scholarly journals S-shaped distal access catheter supported microcatheter navigation into the lenticulostriate artery feeders of brain arteriovenous malformations

2020 ◽  
Vol 26 (6) ◽  
pp. 725-732
Author(s):  
Satoshi Koizumi ◽  
Masaaki Shojima ◽  
Osamu Ishikawa ◽  
Hirotaka Hasegawa ◽  
Satoru Miyawaki ◽  
...  
Keyword(s):  
Retrospective Cohort ◽  
Arteriovenous Malformations ◽  
Strong Support ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
Novel Technique ◽  
Brain Arteriovenous Malformations ◽  
Catheter Technique ◽  
Alternative Approach ◽  
Lenticulostriate Artery

Background Although the embolization of lenticulostriate artery feeders is often warranted in the treatment of brain arteriovenous malformations, it is technically challenging due to steep and repeated angulations. Here, we describe our novel technique of navigating a flow-guided microcatheter into lenticulostriate artery feeders using the strong support provided by an S-shaped distal access catheter. Methods We reviewed our retrospective cohort of brain arteriovenous malformations, in which lenticulostriate artery feeders were attempted to embolize. Result During the study period, endovascular embolization was performed in 25 arteriovenous malformations cases. Of these, eight lenticulostriate artery feeders were present in six cases (24%). In two cases, lenticulostriate artery feeder catheterization was avoided from the beginning due to the small diameters of the feeders. After all, microcatheter navigation for lenticulostriate artery feeders were attempted in four cases with six lenticulostriate artery feeders. In all the six feeders, the S-shaped distal access catheter was successful in supporting the microcatheter to advance distally to the lenticulostriate artery feeders, even if other approaches were unsuccessful. Of the six catheterized lenticulostriate artery feeders, four were embolized. Symptomatic infarction in the lenticulostriate artery territory and mild vasospasm occurred in two cases each, but they did not result in permanent neurological deficits. Conclusion Although some potential complications need to be considered, the S-shaped distal access catheter technique appears to be an effective alternative approach to gaining access to difficult feeders of arteriovenous malformations.

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

2005 ◽  
Vol 11 (2) ◽  
pp. 141-148 ◽  
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.

scholarly journals Comparison of Endovascular Embolization Plus Simultaneous Microsurgical Resection vs. Primary Microsurgical Resection for High-Grade Brain Arteriovenous Malformations

2021 ◽  
Vol 12 ◽  
Author(s):  
Mingze Wang ◽  
Fa Lin ◽  
Hancheng Qiu ◽  
Yong Cao ◽  
Shuo Wang ◽  
...  
Keyword(s):  
Blood Loss ◽  
Arteriovenous Malformations ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
High Grade ◽  
Neurological Outcomes ◽  
Brain Arteriovenous Malformations ◽  
Hybrid Operation ◽  
Microsurgical Resection ◽  
The One

Aim: It remains a challenge in surgical treatments of brain arteriovenous malformations (AVMs) in Spetzler-Martin Grade (SMG) IV and V to achieve both optimal neurological outcomes and complete obliteration. The authors reported a series of patients with AVMs in SMG IV and V who underwent a surgical paradigm of endovascular embolization and simultaneous microsurgical resection based on the one-staged hybrid operation.Methods: Participants in the multicenter prospective clinical trial (NCT 03774017) between January 2016 and December 2019 were enrolled. Patients who received endovascular embolization plus microsurgical resection (EE+MRS) and those who received intraoperative digital subtraction angiography plus microsurgical resection (iDSA+MRS) were divided into two groups. Information on clinical features, operative details, and clinical outcomes were extracted from the database. Deterioration of neurological deficits (DNDs) was defined as the primary outcome, which represented neurological outcomes. The time of microsurgical operation and blood loss were defined as the secondary outcomes representing microsurgical risks and difficulties. Outcomes and technical details were compared between groups.Results: Thirty-eight cases (male: female = 23:15) were enrolled, with 24 cases in the EE+MRS group and 14 in the iDSA+MRS group. Five cases (13.2%) were in SMG V and 33 cases (86.8%) were in SMG IV. Fourteen cases (36.8%) underwent the paradigm of microsurgical resection plus intraoperative DSA. Twenty-four cases (63.2%, n = 24) underwent the paradigm of endovascular embolization plus simultaneous microsurgical resection. Degradations of SMG were achieved in 15 cases. Of the cases, two cases got the residual nidus detected via intraoperative DSA and resected. Deterioration of neurological deficits occurred in 23.7% of cases (n = 9) when discharged, and in 13.5, 13.5, 8.1% of cases at the follow-ups of 3, 6, and 12 months, respectively, without significant difference between groups (P > 0.05). Intracranial hemorrhagic complications were reported in three cases (7.9%) of the EE+MRS group only. The embolization did not significantly affect the surgical time and intraoperative blood loss. The subtotal embolization or the degradation of size by 2 points resulted in no DNDs.Conclusions: The paradigms based on the one-staged hybrid operation were practical and effective in treating high-grade AVMs. Appropriate intraoperative embolization could help decrease operative risks and difficulties and improve neurological outcomes.

Concurrent decompression and resection versus decompression with delayed resection of acutely ruptured brain arteriovenous malformations

2021 ◽  
pp. 1-8
Author(s):  
Rajeev D. Sen ◽  
Isaac Josh Abecassis ◽  
Jason Barber ◽  
Michael R. Levitt ◽  
Louis J. Kim ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Scale Score ◽  
Arteriovenous Malformations ◽  
Endovascular Embolization ◽  
Surgical Decompression ◽  
Low Grade ◽  
Brain Arteriovenous Malformations ◽  
Significant Difference ◽  
Delayed Group

OBJECTIVE Brain arteriovenous malformations (bAVMs) most commonly present with rupture and intraparenchymal hemorrhage. In rare cases, the hemorrhage is large enough to cause clinical herniation or intractable intracranial hypertension. Patients in these cases require emergent surgical decompression as a life-saving measure. The surgeon must decide whether to perform concurrent or delayed resection of the bAVM. Theoretical benefits to concurrent resection include a favorable operative corridor created by the hematoma, avoiding a second surgery, and more rapid recovery and rehabilitation. The objective of this study was to compare the clinical and surgical outcomes of patients who had undergone concurrent emergent decompression and bAVM resection with those of patients who had undergone delayed bAVM resection. METHODS The authors conducted a 15-year retrospective review of consecutive patients who had undergone microsurgical resection of a ruptured bAVM at their institution. Patients presenting in clinical herniation or with intractable intracranial hypertension were included and grouped according to the timing of bAVM resection: concurrent with decompression (hyperacute group) or separate resection surgery after decompression (delayed group). Demographic and clinical characteristics were recorded. Groups were compared in terms of the primary outcomes of hospital and intensive care unit (ICU) lengths of stay (LOSs). Secondary outcomes included complete obliteration (CO), Glasgow Coma Scale score, and modified Rankin Scale score at discharge and at the most recent follow-up. RESULTS A total of 35/269 reviewed patients met study inclusion criteria; 18 underwent concurrent decompression and resection (hyperacute group) and 17 patients underwent emergent decompression only with later resection of the bAVM (delayed group). Hyperacute and delayed groups differed only in the proportion that underwent preresection endovascular embolization (16.7% vs 76.5%, respectively; p < 0.05). There was no significant difference between the hyperacute and delayed groups in hospital LOS (26.1 vs 33.2 days, respectively; p = 0.93) or ICU LOS (10.6 vs 16.1 days, respectively; p = 0.69). Rates of CO were also comparable (78% vs 88%, respectively; p > 0.99). Medical complications were similar in the two groups (33% hyperacute vs 41% delayed, p > 0.99). Short-term clinical outcomes were better for the delayed group based on mRS score at discharge (4.2 vs 3.2, p < 0.05); however, long-term outcomes were similar between the groups. CONCLUSIONS Ruptured bAVM rarely presents in clinical herniation requiring surgical decompression and hematoma evacuation. Concurrent surgical decompression and resection of a ruptured bAVM can be performed on low-grade lesions without compromising LOS or long-term functional outcome; however, the surgeon may encounter a more challenging surgical environment.

scholarly journals Pathogenesis and radiobiology of brain arteriovenous malformations: implications for risk stratification in natural history and posttreatment course

2009 ◽  
Vol 26 (5) ◽  
pp. E9 ◽  
Author(s):  
Achal S. Achrol ◽  
Raphael Guzman ◽  
Monika Varga ◽  
John R. Adler ◽  
Gary K. Steinberg ◽  
...  
Keyword(s):  
Natural History ◽  
Arteriovenous Malformations ◽  
De Novo ◽  
Genetic Disorders ◽  
Treatment Options ◽  
Latency Period ◽  
Endovascular Embolization ◽  
Future Studies ◽  
Brain Arteriovenous Malformations ◽  
Congenital Origin

Brain arteriovenous malformations (BAVMs) are an important cause of intracerebral hemorrhage (ICH) in young adults. Biological predictors of future ICH risk are lacking, and controversy exists over previous studies of natural history risk among predominantly ruptured BAVM cohorts. Recent studies have suggested that the majority of BAVMs are now diagnosed as unruptured lesions, and that the risk according to natural history among these lesions may be less than previously assumed. In the first part of this review, the authors discuss available data on the natural history of BAVMs and highlight the need for future studies that aim to develop surrogate biomarkers of disease progression that accurately predict future risk of ICH in BAVMs. The etiology of BAVM remains unknown. Recent studies have suggested a role for genetic factors in the pathogenesis of sporadic BAVM, which is further supported by reports of familial occurrence of BAVM and association with known systemic genetic disorders (such as Osler-Weber-Rendu disease, Sturge-Weber disease, and Wyburn-Mason syndrome). Molecular characterization of BAVM tissue demonstrates a highly angiogenic milieu with evidence of increased endothelial cell turnover. Taken together with a number of reports of de novo BAVM formation, radiographic growth after initial BAVM diagnosis, and regrowth after successful treatment of BAVM, these findings challenge the long-held assumption that BAVMs are static lesions of congenital origin. In the second part of this review, the authors discuss available data on the origins of BAVM and offer insights into future investigations into genetics and endothelial progenitor cell involvement in the pathogenesis of BAVM. Current treatment options for BAVM focus on removal or obliteration of the lesion in an attempt to protect against future ICH risk, including microsurgical resection, endovascular embolization, and stereotactic radiosurgery (SRS). In the third part of this review, the authors discuss available data on SRS in BAVMs and highlight the need for future studies on the radiobiology of BAVMs, especially in regard to biomarker detection for tracking SRS response during the latency period. Insights from future investigations in BAVM may not only prove important for the development of novel therapies and relevant biomarkers for BAVM, but could also potentially benefit a variety of other disorders involving new vessel formation in the CNS, including stroke, tumors, moyamoya disease, and other cerebrovascular malformations.

scholarly journals Efficacy and Safety of Combined Endovascular Embolization and Stereotactic Radiosurgery for Patients with Intracranial Arteriovenous Malformations: A Systematic Review and Meta-Analysis

2021 ◽  
Vol 2021 ◽  
pp. 1-11
Author(s):  
Zhiqun Jiang ◽  
Xuezhi Zhang ◽  
Xichen Wan ◽  
Minjun Wei ◽  
Yue Liu ◽  
...  
Keyword(s):  
Sensitivity Analysis ◽  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Meta Analysis ◽  
Endovascular Embolization ◽  
Neurological Deficits ◽  
Cochrane Library ◽  
Efficacy And Safety ◽  
Intracranial Arteriovenous Malformations ◽  
Obliteration Rate

Whether the use of endovascular embolization could provide additional benefits in patients treated with stereotactic radiosurgery (SRS) for intracranial arteriovenous malformations (IAVMs) remains controversial. The current meta-analysis was conducted to assess the efficacy and safety of SRS with and without prior endovascular embolization in patients with IAVMs. The electronic databases of PubMed, EmBase, and Cochrane Library were systematically searched for eligible studies published from inception to August 12, 2020. The pooled results for obliteration rate, rehemorrhage rate, and permanent neurological deficits were calculated by odds ratios (ORs) with 95% confidence intervals (CIs) using the random-effects model. The sensitivity analysis, subgroup analysis, and publication bias for investigated outcomes were also evaluated. Nineteen studies (two prospective and 17 retrospective studies) involving a total of 3,454 patients with IAVMs were selected for the final meta-analysis. We noted that prior embolization and SRS were associated with a lower obliteration rate compared with SRS alone (OR, 0.57; 95% CI, 0.44–0.74; P < 0.001 ). However, prior embolization and SRS were not associated with the risk of rehemorrhage (OR, 1.05; 95% CI, 0.81–1.34; P = 0.729 ) and permanent neurological deficits (OR, 0.80; 95% CI, 0.48–1.33; P = 0.385 ) compared with SRS alone. The sensitivity analysis suggested that prior embolization might reduce the risk of permanent neurological deficits in patients with IAVMs treated with SRS. The treatment effects of prior embolization in patients with IAVMs could be affected by nidus volume, margin dose, intervention, and follow-up duration. This study found that prior embolization was associated with a reduced risk of obliteration in patients with IAVMs treated with SRS. Moreover, prior embolization might reduce the risk of permanent neurological deficits in patients with IAVMs.

Onyx embolization prior to stereotactic radiosurgery for brain arteriovenous malformations: a single-center treatment algorithm

2017 ◽  
Vol 10 (3) ◽  
pp. 258-267 ◽  
Author(s):  
John D Nerva ◽  
Jason Barber ◽  
Michael R Levitt ◽  
Jason K Rockhill ◽  
Danial K Hallam ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Complication Rate ◽  
Arteriovenous Malformations ◽  
Treatment Algorithm ◽  
Latency Period ◽  
Neurological Deficits ◽  
Brain Arteriovenous Malformations ◽  
Radiographic Outcomes ◽  
Ethylene Copolymer

BackgroundEmbolization before stereotactic radiosurgery (SRS) for brain arteriovenous malformations (BAVMs) is controversial.ObjectiveTo compare clinical and radiographic outcomes in patients undergoing pre-SRS embolization with ethylene copolymer (Onyx) with outcomes in patients undergoing SRS alone.MethodsSeventy consecutive patients with BAVMs who underwent SRS were retrospectively reviewed. Univariate and multivariate analyses were performed to assess the factors associated with radiographic obliteration and complication.ResultsForty-one (59%) patients presented without BAVM rupture and 29 (41%) patients presented with rupture. Pre-SRS embolization was used in 20 patients (28.6%; 7 unruptured and 13 ruptured). Twenty-five of 70 (36%) patients sustained a complication from treatment, including 6 (9%) patients with a post-SRS latency period hemorrhage. Ten (14%) patients had persistent neurological deficits after treatment. Functional outcome (as modified Rankin Scale), complication rate, and radiographic obliteration at last follow-up were not significantly different between embolized and non-embolized groups in both unruptured and ruptured BAVMs. For unruptured BAVMs, 3- and 5-year rates of radiographic obliteration were 23% and 73% for non-embolized patients and 20% and 60% for embolized patients, respectively. For ruptured BAVMs, 3- and 5-year rates of radiographic obliteration were 45% and 72% for non-embolized patients and 53% and 82% for embolized patients, respectively.ConclusionPre-SRS embolization with Onyx was not associated with worse clinical or radiographic outcomes than SRS treatment without embolization. Pre-SRS embolization has a low complication rate and can safely be used to target high-risk BAVM features in carefully selected patients destined for SRS.

Radiosurgery for Unruptured Brain Arteriovenous Malformations: An International Multicenter Retrospective Cohort Study

Neurosurgery ◽  
2017 ◽  
Vol 80 (6) ◽  
pp. 888-898 ◽  
Author(s):  
Dale Ding ◽  
Robert M. Starke ◽  
Hideyuki Kano ◽  
John Y.K. Lee ◽  
David Mathieu ◽  
...  
Keyword(s):  
Cohort Study ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Arteriovenous Malformations ◽  
Favorable Outcome ◽  
Maximum Diameter ◽  
Brain Arteriovenous Malformations ◽  
Radiation Induced ◽  
Induced Changes

Abstract BACKGROUND: The role of intervention in the management of unruptured brain arteriovenous malformations (AVM) is controversial. OBJECTIVE: To analyze in a multicenter, retrospective cohort study, the outcomes following radiosurgery for unruptured AVMs and determine predictive factors. METHODS: We evaluated and pooled AVM radiosurgery data from 8 institutions participating in the International Gamma Knife Research Foundation. Patients with unruptured AVMs and ≥12 mo of follow-up were included in the study cohort. Favorable outcome was defined as AVM obliteration, no postradiosurgical hemorrhage, and no permanently symptomatic radiation-induced changes. RESULTS: The unruptured AVM cohort comprised 938 patients with a median age of 35 yr. The median nidus volume was 2.4 cm3, 71% of AVMs were located in eloquent brain areas, and the Spetzler-Martin grade was III or higher in 57%. The median radiosurgical margin dose was 21 Gy and follow-up was 71 mo. AVM obliteration was achieved in 65%. The annual postradiosurgery hemorrhage rate was 1.4%. Symptomatic and permanent radiation-induced changes occurred in 9% and 3%, respectively. Favorable outcome was achieved in 61%. In the multivariate logistic regression analysis, smaller AVM maximum diameter (P = .001), the absence of AVM-associated arterial aneurysms (P = .001), and higher margin dose (P = .002) were found to be independent predictors of a favorable outcome. A margin dose ≥ 20 Gy yielded a significantly higher rate of favorable outcome (70% vs 36%; P &lt; .001) CONCLUSION: Radiosurgery affords an acceptable risk to benefit profile for patients harboring unruptured AVMs. These findings justify further prospective studies comparing radiosurgical intervention to conservative management for unruptured AVMs.

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

2010 ◽  
Vol 113 (4) ◽  
pp. 715-722 ◽  
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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