A Study of the Reactivity of Feeding Vessels to Arteriovenous Malformations: Correlation with Clinical Outcome

Neurosurgery ◽  
1990 ◽  
Vol 26 (2) ◽  
pp. 190-200 ◽  
Author(s):  
Karin Muraszko ◽  
Hsueh Hwa Wang ◽  
Gregory Pelton ◽  
Bennett M. Stein
Keyword(s):  
Spontaneous Activity ◽  
Arteriovenous Malformations ◽  
Perfusion Pressure ◽  
Radiographic Evidence ◽  
Vasoactive Substances ◽  
Perfusion Chamber ◽  
In Vitro Technique ◽  
Feeding Vessels ◽  
Normal Perfusion Pressure Breakthrough

Abstract Isolated segments from the feeding arteries to arteriovenous malformations (AVMs) from 24 patients were studied in vitro. In a perfusion chamber, isometric contraction of these arterial rings to various vasoactive substances was recorded and correlated with the following: spontaneous activity, spasm as seen in the operating room; radiographic evidence of ectasia preoperatively and postoperatively; and postoperative course. Of the 24 patients studied, four patients had nonreactive AVM nutrient vessels upon in vitro testing. In addition, these vessel segments displayed no spontaneous activity although all of the other vessels tested developed spontaneous activity while in the perfusion chamber. The patients with “unreactive vessels” had an increased incidence of postoperative edema and hemorrhage in the surrounding brain, consistent with the symptoms of normal perfusion pressure breakthrough. Thus, our study utilizes an in vitro technique to evaluate a specific segment of the AVM complex, the feeding vessel, which permitted us to assess abnormalities of reactivity in these vessel segments. This method may be useful for future evaluations of the pathophysiology of AVMs.

Normal Perfusion Pressure Breakthrough Complicating Surgery for the Vein of Galen Malformation: Report of Three Cases

Neurosurgery ◽  
1989 ◽  
Vol 24 (3) ◽  
pp. 406-410 ◽  
Author(s):  
Michael K. Morgan ◽  
Ian H. Johnston ◽  
Thoralf M. Sundt
Keyword(s):  
Arteriovenous Malformations ◽  
Perfusion Pressure ◽  
Cerebral Atrophy ◽  
Vein Of Galen ◽  
Brain Swelling ◽  
Vein Of Galen Malformation ◽  
Arteriovenous Shunts ◽  
Increased Risk ◽  
Normal Perfusion Pressure Breakthrough ◽  
The Brain

Abstract Three cases are described of infants who developed malignant brain swelling (and in one case hemorrhage) after surgery for vein of Galen malformations. The cause for the brain swelling was felt to be due to hyperperfusion, or the “normal perfusion pressure breakthrough” syndrome. Although well-described for cerebral parenchymal arteriovenous malformations, cases of this complication occurring in vein of Galen malformations have not previously been reported. It is concluded from these cases that infants with large arteriovenous shunts, as attested by cardiac failure and cerebral atrophy, have an increased risk of developing this complication.

Unruptured Cerebral Arteriovenous Malformations Presenting with Intracranial Hypertension

Neurosurgery ◽  
1988 ◽  
Vol 23 (4) ◽  
pp. 484-490 ◽  
Author(s):  
Daniel L. Barrow
Keyword(s):  
Intracranial Hypertension ◽  
Arteriovenous Malformations ◽  
Perfusion Pressure ◽  
Pseudotumor Cerebri ◽  
Surgical Removal ◽  
Cerebral Arteriovenous Malformations ◽  
Normal Perfusion Pressure Breakthrough ◽  
The Relationship

Abstract Two cases of unruptured pial arteriovenous malformations (AVMs) presenting with intracranial hypertension and papilledema are reported. In the absence of previous hemorrhage or associated hydrocephalus, such a manifestation of pial AVMs is quite unusual. Both patients experienced prompt and sustained resolution of papilledema after surgical removal of the malformation. One case was complicated by the normal perfusion pressure breakthrough phenomenon postoperatively. The pathophysiology of intracranial hypertension associated with unruptured pial AVMs and the relationship to pseudotumor cerebri are discussed.

Normal perfusion pressure breakthrough syndrome in giant arteriovenous malformations

1997 ◽  
Vol 19 (2) ◽  
pp. 117-123 ◽  
Author(s):  
Yoko Kato ◽  
Hirotoshi Sano ◽  
Kazuhiko Nonomura ◽  
Tetsuo Kanno ◽  
Kazuhiro Katada ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Perfusion Pressure ◽  
Normal Perfusion Pressure Breakthrough

Preoperative Balloon Occlusion of Arteriovenous Malformations

Neurosurgery ◽  
1988 ◽  
Vol 22 (2) ◽  
pp. 301-308 ◽  
Author(s):  
V. Van Halbach ◽  
Randall T. Higashida ◽  
Peter Yang ◽  
Stan Barnwell ◽  
Charles B. Wilson ◽  
...  
Keyword(s):  
Surgical Resection ◽  
Arteriovenous Malformations ◽  
Vascular Anatomy ◽  
Balloon Occlusion ◽  
Neurological Deficits ◽  
Permanent Occlusion ◽  
Feeding Vessels ◽  
Normal Perfusion Pressure Breakthrough ◽  
Surgical Adjunct ◽  
Risk Of Hemorrhage

Abstract Many materials have been utilized to embolize cerebral arteriovenous malformations (AVMs) preoperatively. Specific vascular anatomy with large feeding vessels deep to the nidus or aneurysms within feeding arteries favor the use of detachable balloons over other embolic agents. Detachable balloons allow test occlusion of a vascular pedicle before permanent occlusion and can obliterate aneurysms in feeding arteries. We describe 36 feeder arterial balloon occlusions performed in 31 patients. Twenty-nine patients subsequently had surgical resection. None of the patients developed normal perfusion pressure breakthrough or required blood transfusions. The preoperative balloon occlusion was judged by the neurosurgeon to decrease significantly the difficulty in surgical resection of the malformation. The remaining 2 patients underwent embolization before radiosurgery. One patient had aneurysms in the feeding artery, which was balloon-occluded to diminish the risk of hemorrhage. There were two neurological deficits and three asymptomatic arterial dissections related to the balloon procedure. Balloon occlusion of feeding arterial pedicles in selected cerebral AVMs may be a valuable surgical adjunct. (Neurosurgery 22:301-308, 1988)

Staged Treatment of Arteriovenous Malformations of the Brain

Neurosurgery ◽  
1987 ◽  
Vol 21 (3) ◽  
pp. 314-323 ◽  
Author(s):  
Brian T. Andrews ◽  
Charles B. Wilson
Keyword(s):  
Intracranial Hemorrhage ◽  
Surgical Procedures ◽  
Arteriovenous Malformations ◽  
Perfusion Pressure ◽  
Good Condition ◽  
Endovascular Embolization ◽  
External Carotid ◽  
Normal Perfusion Pressure Breakthrough ◽  
Staged Treatment ◽  
The Brain

Abstract Twenty-eight patients treated for arteriovenous malformations (AVMs) of the brain had staged therapy consisting of multiple surgical procedures or endovascular embolization followed by surgical treatment. There were 10 men and 18 women, aged 15 to 60 years (mean, 34 years). The clinical symptoms were those associated with intracranial hemorrhage in 13 patients, progressive neurological deficit not due to hemorrhage in 6, intractable headache in 5, and seizures in 4. Four groups were identified based upon the reason for staging therapy. Thirteen patients with large high flow AVMs (Group A) had staged treatment because of the risk of normal perfusion pressure breakthrough. The initial afferent artery occlusion was accomplished surgically in 9 patients and by endovascular embolization in 4. Postoperatively, no patient in this group had malignant cerebral edema or intracranial hemorrhage suggestive of normal perfusion pressure breakthrough, but 1 patient had an intraventricular hemorrhage after initial embolization. In 9 patients (Group B), the AVM had a complex multiple arterial supply that precluded resection from a single operative exposure. Seven had supratentorial AVMs, and 2 had AVMs of the posterior fossa. In 6 of these cases, the AVM was located in the midline and received bilateral arterial input. Six patients had staged surgical procedures, and 3 had an initial endovascular embolization followed by operation. Two patients had intracerebral hemorrhages, one after an initial surgical procedure and another after initial embolization. In 4 patients (Group C), the AVM had a major dural component that was treated separately from the parenchymal component. In 3 of these patients, embolization through the external carotid artery satisfactorily obliterated the dural component; in the remaining patient, a persistent internal carotid supply necessitated resection of the dural malformation. The parenchymal component was excised surgically in 2 patients. Two patients (Group D) had separate surgical procedures to treat an aneurysm associated with a parenchymal AVM. Overall, 19 of 28 patients had complete excision and 9 had partial obliteration of their AVMs. Late follow-up of 27 patients at a mean of 18.6 months showed that 16 patients were in excellent condition and 8 were in good condition. Three patients were in poor condition with debilitating neurological deficits. One patient had a delayed intracranial hemorrhage 22 months after incomplete obliteration of her AVM. Staged treatment of selected AVMs of the brain may avoid the occurrence of normal perfusion pressure breakthrough. This approach also allows satisfactory obliteration of selected malformations that have multiple complex arterial supplies or a dural component and those associated with an aneurysm.

Complications of surgery for arteriovenous malformations of the brain

1993 ◽  
Vol 78 (2) ◽  
pp. 176-182 ◽  
Author(s):  
Michael K. Morgan ◽  
Ian H. Johnston ◽  
John M. Hallinan ◽  
Neville C. Weber
Keyword(s):  
Arteriovenous Malformations ◽  
Perfusion Pressure ◽  
Morbidity Rate ◽  
Separate Analysis ◽  
Content Type ◽  
Complete Surgical Resection ◽  
Complications Of Surgery ◽  
Normal Perfusion Pressure Breakthrough ◽  
The Brain ◽  
Fine Print

✓ A series of 112 patients undergoing complete surgical resection of arteriovenous malformations (AVM's) of the brain between 1974 and 1990 were analyzed for complications and 12-month outcomes. The cohort consisted of 44 patients with small AVM's (< 2 cm in diameter), 43 patients with medium-sized AVM's (2 to 4 cm in diameter), and 25 patients with large AVM's (> 4 cm in diameter). There was a 3.6% series mortality rate and an 18% morbidity rate. One of the four deaths was caused by normal perfusion pressure breakthrough. Analysis of logistic regression found that the most important factor influencing the occurrence of complications in this series was AVM size (p = 0.005) and that the occurrence of complications (p < 0.001) and the neurological grade at the time of surgery (p < 0.004) both significantly contributed to the outcome at 12 months. This study stresses the importance of defining complications in terms of rigid criteria when analyzing AVM series in order to allow for a correct evaluation of the risk:benefit ratio of surgery. Furthermore, it emphasizes the need for a separate analysis of the importance of complications upon outcome.

Experimental rat model of chronic cerebral hypoperfusion–reperfusion mimicking normal perfusion pressure breakthrough phenomenon

Neurocirugía ◽  
2020 ◽  
Vol 31 (5) ◽  
pp. 209-215
Author(s):  
Juan Manuel Revuelta ◽  
Álvaro Zamarrón ◽  
José Fortes ◽  
Gregorio Rodríguez-Boto ◽  
Jesús Vaquero ◽  
...  
Keyword(s):  
Rat Model ◽  
Perfusion Pressure ◽  
Chronic Cerebral Hypoperfusion ◽  
Cerebral Hypoperfusion ◽  
Experimental Rat Model ◽  
Normal Perfusion Pressure Breakthrough

scholarly journals Techniques of Onyx Embolization of Arteriovenous Malformation: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Kathryn M Wagner ◽  
Visish M Srinivasan ◽  
Peter Kan
Keyword(s):  
Informed Consent ◽  
Surgical Resection ◽  
Arteriovenous Malformations ◽  
Preoperative Embolization ◽  
Great Care ◽  
Endovascular Techniques ◽  
Definitive Therapy ◽  
Feeding Vessels ◽  
Multiple Feeding ◽  
Staged Treatment

Abstract Advances in endovascular techniques and tools have allowed for treatment of complex arteriovenous malformations (AVMs), which historically may have posed unacceptable risk for open surgical resection. Endovascular treatment may be employed as an adjunct to surgical resection or as definitive therapy. Improvements in embolization materials have made endovascular AVM treatment safer for patients and useful across a variety of lesions. While many techniques are employed for transarterial AVM embolization, the essential tenets apply to all procedures: (1) great care should be taken to cannulate only vessels directly supplying the lesion, and not en passage vessels, prior to injecting embolisate; (2) embolisate should travel into the nidus, but not into the draining veins; (3) embolistate reflux proximal to the microcatheter should be avoided. There are several techniques that accomplish these goals, including the plug and push method, or using a balloon to prevent embolisate reflux. We use controlled injection of liquid Onyx (Medtronic), with increasing pressure over multiple injections pushing the embolisate forward into the AVM. This is repeated in multiple feeding vessels to decrease or eliminate supply to the AVM. Here, we present a 36-yr-old female with a right parietal AVM discovered on workup of headaches. After informed consent was obtained, she underwent preoperative embolization using this technique prior to uncomplicated surgical resection. The video shows the endovascular Onyx embolization of multiple feeding vessels over staged treatment.

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