Embolization of Cerebral Arteriovenous Malformations to Enhance the Success of Subsequent Radiosurgery

1998 ◽  
Vol 4 (1_suppl) ◽  
pp. 121-126 ◽  
Author(s):  
S. Miyachi ◽  
T. Tanaka ◽  
T. Kobayashi ◽  
Y. Kida ◽  
M. Negoro ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Size Reduction ◽  
Diffuse Type ◽  
Cerebral Arteriovenous Malformations ◽  
Shunt Flow ◽  
Increased Risk ◽  
Mean Size ◽  
The Mean ◽  
Embolic Materials

We studied angiographic changes in embolized arteriovenous malformations (AVMs) by comparing pre- and postembolization angiograms and angiograms preceding radiosurgery. This study sought factors determining the usefulness of embolization as a pretreatment to enhance the success of subsequent radiosurgery. Thirty patients with cerebral AVMs treated in this manner over 4 years were studied. In these cases AVMs were embolized with cyanoacrylate and were treated with Gamma-knife radiosurgery. The mean size of the AVM nidus was reduced by a fraction of seven following embolization. The subsequent angiogram for planning radiosurgery showed further nidus reduction in 10 AVMs, no change in 12, and regrowth in 8. In all size-reduction cases the nidus was sufficiently packed, and 2 AVMs had thrombosed completely before radiosurgery. All the regrowing AVMs were of diffuse type; 6 were associated with already-developed leptomeningeal channels, and the remaining 3 were fed by newly sprouted meningeal feeders. Five AVMs disappeared following radiosurgery, all representing size-reduction or no-change cases. Analysis of cases with regrowth showed increased risk of that event with feeder occlusion of a multi-axially supplied AVM, lack of reduction of shunt flow, or remaining meningeal feeders. On the other hand, when embolization as pretreatment prior to radiosurgery succeeds in producing a small, compacted, plexiform nidus with slow shunt flow, it furthers the likelihood of successful radiosurgery, Nidus embolization and occlusion of fistulous and meningeal feeders are mandatory, while proximal feeder occlusion and use of embolic materials which risk recanalization should be avoided to prevent nidus regrowth.

scholarly journals P03.08 Large cerebral arteriovenous malformations management with Volume-staged gamma knife radiosurgery

2019 ◽  
Vol 21 (Supplement_3) ◽  
pp. iii26-iii26
Author(s):  
R M Emad Eldin ◽  
W A Reda ◽  
A M El-Shehaby ◽  
K Abdel Karim ◽  
A Nabeel ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Cerebral Arteriovenous Malformations ◽  
Factors Affecting ◽  
Prescription Dose ◽  
The Mean ◽  
Cerebral Avms ◽  
Grade 3

Abstract BACKGROUND Large cerebral arteriovenous malformations (AVM) pose a management dilemma because of the limited success of any single treatment modality by itself. Surgery alone is associated with significant morbidity and mortality. Similarly, embolization alone has limited efficacy. Volume-staged gamma knife radiosurgery (VSGR) has been developed for the treatment of large AVMs, to increase the efficacy and improve safety of treatment of these lesions. The aim of the study was to assess the efficacy and safety of VSGR technique for the treatment of large cerebral AVMs. METHODS The study included patients treated by VSGR between May 2009 and July 2015. All cases had large AVMs (>10 cc). These were 29 patients. RESULTS Twenty-four patients completed radiographic follow up with 15 obliteration cases (62.5%). There was a total of 56 sessions performed. The mean AVM volume was 16 cc (10.1–29.3 cc). The mean prescription dose was 18 Gy (14–22 Gy). The mean follow up duration was 43 months (21–73 months). One patient died during follow up from unrelated cause. Two cases suffered haemorrhage during follow up. Symptomatic edema developed in 5 (17%) patients. The factors affecting obliteration were smaller total volume, higher dose/stage, non-deep location, compact AVM, AVM score less than 3, >18 Gy dose and <15 cc total volume. The factors affecting symptomatic edema were smaller total volume and shorter time between first and last sessions (p 0.012). T2 image changes were affected by SM grade 3 or more (p 0.013) and AVM score 3 or more (p 0.014). CONCLUSION VSGR provides an effective and safe treatment option for large cerebral AVMs. Smaller AVM volume is associated with higher obliteration rate.

scholarly journals 45. Relative Shunt Flow in Cerebral Arteriovenous Malformations

1967 ◽  
Vol 9 ◽  
pp. 77-78
Author(s):  
Keiji SANO ◽  
Minoru JIMBO ◽  
Isamu SAITO ◽  
Teruo NAGAI
Keyword(s):  
Arteriovenous Malformations ◽  
Cerebral Arteriovenous Malformations ◽  
Shunt Flow

scholarly journals Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformations

1999 ◽  
Vol 27 (4) ◽  
pp. 241-247 ◽  
Author(s):  
Masaaki YAMAMOTO ◽  
Takayuki TANAKA ◽  
Nagatoshi BOKU ◽  
Seiji FUKUOKA ◽  
Hiromichi HOSODA ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Cerebral Arteriovenous Malformations

Combined Embolization and Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformations

1993 ◽  
Vol 34 (6) ◽  
pp. 600-606 ◽  
Author(s):  
W. Y. Guo ◽  
G. Wikholm ◽  
B. Karlsson ◽  
C. Lindquist ◽  
P. Svendsen ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Combined Treatment ◽  
Time Lag ◽  
Gamma Knife Radiosurgery ◽  
Cerebral Arteriovenous Malformations ◽  
Neurologic Deficits ◽  
Feeding Vessels ◽  
Grade Iii

In a study of 46 patients with cerebral arteriovenous malformations (AVMs) the value of combining embolization and gamma knife radiosurgery was assessed. In 35 patients with large grade III to V AVMs (Spetzler-Martin system) staged combined treatment was planned. In 11 patients, radiosurgery complemented embolization for a residual AVM. The number of embolization sessions ranged from 1 to 7 (median 2). Twenty-six patients needed multiple embolization sessions. In 28 patients the grade of AVMs decreased as a result of embolization. In 16 patients collateral feeding vessels developed after embolization which made delineation of the residual nidus difficult. The time lag between the last embolization and radiosurgery ranged from 1 to 24 months (median 4). Nineteen of 35 large grade III to V AVMs were possible to treat by radiosurgery following embolization. In the 46 patients complications occurred in 9 from embolization and in 2 from radiosurgery. Two patients had transient and 9 had permanent neurologic deficits. It is concluded that embolization facilitates radiosurgery for some large AVMs and therefore this combined treatment has a role in the management of AVMs.

Clinical and neuroimaging outcome of cerebral arteriovenous malformations after Gamma Knife surgery: analysis of the radiation injury rate depending on the arteriovenous malformation volume

2008 ◽  
Vol 109 (2) ◽  
pp. 191-198 ◽  
Author(s):  
Jung Ho Han ◽  
Dong Gyu Kim ◽  
Hyun-Tai Chung ◽  
Chul-Kee Park ◽  
Sun Ha Paek ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Radiation Effects ◽  
Radiation Injury ◽  
Injury Rate ◽  
Gamma Knife Surgery ◽  
Cerebral Arteriovenous Malformations ◽  
Bleeding Rate ◽  
Reduced Dose ◽  
The Mean

Object In this paper the authors analyzed the clinical and neuroimaging outcomes of patients with cerebral arteriovenous malformations (AVMs) after Gamma Knife surgery (GKS), focusing on the analysis of the radiation injury rate depending on the AVM volume. Methods Between 1997 and 2004, 277 consecutive patients with cerebral AVMs were treated with GKS. Of these patients, 218 were followed up for ≥ 2 years. The mean age was 31 ± 15 years, the median AVM volume was 3.4 cm3 (range 0.17–35.2 cm3), the median marginal dose was 18.0 Gy (range 10.0–25.0 Gy), and the mean follow-up duration was 44 ± 20 months. The authors reduced the prescription dose by various amounts, depending on the AVM volume and location as prescribed in the classic guideline to avoid irreversible radiation injuries. Results The angiographic obliteration rate was 66.4% overall, and it was 81.7, 53.1, and 12.5% for small, medium, and large AVMs, respectively. The overall annual bleeding rate was 1.9%. The annual bleeding rate was 0.44 and 4.64% for small and large AVMs, respectively. Approximately 20% of the patients showed severe postradiosurgery imaging (PRI) changes. The rate of PRI change was 11.4, 33.3, and 9.5% for small, medium, and large AVM volume groups, respectively, and a permanent radiation injury developed in 5.1% of patients. Conclusions By using the reduced dose from what is usually prescribed, the authors were able to obtain outcomes in small AVMs that were comparable to the outcomes described in previous reports. However, medium AVMs appear to still be at risk for adverse radiation effects. Last, in large AVMs, the authors were able to attain a tolerable rate of radiation injury; however, the clinical outcomes were quite disappointing following administration of a reduced dose of GKS for large AVMs.

scholarly journals Curative Glubran 2 Embolization of Cerebral Arteriovenous Malformations Patient Selection and Initial Results

2014 ◽  
Vol 20 (6) ◽  
pp. 722-728 ◽  
Author(s):  
Jie Liu ◽  
Ming Lv ◽  
Xianli Lv ◽  
Hongwei He ◽  
Aihua Liu ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Clinical Results ◽  
Hemorrhagic Complication ◽  
Cerebral Arteriovenous Malformations ◽  
Complete Obliteration ◽  
Glubran 2 ◽  
Cerebral Avms

The liquid embolic agents currently used for embolization of cerebral arteriovenous malformations are Onyx and NBCA. Glubran 2, a cyanoacrylate-based synthetic glue, has recently been applied for embolization of cerebral arteriovenous malformations (AVMs). We report the clinical results of selected cerebral AVMs treated with Glubran 2 targeting for curative embolization. Between October 2011 and March 2013, 31 patients with cerebral AVMs were selected for curative embolization with Glubran 2. There were 19 men and 12 women with a mean age of 32 years (range 4–65 years). Initial clinical presentation included hemorrhage in 28 and seizures in three patients. AVM location was frontal in eight patients, parietal in four, occipital in eight temporal in six, cerebellar in two and cerebellar vermis in three patients. Follow-up was performed clinically and with angiography examination at three to six months. Clinical outcomes were evaluated based on the modified Rankin Scale (mRS). A mean of 2.5 (range, 1–12) feeding pedicles were embolized per patient. Complete angiographic obliteration of AVM was achieved in 27 patients. A hemorrhagic complication was observed in one patient, an ischemic complication in one patient and technical complications in four patients. There was no procedure-related disabling neurological deficit or death at discharge. Additional gamma knife radiosurgery was performed in five patients, including one patient with recurrent AVM. All of the patients had favorable clinical outcomes at three to six month follow-up (mRS≤2). The curative embolization technique with Glubran 2 for selected cerebral AVMs achieved a high initial complete obliteration rate with an acceptable complication frequency.

Effectiveness and Pitfall of Embolization of Cerebral Arteriovenous Malformations

1999 ◽  
Vol 5 (1_suppl) ◽  
pp. 151-156 ◽  
Author(s):  
S. Miyachi ◽  
M. Negoro ◽  
T. Okamoto ◽  
O. Suzuki ◽  
J. Yoshida
Keyword(s):  
High Risk ◽  
Functional Imaging ◽  
Brain Function ◽  
Arteriovenous Malformations ◽  
High Flow ◽  
Surgical Removal ◽  
Cerebral Arteriovenous Malformations ◽  
Total Occlusion ◽  
Embolic Materials ◽  
The Relationship

We studied the course of perisurgical complications of 66 AVMs and discussed the approapriate precautions. Of 66 patients with AVMs, 14 underwent postembolization surgical removal, and 43 underwent radiosurgery. Four patients were cured with total occlusion of their AVM by embolization alone. 48 patients achieved a more than 70% occlusion of the nidus. We observed 12 complications including 3 permanent and 9 temporary. Four complications occurred immediately after the embolization due to overembolization or thromboembolism, and 7 were observed several hours later which might have been caused by retrograde thrombosis or a chemical reaction to the glue. While presurgical embolization deep-seated feeders must be embolized along with fistulous or high-flow feeders, 4 cases of 2nd embolization following radiosurgery showed that meningeal feeders developed or recanalized in cases embolized with absorbable particles. Thus, preradiosurgically, fistulous and meningeal feeders should be treated, and the nidus must be packed with embolic materials with no risk of recanalization. Successful nidus packing performed in 10 AVMs yielded a further nidus reduction before radiosurgery. The intranidal aneurysms which pose a high risk of rebleeding were also embolized. In order to avoid complications in the embolization of AVM, the angioarchitecture, hemodynamics and the relationship to brain function should be well recognized by preoperative functional imaging and superselective angiograms, and adequate embolic materials should be properly injected. As an embolization strategy, the priority of the target feeders should depend on the treatment to follow, and aggressive embolization of risky feeders or causing abrupt hemodynamic change should be avoided.

scholarly journals Endovascular Therapy Followed by Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations

2006 ◽  
Vol 12 (1_suppl) ◽  
pp. 163-166 ◽  
Author(s):  
Y. Arai ◽  
Y. Handa ◽  
H. Ishii ◽  
Y. Ueda ◽  
H. Uno ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
High Rate ◽  
Neurological Deficits ◽  
Cerebral Arteriovenous Malformations ◽  
Increased Risk ◽  
Irradiation Therapy ◽  
Complete Obliteration ◽  
Vascular Structures

Pre-radiosurgical embolization was carried out using cyanoacrylate in seven of 13 patients with cerebral arteriovenous malformations (AVMs) treated by stereotactic radiosurgery (SRS) with a linear accelerator (LINAC). The aim of embolization before SRS was the reduction of AVM volume and/or the elimination of vascular structures bearing an increased risk of haemorrhage. Staged-volume SRS was also performed in two patients because of residual irregular shaped nidus of AVMs even after the embolizations. Complete obliteration of the AVM nidus on angiogram was presented in five patients with embolizations (including one with staged-volume SRS) and in three of six patients with SRS alone, during follow-up periods after radiosurgery. No patients experienced haemorrhagic events after SRS. Although transient neurological symptoms were observed after embolizations in two patients, no permanent neurological deficits were presented in all patients with SRS. Pre-radiosurgical embolization may allow the effective influence on irradiation therapy in relatively large AVMs and promote more frequent obliteration in more small sized AVMs compared to those with SRS alone. However, further study must be needed to determine whether staged-volume SRS provides a high rate of AVM obliteration and its safeness.

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