scholarly journals Transarterial Coil-Augmented Onyx Embolization for Brain Arteriovenous Malformation Technique and Experience in 22 Consecutive Patients

2014 ◽  
Vol 20 (1) ◽  
pp. 83-90 ◽  
Author(s):  
Xu Gao ◽  
Guobiao Liang ◽  
Zhiqing Li ◽  
Xiaogang Wang ◽  
Chunyong Yu ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Injection Technique ◽  
Initial Experience ◽  
Brain Arteriovenous Malformation ◽  
Technical Feasibility ◽  
Valuable Adjunct ◽  
Procedural Complication ◽  
Brain Avms ◽  
Age Range

Onyx has been widely adopted for the treatment of arteriovenous malformations (AVMs). However, its control demands operators accumulate a considerable learning curve. We describe our initial experience using a novel injection method for the embolization of AVMs. We retrospectively reviewed the data of all 22 patients with brain AVMs (12 men, 10 women; age range, 12–68 years; mean age, 43.2 years) treated by the transarterial coil-augmented Onyx injection technique. The size of the AVMs ranged from 25 mm to 70 mm (average 35.6 mm). The technical feasibility of the procedure, procedure-related complications, angiographic results, and clinical outcome were evaluated. In every case, endovascular treatment (EVT) was completed. A total of 31 sessions were performed, with a mean injection volume of 6.1 mL (range, 1.5–16.0 mL). An average of 96.7% (range 85%-100%) estimated size reduction was achieved, and 18 AVMs could be completely excluded by EVT alone. The results remained stable on follow-up angiograms. A procedural complication occurred in one patient, with permanent mild neurologic deficit. Our preliminary series demonstrated that the coil-augmented Onyx injection technique is a valuable adjunct achieving excellent nidal penetration and improving the safety of the procedure.

Abstract TMP120: Endovascular Balloon-Assisted Embolization of Intracranial Arteriovenous Malformations Using Dual Lumen Co-Axial Balloon Microcatheters and Onyx: Initial Experience.

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Bharathi D Jagadeesan ◽  
Mikayel Grigoryan ◽  
Ameer E Hassan ◽  
Andrew W Grande ◽  
Ramachandra P Tummala
Keyword(s):  
Arteriovenous Malformations ◽  
Balloon Catheter ◽  
Arterial Embolization ◽  
Initial Experience ◽  
Intracranial Arteriovenous Malformations ◽  
Balloon Inflation ◽  
Ethylene Vinyl Alcohol ◽  
Catheter Navigation ◽  
Brain Avms ◽  
Vessel Rupture

Background: Ethylene Vinyl alcohol co-polymer (Onyx) is widely used for embolization of intracranial arteriovenous malformations. Traditional catheter based techniques for Onyx infiltration may be associated with reflux of Onyx resulting in cathteter retention, vessel rupture or reflux into en-passage arteries. Balloon assisted Onyx embolization may eliminate some of these problems encountered with traditional catheter based techniques. Herein, we report our initial experience in performing balloon assisted AVM embolization for brain AVMs and dural AVFs using the new Scepter-C and Scepter-XC co- axial dual lumen balloon microcatheters. Methods: Balloon-assisted trans-arterial embolization was carried out in a series of six patients (5 with brain AVMs, one with a dural AVF ) using Onyx delivered through the lumen of Scepter-C or Scepter XC co-axial balloon microcatheters. Following initial balloon-catheter navigation into a feeding artery as close to the nidus of the malformation as possible, and subsequent balloon inflation, embolization was performed using Onyx 18 or Onyx 34 or both. The balloon was delated and removed once adequate embolization had been achieved. Results: A total of ten embolization sessions were performed via fifteen arterial feeders in these five patients. In one out of fifteen vessels (7%), there was a quickly controlled arterial perforation from balloon inflation, in all others embolization goals for each session were successfully achieved with no adverse events. Conclusion: We found that the balloon microcatheters showed excellent navigability and there were no problems with retrieval or repeated inflation and deflation of the balloons. Using this technique, we were able to avoid the need for formation of a proximal Onyx plug and its associated risks. Additionally, fluoroscopy and procedural times seemed lower with this technique compared to conventional embolization methods.

scholarly journals Palliative Embolisation of Brain Arteriovenous Malformations Presenting with Progressive Neurological Deficit

2000 ◽  
Vol 6 (3) ◽  
pp. 177-183 ◽  
Author(s):  
M. Al-Yamany ◽  
K. G. terBrugge ◽  
R. Willinsky ◽  
W. Montanera ◽  
M. Tymianski ◽  
...  
Keyword(s):  
Neurological Deficit ◽  
Arteriovenous Malformations ◽  
Clinical Results ◽  
Neurological Deficits ◽  
Therapeutic Modality ◽  
High Morbidity ◽  
Progressive Neurological Deficit ◽  
Permanent Morbidity ◽  
Brain Avms

Large arteriovenous malformations (AVMs) located in eloquent areas of the brain are generally considered incurable because of the high morbidity and mortality associated with their treatment. When these patients develop a progressive neurological deficit they in time often become severely disabled. This report presents the results of palliative embolisation in this subgroup of patients. Analysis of our data-base of 714 patients with known brain AVMs revealed 17 patients who presented with progressive neurological deficit and who underwent palliative embolisation as the therapeutic modality of choice for management of their AVM. One patient was excluded due to lack of follow-up and two were excluded because they later received radiation therapy. Following embolisation 43% had improvement of their neurological deficit, 50% stabilized and 7% continued to deteriorate and these clinical results persisted for an average of more than 2 years follow-up. Transient neurological morbidity associated with embolisation treatment was 7% and there was no permanent morbidity and no mortality. Palliative embolisation of brain AVMs presenting with progressive neurological deficits arrested deterioration in more than 90% of patients and was associated with low morbidity and no mortality.

scholarly journals Fatal Hemorrhage in Cerebral Proliferative Angiopathy

2012 ◽  
Vol 18 (3) ◽  
pp. 309-313 ◽  
Author(s):  
H. Maekawa ◽  
M. Tanaka ◽  
H. Hadeishi
Keyword(s):  
Lower Risk ◽  
Arteriovenous Malformations ◽  
Brain Parenchyma ◽  
High Flow ◽  
Remarkable Change ◽  
Vascular Abnormality ◽  
Fatal Hemorrhage ◽  
History Of ◽  
Brain Avms

Cerebral proliferative angiopathy (CPA) is a rare vascular abnormality with several angiomorphological features that are distinct from brain arteriovenous malformations (AVMs). The natural history of CPAs indicates a lower risk for hemorrhage compared to brain AVMs. A 62-year-old woman presented with gait instability and dysarthria. MRI and angiography revealed a diffuse vascular network involving the tectum and cerebellar vermis with intermingled brain parenchyma. This lesion had no dominant feeder, high-flow arteriovenous shunt, flow-related aneurysm or highly dilated veins on angiogram. These findings were consistent with a diagnosis of CPA. During follow-up, she developed progressive gait instability and eye movement abnormalities, but no remarkable change was detected on the repeated MRI and angiography. Nine years later, she died of mesencephalic hemorrhage originating from the CPA. To the best of our knowledge, this is the first description of a patient with CPA who died as a result of the initial hemorrhage. It is important to recognize that a part of CPAs is aggressive and can be more vulnerable to critical hemorrhage.

scholarly journals Surgical Treatment vs Nonsurgical Treatment for Brain Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia: A Retrospective Multicenter Consortium Study

Neurosurgery ◽  
2017 ◽  
Vol 82 (1) ◽  
pp. 35-47 ◽  
Author(s):  
Ali Tayebi Meybodi ◽  
Helen Kim ◽  
Jeffrey Nelson ◽  
Steven W Hetts ◽  
Timo Krings ◽  
...  
Keyword(s):  
Functional Status ◽  
Surgical Resection ◽  
Hereditary Hemorrhagic Telangiectasia ◽  
Functional Outcomes ◽  
Arteriovenous Malformations ◽  
Group 2 ◽  
Brain Avms ◽  
Group 1

Abstract BACKGROUND Cerebral arteriovenous malformations (AVMs) are common in patients with hereditary hemorrhagic telangiectasia (HHT). However, due to the rarity of HHT and little published evidence of outcomes from management of brain AVMs in this disease, current international HHT guidelines recommend an individualized approach. Specifically, the outcomes for surgical vs nonsurgical management of these lesions have not been reported to date. OBJECTIVE To report long-term outcomes of surgical resection of brain AVMs in HHT patients compared to outcomes in nonsurgically treated patients. METHODS From the database of the Brain Vascular Malformation Consortium HHT project, 19 patients with 20 resected AVMs (group 1) and 22 patients with 33 AVMs who received nonsurgical treatment (group 2) were studied. The groups were retrospectively reviewed for changes in functional status (modified Rankin Scale score) during the follow-up period. RESULTS During the follow-up period, 9% of patients in group 1 suffered from worsening of functional status, whereas this figure was 16% for group 2 (P > .05). Functional outcomes were not statistically different between the 2 groups at the latest follow-up (P > .05). CONCLUSION HHT patients treated surgically for brain AVMs appear to have long-term functional outcomes comparable to nonsurgical (including observational) therapy with fewer unfavorable outcomes. It is therefore reasonable to consider surgical resection as a management option in the multidisciplinary team's individualized treatment strategy for HHT patients with brain AVMs.

scholarly journals Short Term Effectiveness of Gamma Knife Radiosurgery in the Management of Brain Arteriovenous Malformation

2019 ◽  
Vol 7 (19) ◽  
pp. 3221-3224
Author(s):  
Bassam Mahmood Flamerz Arkawazi ◽  
Moneer K. Faraj ◽  
Zaid Al-Attar ◽  
Hayder Ali A. Hussien
Keyword(s):  
Arteriovenous Malformation ◽  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Clinical Symptoms ◽  
Gamma Knife Radiosurgery ◽  
Signs And Symptoms ◽  
Brain Arteriovenous Malformation ◽  
Short Term ◽  
Brain Malformations

AIM: To evaluate the short-term effectiveness of Gamma knife radiosurgery as a modality of treatment of brain arteriovenous malformation. METHODS: Sixty-three patients with arteriovenous brain malformations underwent Gamma knife radiosurgery included in this prospective study between April 2017 and September 2018 with clinical and radiological with MRI follow up was done at three months and six months post-Gamma knife radiosurgery. By the end of the 12th-month post-Gamma knife radiosurgery, the patients were re-evaluated using digital subtraction angiography co-registered with M.R.I. During the 12 months follow up, CT scan or MRI was done at any time if any one of the patients᾽ condition deteriorated or developed signs and symptoms of complications. The mean volume of the arteriovenous malformations treated was 26.0 ± 5 cm3 (range 12.5–39.5 cm3) in The Neurosciences Hospital, Baghdad/Iraq. RESULTS: By the end of the 12th month of follow up, the overall obliteration of the arteriovenous malformations was seen in six patients only (9.5%), while shrinkage was noticed in 57 patients (90.5%). Improvement or clinical stability was found in 24 out of 39 patients (61.5%) presented with epilepsy as a chief complaint before Gamma knife radiosurgery and 21 out of 24 patients (87.0%) complained of a headache before Gamma knife radiosurgery. Post-Gamma knife radiosurgery bleeding was found in only three patients (5.0%). CONCLUSION: Even with the short term follow up, Gamma knife radiosurgery has an excellent clinical outcome in most patients with arteriovenous brain malformations. The clinical symptoms like headache and seizure were either diminished or controlled with the same medical treatment dose before Gamma knife radiosurgery. Long term clinical and radiological follow up is recommended.

Abstract 156: Embolization Followed by Radiosurgery for the Treatment of Brain Arteriovenous Malformations (AVMs)

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Michael P Marks ◽  
Mary L Marcellus ◽  
Justin Santarelli ◽  
Robert L Dodd ◽  
Huy M Do ◽  
...  
Keyword(s):  
Retrospective Review ◽  
Arteriovenous Malformations ◽  
Combined Therapy ◽  
Case Series ◽  
Multimodality Therapy ◽  
Excellent Outcome ◽  
Complete Obliteration ◽  
Treatment Volume ◽  
Brain Avms

Purpose: Multimodality therapy of brain AVMs with embolization followed by radiosurgery is controversial. We present the largest case series to date of AVM patients treated with embolization and radiosurgery. Methods: Retrospective review of our institutional AVM database identified 92 patients treated from 1995-2009 with embolization followed by radiosurgery. Patients treated with surgery or radiosurgery prior to embolization were excluded. Pre- and post-embolization AVM volumes were calculated using angiography. The modified Pollock-Flickinger (PF) score was also calculated pre and post-embolization. PF scores from pre-embolization volumes were used to report obliteration rates. Post-radiosurgical obliteration was assessed using angiography or MRI. Results: Mean AVM volume went from 19.95 ml (IQR, 10.3 - 32.75) to 10.17 (3.15 - 20.65) following embolization (p<0.001) and mean PF scores decreased from 2.78 (1.77-3.94) to 1.83 (1.07 - 2.79), p<0.001. 2/92 (2.2 %) had new fixed deficits following embolization, however no patient had new disabling deficits (mRS>2). 61/92 (66%) have had ≥3 year follow-up and 35/61 (57%) had excellent outcomes (complete obliteration without neurologic decline). Excellent outcome was seen in 88% of patients with modified PF score <1, 67% of patients with score 1-1.5, 44% patients with score 1.5-2, and 48% of patients with score >2. In addition 16 patients had complete obliteration with further treatment (total 51/61 patients- 84%). Two patients died in the follow-up period due to AVM bleed. Conclusion: These data suggest that embolization of brain AVMs can safely and effectively reduce the treatment volume prior to radiosurgery. Combined therapy with embolization and radiosurgery does not adversely affect rates of excellent outcome.

Multimodal cerebral arteriovenous malformation treatment: a 12-year experience and comparison of key outcomes to ARUBA

2020 ◽  
Vol 133 (6) ◽  
pp. 1792-1801 ◽  
Author(s):  
Benjamin Pulli ◽  
Paul H. Chapman ◽  
Christopher S. Ogilvy ◽  
Aman B. Patel ◽  
Christopher J. Stapleton ◽  
...  
Keyword(s):  
Natural History ◽  
Clinical Outcomes ◽  
Medical Management ◽  
Arteriovenous Malformations ◽  
Controlled Trial ◽  
Tertiary Care ◽  
Randomized Controlled ◽  
Brain Arteriovenous Malformations ◽  
Brain Avms

OBJECTIVECurative treatment of unruptured brain arteriovenous malformations (AVMs) remains controversial after the only randomized controlled trial, A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA), was halted prematurely because interim analysis revealed superiority of the medical management group. In contrast, meta-analyses of retrospective cohorts suggest that intervention is much safer than was found in ARUBA.METHODSThe authors retrospectively analyzed 318 consecutive adult patients with brain AVMs treated at their institution with embolization, surgery, and/or proton beam radiosurgery. Analysis was performed in 142 ARUBA-eligible patients (baseline modified Rankin Scale [mRS] score 0–1, no history of hemorrhage), and results were compared to primary and secondary outcomes from ARUBA, as well as to natural history cohorts.RESULTSThe annualized stroke rate (hemorrhagic or ischemic) in this cohort was 1.8%, 4.9% in the first 12 months and 0.8% after the first 12 months, which was lower than in natural history studies and the ARUBA medical management arm (p = 0.001). The primary ARUBA endpoint of symptomatic stroke was reached in 13 patients (9.2%), which compares favorably to the ARUBA intervention arm (39.6%, p = 0.0001) and is similar to the ARUBA medical management arm (9.2%, p = 1.0). The secondary ARUBA endpoint (mRS score ≥ 2 at 5 years of follow-up) was reached in 14.3% of patients, compared to 40.5% in the ARUBA intervention arm (p = 0.002) and 16.7% in the ARUBA medical management arm (p = 0.6).CONCLUSIONSThis multimodal approach to the selection and treatment of patients with brain AVMs yields good clinical outcomes with key safety endpoints (stroke, death, and mRS score 0–1) better than the ARUBA intervention arm and similar to the ARUBA medical arm at 5 years of follow-up. Results compare favorably to natural history cohorts at longer follow-up times. This suggests that tertiary care centers with integrated programs, expertise in patient selection, and individualized treatment approaches may allow for better clinical outcomes than reported in ARUBA. It supports current registry studies and merits consideration of future randomized controlled trials in patients with brain AVMs.

Presence of direct vertebrobasilar perforator feeders in posterior fossa arteriovenous malformations and association with poor outcomes after endovascular treatment

2020 ◽  
Vol 133 (6) ◽  
pp. 1802-1810
Author(s):  
Etienne Lefevre ◽  
Thomas Robert ◽  
Simon Escalard ◽  
Robert Fahed ◽  
Stanislas Smajda ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Neurological Deterioration ◽  
Complication Rates ◽  
Long Term Outcomes ◽  
Obliteration Rate ◽  
Brain Avms

OBJECTIVETreatment of posterior fossa arteriovenous malformations (PFAVMs) remains controversial as it is always challenging and may lead to major complications. Nonetheless, these lesions are more likely to bleed and generate poorer outcomes than other brain AVMs. The aim of this study was to evaluate the effect of endovascular treatment on long-term outcomes and identify the patient subgroups that might benefit from endovascular treatment.METHODSThe authors performed a retrospective analysis of all consecutive cases of PFAVM managed at the Fondation Rothschild Hospital between 1995 and 2018. Clinical, imaging, and treatment data were prospectively gathered; these data were analyzed with respect to long-term outcomes.RESULTSAmong the 1311 patients with brain AVMs, 114 (8.7%) had a PFAVM, and 88 (77.2%) of these patients had a history of bleeding. Of the 114 PFAVMs, 101 (88.6%) were treated (83 ruptured and 18 unruptured). The mean duration of follow-up was 47.6 months (range 0–240 months). Good neurological outcome at last follow-up was achieved in 79 cases (78.2%). Follow-up angiography showed obliteration of the PFAVM in 68.3% of treated cases. The presence of direct vertebrobasilar perforator feeders was associated with neurological deterioration (OR 5.63, 95% CI 11.15–30.76) and a lower obliteration rate (OR 15.69, 95% CI 2.52–304.03) after endovascular treatment. Other predictors of neurological deterioration and obliteration rate were consistent with the Spetzler-Martin grading system.CONCLUSIONSAdvances in endovascular techniques have enabled higher obliteration rates in the treatment of PFAVMs, but complication rates are still high. Subgroups of patients who might benefit from treatment must be carefully selected and the presence of direct vertebrobasilar perforator feeders must call into question the indication for endovascular treatment.

Stereotactic radiosurgery for arteriovenous malformations, Part 5: management of brainstem arteriovenous malformations

2012 ◽  
Vol 116 (1) ◽  
pp. 44-53 ◽  
Author(s):  
Hideyuki Kano ◽  
Douglas Kondziolka ◽  
John C. Flickinger ◽  
Huai-che Yang ◽  
Thomas J. Flannery ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Arteriovenous Malformations ◽  
Radiation Effects ◽  
Latency Period ◽  
Target Volume ◽  
Neurological Deficits ◽  
Latency Interval ◽  
Brain Avms

Object In this paper, the authors' goal was to define the long-term outcomes and risks of stereotactic radiosurgery (SRS) for arteriovenous malformations (AVMs) of the medulla, pons, and midbrain. Methods Between 1987 and 2006, the authors performed Gamma Knife surgery in 996 patients with brain AVMs; 67 patients had AVMs in the brainstem. In this series, 51 patients (76%) had a prior hemorrhage. The median target volume was 1.4 cm3 (range 0.1–13.4 cm3). The median margin dose was 20 Gy (range 14–25.6 Gy). Results Obliteration of the AVMs was eventually documented in 35 patients at a median follow-up of 73 months (range 6–269 months). The actuarial rates of documentation of total obliteration were 41%, 70%, 70%, and 76% at 3, 4, 5, and 10 years, respectively. Higher rates of AVM obliteration were associated only with a higher margin dose. Four patients (6%) suffered a hemorrhage during the latency period, and 2 patients died. The rate of AVM hemorrhage after SRS was 3.0%, 3.0%, and 5.8% at 1, 5, and 10 years, respectively. The overall annual hemorrhage rate was 1.9%. Permanent neurological deficits due to adverse radiation effects (AREs) developed in 7 patients (10%) after SRS, and a delayed cyst developed in 2 patients (3%). One patient died at an outside institution with symptoms of AREs and unrecognized hydrocephalus. Higher 12-Gy volumes and higher Spetzler-Martin grades were associated with a higher risk of symptomatic AREs. Ten of 22 patients who had ocular dysfunction before SRS had improvement, 9 were unchanged, and 3 were worse due to AREs. Eight of 14 patients who had hemiparesis before SRS improved, 5 were unchanged, and 1 was worse. Conclusions Although hemorrhage after obliteration did not occur in this series, patients remained at risk during the latency interval until obliteration occurred. Thirty-eight percent of the patients who had neurological deficits due to prior hemorrhage improved. Higher dose delivery in association with conformal and highly selective SRS is required for safe and effective radiosurgery.

Initial experience with the new ethylene vinyl alcohol copolymer based liquid embolic agent Menox in the endovascular treatment of cerebral arteriovenous malformations

2019 ◽  
Vol 11 (10) ◽  
pp. 1040-1044 ◽  
Author(s):  
Stanimir Sirakov ◽  
Alexander Sirakov ◽  
Krasimir Minkin ◽  
Marin Penkov ◽  
Kristian Ninov ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Vinyl Alcohol ◽  
Arteriovenous Malformations ◽  
Embolic Agent ◽  
Initial Experience ◽  
Cerebral Arteriovenous Malformations ◽  
Ethylene Vinyl Alcohol ◽  
Arteriovenous Shunts ◽  
Liquid Embolic

Background and PurposeLiquid embolic agents (LEAs) are the determinant tool for successful embolization of cranial arteriovenous shunts. There are few currently available LEAs. The aim of the study was to summarize our initial experience with a recently introduced non-adhesive ethylene vinyl alcohol (EVOH) copolymer based LEA (Menox 18) in the endovascular treatment of cerebral arteriovenous malformations.MethodsFrom April 2018 to November 2018, 24 patients harboring cerebral arteriovenous malformations underwent endovascular embolization with Menox 18. Clinical features, angiographic results, procedural details, complications, and follow-up details were prospectively collected and retrospectively analyzed.ResultsCurative embolization in one endovascular session was achieved in 14/24 (58.3%) of the treated patients. Partial embolization was achieved in 10 patients (42.6%) in whom staged treatment with radiosurgery or microsurgical resection was planned. No mortality was recorded in our series. Clinical complications after embolization occurred in 1/24 (4.66%) patients. No technical complications were notedConclusionsOur pilot study suggests that the Menox embolization system offers similar technical and clinical results in comparison with the other currently available LEAs. Further studies with larger cohorts and long term follow-up data are needed to fully evaluate its efficacy

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