Thalamic and Basal Ganglia Arteriovenous Malformations: Redefining “Inoperable”

2008 ◽  
Vol 63 (suppl_1) ◽  
pp. ONS63-ONS68 ◽  
Author(s):  
Edward A.M. Duckworth ◽  
Bradley Gross ◽  
H. Hunt Batjer
Keyword(s):  
Basal Ganglia ◽  
Natural History ◽  
Stereotactic Radiosurgery ◽  
Surgical Resection ◽  
Arteriovenous Malformations ◽  
Venous Drainage ◽  
Lesion Size ◽  
Small Lesion ◽  
History Of ◽  
Microsurgical Techniques

Abstract Deep Arteriovenous Malformations of the basal ganglia and thalamus have an aggressive natural history and present a therapeutic challenge. More often than not, these lesions are deemed “inoperable” and are treated expectantly or with stereotactic radiosurgery. In some cases, clinical details combined with an opportune route of access dictate surgical resection. History of hemorrhage, small lesion size, and deep venous drainage each add to the aggressive natural history of these malformations. Interestingly, these same factors can point toward surgery. We present a discussion of the microsurgical techniques involved in managing these lesions, with an emphasis on situations that allow these lesions to be approached surgically.

Deep arteriovenous malformations of the basal ganglia and thalamus: natural history

2003 ◽  
Vol 98 (4) ◽  
pp. 747-750 ◽  
Author(s):  
Ian G. Fleetwood ◽  
Mary L. Marcellus ◽  
Richard P. Levy ◽  
Michael P. Marks ◽  
Gary K. Steinberg
Keyword(s):  
Basal Ganglia ◽  
Natural History ◽  
Arteriovenous Malformations ◽  
Venous Drainage ◽  
Neurological Injury ◽  
Content Type ◽  
Hemorrhagic Event ◽  
History Of ◽  
Risk Of Hemorrhage ◽  
Fine Print

Object. Patients with arteriovenous malformations (AVMs) in a deep location and with deep venous drainage are thought to be at higher risk for hemorrhage than those with AVMs in other locations. Despite this, the natural history of AVMs of the basal ganglia and thalamus has not been well studied. Methods. The authors retrospectively evaluated a cohort of 96 patients with AVMs in the basal ganglia and thalamus with respect to the tendency of these lesions to hemorrhage between the time of detection and their eventual successful management. The 96 patients studied had a mean age of 22.7 years at diagnosis, and 51% were male. Intracranial hemorrhage (ICH) was the event leading to clinical detection in 69 patients (71.9%), and 85.5% of these patients were left with hemiparesis. After diagnosis, 25 patients bled a total of 49 times. The cumulative clinical follow up after detection but before surgical management was 500.2 patient-years. The risk of hemorrhage after detection of an AVM of the basal ganglia or thalamus was 9.8% per patient-year. Conclusions. The rate of ICH in patients with AVMs of the basal ganglia or thalamus (9.8%/year) is much higher than the rate in patients with AVMs in other locations (2–4%/year). The risk of incurring a neurological deficit with each hemorrhagic event is high. Treatment of these patients at specialized centers is recommended to prevent neurological injury from a spontaneous ICH.

Surgical Management Of Posterior Fossa Arteriovenous Malformations

2006 ◽  
Vol 58 (suppl_4) ◽  
pp. ONS-189-ONS-201 ◽  
Author(s):  
John Sinclair ◽  
Michael E. Kelly ◽  
Gary K. Steinberg
Keyword(s):  
Stereotactic Radiosurgery ◽  
Surgical Resection ◽  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Cranial Nerves ◽  
Venous Drainage ◽  
Cerebellar Nuclei ◽  
Preoperative Embolization ◽  
Frameless Stereotaxy ◽  
Microsurgical Resection

Abstract Objective: Arteriovenous malformations (AVMs) involving the cerebellum and brainstem are relatively rare lesions that most often present clinically as a result of a hemorrhagic episode. Although these AVMs were once thought to have a more aggressive clinical course in comparison with supratentorial AVMs, recent autopsy data suggests that there may be little difference in hemorrhage rates between the two locations. Although current management of these lesions often involves preoperative embolization and stereotactic radiosurgery, surgical resection remains the treatment of choice, conferring immediate protection to the patient from the risk of future hemorrhage. Methods: Most symptomatic AVMs that involve the cerebellum and the pial or ependymal surfaces of the brainstem are candidates for surgical resection. Preoperative angiography and magnetic resonance imaging studies are critical to determine suitability for resection and choice of operative exposure. In addition to considering the location of the nidus, arterial supply, and predominant venous drainage, the surgical approach must also be selected with consideration of the small confines of the posterior fossa and eloquence of the brainstem, cranial nerves, and deep cerebellar nuclei. Results: Since the 1980s, progressive advances in preoperative embolization, frameless stereotaxy, and intraoperative electrophysiologic monitoring have significantly improved the number of posterior fossa AVMs amenable to microsurgical resection with minimal morbidity and mortality. Conclusion: Future improvements in endovascular technology and stereotactic radiosurgery will likely continue to increase the number of posterior fossa AVMs that can safely be removed and further improve the clinical outcomes associated with microsurgical resection.

Advances in Radiosurgery for Arteriovenous Malformations of the Brain

Neurosurgery ◽  
2014 ◽  
Vol 74 (suppl_1) ◽  
pp. S50-S59 ◽  
Author(s):  
Benjamin A. Rubin ◽  
Andrew Brunswick ◽  
Howard Riina ◽  
Douglas Kondziolka
Keyword(s):  
Natural History ◽  
Stereotactic Radiosurgery ◽  
Endovascular Therapy ◽  
Arteriovenous Malformations ◽  
Morbidity And Mortality ◽  
Cerebral Arteriovenous Malformations ◽  
History Of ◽  
The Brain ◽  
Management Algorithms

Abstract Arteriovenous malformations of the brain are a considerable source of morbidity and mortality for patients who harbor them. Although our understanding of this disease has improved, it remains in evolution. Advances in our ability to treat these malformations and the modes by which we address them have also improved substantially. However, the variety of patient clinical and disease scenarios often leads us into challenging and complex management algorithms as we balance the risks of treatment against the natural history of the disease. The goal of this article is to provide a focused review of the natural history of cerebral arteriovenous malformations, to examine the role of stereotactic radiosurgery, to discuss the role of endovascular therapy as it relates to stereotactic radiosurgery, and to look toward future advances.

scholarly journals Natural history of brain arteriovenous malformations: a systematic review

2014 ◽  
Vol 37 (3) ◽  
pp. E7 ◽  
Author(s):  
Isaac Josh Abecassis ◽  
David S. Xu ◽  
H. Hunt Batjer ◽  
Bernard R. Bendok
Keyword(s):  
Natural History ◽  
Arteriovenous Malformations ◽  
Venous Drainage ◽  
Cerebral Arteriovenous Malformations ◽  
Brain Arteriovenous Malformations ◽  
Increased Risk ◽  
Risk Of Rupture ◽  
History Of ◽  
Arterial Aneurysms

Object The authors aimed to systematically review the literature to clarify the natural history of brain arteriovenous malformations (BAVMs). Methods The authors searched PubMed for one or more of the following terms: natural history, brain arteriovenous malformations, cerebral arteriovenous malformations, and risk of rupture. They included studies that reported annual rates of hemorrhage and that included either 100 patients or 5 years of treatment-free follow-up. Results The incidence of BAVMs is 1.12–1.42 cases per 100,000 person-years; 38%–68% of new cases are first-ever hemorrhage. The overall annual rates of hemorrhage for patients with untreated BAVMs range from 2.10% to 4.12%. Consistently implicated in subsequent hemorrhage are initial hemorrhagic presentation, exclusively deep venous drainage, and deep and infrantentorial brain location. The risk for rupture seems to be increased by large nidus size and concurrent arterial aneurysms, although these factors have not been studied as thoroughly. Venous stenosis has not been implicated in increased risk for rupture. Conclusions For patients with BAVMs, although the overall risk for hemorrhage seems to be 2.10%–4.12% per year, calculating an accurate risk profile for decision making involves clinical attention and accounting for specific features of the malformation.

scholarly journals Hypofractionated Stereotactic Radiosurgery in a Large Bilateral Thalamic and Basal Ganglia Arteriovenous Malformation

2013 ◽  
Vol 2013 ◽  
pp. 1-8
Author(s):  
Janet Lee ◽  
Tomoko Tanaka ◽  
Steven Westgate ◽  
Ashish Nanda ◽  
Marshall Cress ◽  
...  
Keyword(s):  
Basal Ganglia ◽  
Natural History ◽  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Intensity Modulated Radiotherapy ◽  
Neurological Deficits ◽  
Digital Subtraction ◽  
Intensity Modulated ◽  
Complete Obliteration ◽  
Hypofractionated Stereotactic Radiosurgery

Purpose. Arteriovenous malformations (AVMs) in the basal ganglia and thalamus have a more aggressive natural history with a higher morbidity and mortality than AVMs in other locations. Optimal treatment—complete obliteration without new neurological deficits—is often challenging. We present a patient with a large bilateral basal ganglia and thalamic AVM successfully treated with hypofractionated stereotactic radiosurgery (HFSRS) with intensity modulated radiotherapy (IMRT).Methods. The patient was treated with hypofractionated stereotactic radiosurgery to 30 Gy at margin in 5 fractions of 9 static fields with a minimultileaf collimator and intensity modulated radiotherapy.Results. At 10 months following treatment, digital subtraction angiography showed complete obliteration of the AVM.Conclusions. Large bilateral thalamic and basal ganglia AVMs can be successfully treated with complete obliteration by HFSRS with IMRT with relatively limited toxicity. Appropriate caution is recommended.

scholarly journals The Natural History of Brain Arteriovenous Malformations

2017 ◽  
Vol 36 (03) ◽  
pp. 153-159
Author(s):  
Carlos Peres ◽  
Vitor Yamaki ◽  
Eberval Figueiredo
Keyword(s):  
Natural History ◽  
Arteriovenous Malformations ◽  
Functional Performance ◽  
Brain Infarction ◽  
Treatment Decision ◽  
Venous Drainage ◽  
Brain Arteriovenous Malformations ◽  
Risk Of Rupture ◽  
Choice Of Treatment ◽  
History Of

AbstractBrain arteriovenous malformations (AVMs) are relatively rare lesions with irreversible consequences in the context of hemorrhage. They are characterized by direct connections between arteries and veins without an intervening capillary network. The natural history of brain AVMs is controversial in the literature, with low evidence level gathered in the papers published, and with large divergence of results among them. A detailed understanding of the natural history is critical for treatment decision. The risk of development of deleterious outcomes such as hemorrhage or brain infarction should always be considered when submitting a patient to the risks of treatment. Several factors related to the patient and to the AVMs are determinants in the natural history of this disease. The topography, size, morphology and angioarchitecture of AVMs determine the risk of rupture. Large AVMs, those located in the posterior fossa and with deep venous drainage, have higher risk of rupture. Due to divergence in the literature regarding the natural history of AVMs, the choice of treatment should also consider experiences acquired over the years from reference centers with a high number of AVMs treated per year. We determined 7 variables that should be considered during the decision to treat an AVM: 1) previous hemorrhage; 2) aneurysm associated to the AVM; 3) direct arteriovenous fistula; 4) factors related to the nidus; 5) age and habits (smoking, sedentary lifestyle, diet quality); 6) the functional performance of the patient; 7) psychological factors.

The Natural History of Cerebral Dural Arteriovenous Fistulae

Neurosurgery ◽  
2012 ◽  
Vol 71 (3) ◽  
pp. 594-603 ◽  
Author(s):  
Bradley A. Gross ◽  
Rose Du
Keyword(s):  
Natural History ◽  
Significant Risk ◽  
Venous Drainage ◽  
Type I ◽  
Type Ii ◽  
Arteriovenous Fistulae ◽  
Type Iii ◽  
History Of ◽  
Venous Ectasia ◽  
Cortical Venous Drainage

Abstract BACKGROUND: Hemorrhage from cerebral dural arteriovenous fistulae (dAVF) is a considerable source of neurological morbidity and even mortality. OBJECTIVE: To evaluate the natural history of cerebral dAVF. METHODS: We reviewed our own cohort of 70 dAVF and incorporated results from the literature, synthesizing pooled hemorrhage rates and evaluating risk factors for 395 dAVF in 6 studies. RESULTS: No hemorrhages occurred during 409 lesion-years of follow-up of Borden type I dAVF; however, cortical venous drainage developed in 1.4%. Like type I dAVF, type II dAVF demonstrated a female predilection and were most commonly transverse-sigmoid or cavernous. Eighteen percent of type II dAVF presented with hemorrhage (95% confidence interval [CI]: 8%-36%), and the annual hemorrhage rate was 6% (95% CI: 0.1%-19%). Borden type III dAVF demonstrated a male predilection and were most commonly tentorial or petrosal. Thirty-four percent presented with hemorrhage (95% CI: 0.4%-49%), with an annual hemorrhage rate of 10% (95% CI: 4%-20%), increasing to 21% for those with venous ectasia (95% CI: 4%-66%). The hemorrhage rate decreased to 2% for asymptomatic or minimally symptomatic type II or III dAVF (95% CI: 0.2%-8%), and increased to 10% for those presenting with nonhemorrhagic neurological deficits (95% CI: 0.9%-41%) and to 46% for those presenting with hemorrhage (95% CI: 11%-130%). CONCLUSION: Venous ectasia is a significant risk factor for hemorrhage among dAVF with cortical venous drainage. In addition, those with hemorrhagic presentation, even compared with nonhemorrhagic neurological deficit presentation, as well as Borden type III dAVF compared with type II dAVF demonstrated a trend toward greater hemorrhage rates.

The natural history of intracranial venous angiomas

1991 ◽  
Vol 75 (5) ◽  
pp. 715-722 ◽  
Author(s):  
Timothy B. Garner ◽  
O. Del Curling ◽  
David L. Kelly ◽  
D. Wayne Laster
Keyword(s):  
Natural History ◽  
Imaging Techniques ◽  
Venous Drainage ◽  
Vascular Lesion ◽  
Neurological Dysfunction ◽  
Content Type ◽  
History Of ◽  
Clinical Records ◽  
Venous Angiomas ◽  
Fine Print

✓ Cerebral venous angiomas are congenital anomalies of the intracranial venous drainage. Many believe that they are associated with a high risk of hemorrhage and neurological dysfunction, but newer neurodiagnostic imaging techniques are showing not only that they are more common than previously known but also that many have no associated symptoms. In this retrospective study, the natural history of venous angiomas was examined in 100 patients (48 males and 52 females) with radiographically identifiable lesions treated over a 14-year period. Information on the natural history of the lesion was obtained from clinical records and follow-up data. Imaging studies included angiography, computerized tomography, and magnetic resonance imaging. Angioma locations were classified as frontal (42 cases), parietal (24 cases), occipital (4 cases), temporal (2 cases), basal or ventricular (11 cases), cerebellar (14 cases), or brain stem (3 cases); 47 lesions were on the left side. Headache as a presenting symptom was common (36 patients) and often led to other radiographic studies, but this appeared to be related to the vascular lesion in only four patients. Other possibly related complications were hemorrhage in one patient, seizures in five, and transient focal deficits in eight. Fifteen patients had no neurological signs or symptoms. The mean patient age at last contact was 45.3 years (range 3 to 94 years). All patients have been managed without surgery. It is concluded that significant complications secondary to venous angiomas are infrequent and that surgical resection of these lesions and of surrounding brain is rarely indicated.

The Natural History and Management of Intracranial Dural Arteriovenous Fistulae

1997 ◽  
Vol 3 (4) ◽  
pp. 303-311 ◽  
Author(s):  
M.A. Davies ◽  
K. ter Brugge ◽  
R. Willinsky ◽  
M.C. Wallace
Keyword(s):  
Natural History ◽  
Venous Drainage ◽  
Treated Group ◽  
Adverse Outcomes ◽  
Arteriovenous Fistulae ◽  
Surgical Access ◽  
History Of ◽  
Grade Ii ◽  
Intracranial Dural Arteriovenous Fistulae

The natural history of aggressive intracranial dural arteriovenous fistulae (ICDAVF) is unknown. Despite this, the recently proposed classification scheme of Borden et al (Borden*) has the potential to predict aggressive lesion behavior after presentation for any lesion, but has so far been untested. In addition, they discuss a new but logical treatment strategy for aggressive ICDAVF based on the elimination of retrograde leptomeningeal venous drainage (RLVD). Our similar philosophy and substantial experience with these lesions, provides a unique opportunity to test these hypotheses. A cohort of 46 Borden* grade II and III ICDAVF was selected from a series of 102 ICDAVF seen at a single institution between 1984 and 1995. Patients with these lesions, presumed to have an aggressive course were all offered treatment. Conservative therapy was chosen by 14 (30%) patients, 22 (47%) had surgery, and 20 (43%) had embolisation either as sole treatment or prior to surgery. During the follow-up period (249 lesion months) for the conservatively treated group, four (29%) patients died. Excluding presentation, these patients were observed to have interval rates of intracranial hemorrhage (ICH), non haemorrhagic neurological deficit (NHND), and mortality, of 19.2%, 10.9%, and 19.3% / lesion year respectively. The 11 patients who had embolisation alone were followed for a total of 344 months after treatment. All nine patients who had lesion obliteration, or subtotal obliteration with elimination of RLVD, as confirmed by angiography, experienced improvement or complete clinical recovery. Two patients had subtotal obliteration without elimination of RLVD. One died from interval ICH and the other experienced a delayed NHND. Twenty-five surgical operations were performed on 23 ICDAVF in 22 patients. Resection of the ICDAVF was performed in 9 patients, and 16 patients were treated with surgical disconnection alone. Complications occurred in 3/9 (33%) patients who had their lesions resected and none of the disconnected group. Failure to achieve angiographic obliteration of RLVD in 2 patients treated with resection was associated with an adverse outcome in both cases (death, and interval NHND). All 16 (100%) of the disconnected group were shown to have undergone angiographic obliteration with excellent clinical outcome. Untreated, Borden* grade II and III ICDAVF have a poor natural history. Also, persistence of RLVD after inadequate treatment results in adverse outcomes. Embolisation usually improves the safety of surgical access and may lead to obliteration on its own in some cases. For the aggressive ICDAVF, surgery is required in most cases, and our data confirm that surgical disconnection alone results in cure of all Borden* grade III ICDAVF, and in grade II lesions, if not cure, conversion to a benign grade I lesion.

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