0.001). The mean follow-up was 59 ± 35 months for MVD and 59 ± 45 months for SRS. Approximately 38% of patients who underwent MVD or SRS had > 5 years of follow-up (60 of 164 and 64 of 168 patients, respectively). Immediate or short-term (< 3 months) postoperative pain-free rates (Barrow Neurological Institute Pain Intensity score of I) were 96% for MVD and 75% for SRS. Percentages of patients with Barrow Neurological Institute Pain Intensity score of I at 1, 5, and 10 years after MVD were 83%, 61%, and 44%, and the corresponding percentages after SRS were 71%, 47%, and 27%, respectively. The median time to pain recurrence was 94 months (25th–75th quartiles: 57–131 months) for MVD and 53 months (25th–75th quartiles: 37–69 months) for SRS (p = 0.006). A subset of patients who had MVD also underwent partial sensory rhizotomy, usually in the setting of insignificant vascular compression. Compared with MVD alone, those who underwent MVD plus partial sensory rhizotomy had shorter pain-free intervals (median 45 months vs no median reached; p = 0.022). Multivariable regression demonstrated that shorter preoperative symptom duration (HR 1.005, 95% CI 1.001–1.008; p = 0.006) was associated with favorable outcome for MVD and that post-SRS sensory changes (HR 0.392, 95% CI 0.213–0.723; p = 0.003) were associated with favorable outcome for SRS.CONCLUSIONSIn this longitudinal study, patients who received MVD had longer pain-free intervals compared with those who underwent SRS. For patients who received SRS, postoperative sensory change was predictive of favorable outcome. However, surgical decision making depends upon many factors. This information can help physicians counsel patients with idiopathic TN on treatment selection.

Radiosurgical treatment for rolandic arteriovenous malformations

2006 ◽  
Vol 105 (5) ◽  
pp. 689-697 ◽  
Author(s):  
Yuri M. Andrade-Souza ◽  
Meera Ramani ◽  
Daryl Scora ◽  
May N. Tsao ◽  
Karel terBrugge ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Latency Period ◽  
Obliteration Rate ◽  
University Of Toronto ◽  
First Choice ◽  
Study Population ◽  
Radiation Induced ◽  
Risk Of Hemorrhage ◽  
The University

Object The authors reviewed the radiosurgical outcomes in patients with arteriovenous malformations (AVMs) located in the rolandic area, including the primary motor and sensory gyri. Methods The study population consisted of 38 patients with rolandic-area AVMs who underwent linear accelerator radiosurgery at the University of Toronto between 1989 and 2000. Obliteration rate, risk of hemorrhage during the latency period, radiation-induced complications, seizure control, and functional status were evaluated. Patients were also divided into two subgroups according to AVM volume (< 3 cm3 and ≥ 3 cm3). Patients were followed up for a median of 42.4 months (range 30–103 months), and the median age of the patients was 40 years (range 12–67 years). The median AVM volume was 8.1 cm3 (range 0.32–21, mean 8.32 cm3), and the median dose at the tumor margin was 15 Gy (range 15–22, mean 16.8 Gy). The risk of hemorrhage after radiosurgery was 5.3% for the 1st year, 2.6% for the 2nd, and 0% for the 3rd. Two patients (5.3%) sustained adverse effects related to radiation for more than 6 months. Complete nidus obliteration after a single radiosurgical treatment was achieved in 23 patients (60.5%). The obliteration rate for AVMs smaller than 3 cm3 was 83.3% (10 of 12) and that for AVMs larger than or equal to 3 cm3 was 50% (13 of 26). Among the patients who had seizures as the initial presentation, 51.8% were free of seizures after radiosurgery and the seizure pattern improved in 40.7% during the 3rd and last year of follow up. Overall, excellent results (obliteration and no new or worsening neurological deficit) can be achieved in approximately 60% of patients. This percentage varies according to the AVM size and can reach 83% in patients with AVMs smaller than 3 cm3. Conclusions Radiosurgery is a safe and effective treatment for people with rolandic AVMs. The low rate of morbidity associated with radiosurgery, compared with other treatments, indicates that this method may be the first choice for patients with AVMs located in this area.

Parallel Venous Channel as the Recipient Pouch in Transverse/Sigmoid Sinus Dural Fistulae

Neurosurgery ◽  
2003 ◽  
Vol 53 (6) ◽  
pp. 1261-1267 ◽  
Author(s):  
Louis P. Caragine ◽  
Van V. Halbach ◽  
Chris F. Dowd ◽  
Perry P. Ng ◽  
Randall T. Higashida
Keyword(s):  
San Francisco ◽  
Medical Center ◽  
Venous Drainage ◽  
Sigmoid Sinus ◽  
Common Location ◽  
Arterial Inflow ◽  
Cortical Venous Drainage ◽  
Ablative Procedures ◽  
The University

Abstract OBJECTIVE The most common location for dural arteriovenous fistulae (AVFs) is the transverse/sigmoid sinus. We describe our prospective analysis of data for 10 patients with recipient fistulae parallel to the transverse/sigmoid sinus. Recognition of this entity allows embolization of the fistula with preservation of the parent sinus. This report reviews the presentation and angiographic characteristics of the “parallel venous channel” and the treatment results for this series of patients. METHODS Between 1995 and June 2002, at the medical center of the University of California, San Francisco, we identified 10 patients with a parallel venous channel as the recipient pouch for all arterial input into a transverse/sigmoid sinus AVF. The clinical presentations, angiographic features, endovascular treatments, and outcomes are described. Angiographic follow-up monitoring was performed for 1 to 6 years for all patients with cortical venous drainage (5 of 10 patients). Clinical follow-up periods ranged from 1 to 7 years. RESULTS All patients presented with pulsatile tinnitus disruptive to sleep. Other symptoms included severe headaches, papilledema and visual disturbances, hemiparesis, and mastoid pain. All 10 parallel venous channels communicated with the transverse or sigmoid sinus. Cortical venous drainage was present in 50% of cases. Endovascular ablative procedures, using either coils or ethanol, were performed for all patients. The parallel venous channel was successfully embolized, with preservation of the transverse/sigmoid sinus, for all 10 patients. There were no major complications. All patients experienced resolution of their symptoms, with no recurrence. CONCLUSION The existence of a parallel venous channel as the recipient pouch for all arterial inflow in a series of 10 transverse/sigmoid sinus AVFs is described. Endovascular obliteration of the parallel channel, with preservation of the parent sinus, was successfully performed for all 10 patients. Recognition of the parallel venous channel is clinically important for the treatment of transverse/sigmoid AVFs.

Cranial Chordomas: Clinical Presentation and Results of Operative and Radiation Therapy in Twenty-six Patients

Neurosurgery ◽  
1985 ◽  
Vol 17 (5) ◽  
pp. 703-710 ◽  
Author(s):  
Corey Raffel ◽  
Donald C. Wright ◽  
Philip H. Gutin ◽  
Charles B. Wilson
Keyword(s):  
Radiation Therapy ◽  
San Francisco ◽  
Clinical Presentation ◽  
Average Length ◽  
Heavy Charged Particles ◽  
Presenting Symptoms ◽  
Average Survival ◽  
The University ◽  
Lost To Follow Up

Abstract The clinical presentation and the results of operative and radiation therapy in a series of 26 patients with cranial chordomas seen at the University of California, San Francisco, between 1940 and 1984 are reviewed. There were 14 men and 12 women, with a mean age of 39.6 years. Six patients had chondroid chordomas. The most common presenting symptoms were headache and diplopia, and the most common presenting sign was extraocular palsy. Fifty-three operations directed at removal of the tumor were performed. Twenty-three patients received various forms of radiation therapy postoperatively, including conventional external beam therapy, heavy charged particles, and interstitial implants. The average length of follow-up is 5.6 years. Eleven of 26 patients have died; the mean duration of survival in this group, excluding 1 perioperative death, was 4 years and 2 months. Although the average survival time of 6 years and 4 months was the same in patients with typical chordomas (excluding the perioperative death and 1 patient lost to follow-up) and in those with the chondroid variant, all of the latter are still alive, whereas more than half of the patients with typical chordoma have died.

scholarly journals Nasolacrimal Obstruction Following the Placement of Maxillofacial Hardware

2020 ◽  
Vol 13 (1) ◽  
pp. 32-37
Author(s):  
J. Minjy Kang ◽  
Evan Kalin-Hajdu ◽  
Oluwatobi O. Idowu ◽  
M. Reza Vagefi ◽  
Robert C. Kersten
Keyword(s):  
San Francisco ◽  
Case Series ◽  
Nasolacrimal Duct ◽  
Maxillofacial Reconstruction ◽  
Institutional Review ◽  
Chronic Dacryocystitis ◽  
External Dacryocystorhinostomy ◽  
The University ◽  
External Dcr

Purpose: This article reviews cases of nasolacrimal obstruction (NLO) secondary to maxillofacial hardware placement. Methods: A retrospective review was performed at a single institution from 2012 to 2017 of patients with NLO following maxillofacial reconstruction. The study was approved by the Institutional Review Board of the University of California, San Francisco, adhered to the tenets of the Declaration of Helsinki, and was Health Insurance Portability and Accountability Act compliant. Patients were included if external dacryocystorhinostomy (DCR) confirmed previously placed maxillofacial hardware as the primary contributor to lacrimal outflow obstruction and had at least 3 months of follow-up. Results: Of 420 patients who underwent external DCR, 6 cases of implant-related NLO were identified. The mean age was 47.3 ± 9.6 years and 66.7% of patients were male. All patients presented with epiphora and 50% also had chronic dacryocystitis. Patients had prior maxillofacial hardware placement for paranasal sinus tumors (66.7%) or facial fractures (33.3%). In addition to external DCR, all patients had revision or removal of implants that were impeding lacrimal outflow by 2 mechanisms: (1) an orbital implant impinging the lacrimal sac or nasolacrimal duct (NLD) and/or (2) maxillofacial screws placed into the bony NLD or nasolacrimal fossa. Five of the 6 patients (83.3%) had complete resolution of symptoms and patency of the nasolacrimal system at their last follow-up visit (range 3-30 months). Conclusion: NLO secondary to hardware placement, though infrequent, is underreported. Two mechanisms of hardware-induced NLO were encountered in this case series. Specific attention to nasolacrimal anatomy at the time of maxillofacial reconstruction may help minimize implant-induced NLO.

Stereotactic radiosurgery for pediatric intracranial arteriovenous malformations: the University of California at San Francisco experience

2002 ◽  
Vol 97 (1) ◽  
pp. 48-55 ◽  
Author(s):  
Matthew D. Smyth ◽  
Penny K. Sneed ◽  
Samuel F. Ciricillo ◽  
Michael S. Edwards ◽  
William M. Wara ◽  
...  
Keyword(s):  
Partial Response ◽  
San Francisco ◽  
Arteriovenous Malformations ◽  
University Of California ◽  
Content Type ◽  
Obliteration Rate ◽  
The Mean ◽  
The University ◽  
Fine Print

Object. Stereotactic radiosurgery for arteriovenous malformations (AVMs) is an accepted treatment option, but few reports have been published on the results of this treatment in children. In this study the authors describe a series of pediatric patients with a minimum follow-up duration of 36 months. Methods. From 1991 to 1997, 40 children (26 boys and 14 girls) with AVMs were treated with radiosurgery at the University of California at San Francisco (UCSF). Follow-up information was available for 31 children (20 boys and 11 girls) in whom the median age at initial treatment was 11.2 years (range 3.4–17.5 years). The median follow-up duration was 60 months (range 6–99 months). Sixteen percent of the AVMs were Spetzler—Martin Grade II; 68%, Grade III; 10%, Grade IV; and 6%, Grade V. The mean volume of the AVMs was 5.37 cm3 and the median volume was 1.6 cm3. The mean marginal dose of radiation was 16.7 Gy and the median dose was 18 Gy (range 12–19 Gy). Angiography performed in 26 children confirmed obliteration of the AVM nidus in nine patients (35%), partial response in 16 patients (62%), and no response in one patient (4%). In five patients who refused angiography, magnetic resonance (MR) imaging revealed obliteration in two patients and partial response in three patients, bringing the overall obliteration rate associated with initial radiosurgery to 35%. Logistic regression analysis confirmed a significant correlation between marginal dose prescription and response (p = 0.025); in AVMs that received at least 18 Gy there was a 10-fold increase in the obliteration rate (63%) over AVMs that received a lower dose. Lesions smaller than 3 cm3 were associated with a sixfold increased obliteration rate (53%) over lesions larger than 3 cm3 (8%), but AVM volume was not a statistically significant predictor of response (p = 0.09). Twelve patients have since undergone repeated radiosurgery and are currently being followed up with serial MR imaging studies (in five cases, the AVM is now obliterated). During the follow-up period (1918 patient-months) there were eight hemorrhages in five patients, with a cumulative posttreatment hemorrhage rate of 3.2%/patient/year in the 1st year and a rate of 4.3%/patient/year over the first 3 years. There were two permanent neurological complications (6%) and no deaths in this study. Conclusions. The lower overall obliteration rate reported in this series is most likely due to the larger mean AVM volumes treated at UCSF as well as conservative dose—volume prescriptions delivered to children. Significantly higher obliteration rates were observed when a marginal radiation dose of at least 18 Gy was delivered. The permanent complication rate is low and should encourage those treating children to use doses similar to those used in adults.

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