Dural Arteriovenous Shunt Development in Patients with Vein of Galen Malformation

Dural arteriovenous fistulas (DAVF) associated with our series of patients with vein of Galen malformations (VOGM) are analyzed and discussed. We retrospectively analyzed 87 consecutive cases of VOGM treated between May 2002 and December 2011 and identified 26 patients with DAVF. We gathered information from the clinical case records, angiographic images, MRI on presentation and during follow-up. The findings were analyzed to aid discussion. Among 87 patients treated by multi-stage endovascular embolization, age range from newborn to 19 years, 26 (30%) had DAVF. In seven patients (8%), DAVF were found on initial angiogram and were all into the VOGM. Nineteen (21%) DAVF found on follow-up angiograms were all into the VOGM and distant locations. Sprouting and non-sprouting angiogenesis resulted in the formation of a network of vessels around partially thrombosed VOGM, recruiting blood from the surrounding dura mater resulting in a secondary network on the dura mater supplied by the blood vessels of dura mater in the region or from its natural collaterals. Embolization targeting DAVFs was done in 13 (52%) with complete cure in eight (32%) and recurrence in five (20%). Among 12 non-embolized patients (48%), eight (32%) had spontaneous regression with continued treatment of VOGM. In others, the DAVF either remained stable or progressed. DAVF associated with VOGM represent the dural response to angiogenic stimuli. They are observed to regress spontaneously or mature while continuing to treat the primary feeders of VOGM. It is important to include the external carotid system during angiograms. Persistent DAVF with residual VOGM that do not have access though the pial vessels are used as a conduit to treat the dural shunt and to achieve obliteration of residual VOGM at later stages of treatment.

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Assessing the rate, natural history, and treatment trends of intracranial aneurysms in patients with intracranial dural arteriovenous fistulas: a Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) investigation

Journal of Neurosurgery ◽

10.3171/2021.1.jns202861 ◽

2021 ◽

pp. 1-10

Author(s):

Isaac Josh Abecassis ◽

R. Michael Meyer ◽

Michael R. Levitt ◽

Jason P. Sheehan ◽

Ching-Jen Chen ◽

...

Keyword(s):

Natural History ◽

Arteriovenous Fistula ◽

Outcomes Research ◽

Intracranial Aneurysms ◽

Dural Arteriovenous Fistula ◽

Aneurysm Rupture ◽

External Carotid ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas

OBJECTIVE There is a reported elevated risk of cerebral aneurysms in patients with intracranial dural arteriovenous fistulas (dAVFs). However, the natural history, rate of spontaneous regression, and ideal treatment regimen are not well characterized. In this study, the authors aimed to describe the characteristics of patients with dAVFs and intracranial aneurysms and propose a classification system. METHODS The Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database from 12 centers was retrospectively reviewed. Analysis was performed to compare dAVF patients with (dAVF+ cohort) and without (dAVF-only cohort) concomitant aneurysm. Aneurysms were categorized based on location as a dAVF flow-related aneurysm (FRA) or a dAVF non–flow-related aneurysm (NFRA), with further classification as extra- or intradural. Patients with traumatic pseudoaneurysms or aneurysms with associated arteriovenous malformations were excluded from the analysis. Patient demographics, dAVF anatomical information, aneurysm information, and follow-up data were collected. RESULTS Of the 1077 patients, 1043 were eligible for inclusion, comprising 978 (93.8%) and 65 (6.2%) in the dAVF-only and dAVF+ cohorts, respectively. There were 96 aneurysms in the dAVF+ cohort; 10 patients (1%) harbored 12 FRAs, and 55 patients (5.3%) harbored 84 NFRAs. Dural AVF+ patients had higher rates of smoking (59.3% vs 35.2%, p < 0.001) and illicit drug use (5.8% vs 1.5%, p = 0.02). Sixteen dAVF+ patients (24.6%) presented with aneurysm rupture, which represented 16.7% of the total aneurysms. One patient (1.5%) had aneurysm rupture during follow-up. Patients with dAVF+ were more likely to have a dAVF located in nonconventional locations, less likely to have arterial supply to the dAVF from external carotid artery branches, and more likely to have supply from pial branches. Rates of cortical venous drainage and Borden type distributions were comparable between cohorts. A minority (12.5%) of aneurysms were FRAs. The majority of the aneurysms underwent treatment via either endovascular (36.5%) or microsurgical (15.6%) technique. A small proportion of aneurysms managed conservatively either with or without dAVF treatment spontaneously regressed (6.2%). CONCLUSIONS Patients with dAVF have a similar risk of harboring a concomitant intracranial aneurysm unrelated to the dAVF (5.3%) compared with the general population (approximately 2%–5%) and a rare risk (0.9%) of harboring an FRA. Only 50% of FRAs are intradural. Dural AVF+ patients have differences in dAVF angioarchitecture. A subset of dAVF+ patients harbor FRAs that may regress after dAVF treatment.

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Endovascular Treatment of Chronic Subdural Hematomas through Embolization: A Pilot Study with a Non-Adhesive Liquid Embolic Agent of Minimal Viscosity (Squid)

Journal of Clinical Medicine ◽

10.3390/jcm10194436 ◽

2021 ◽

Vol 10 (19) ◽

pp. 4436

Author(s):

Andrey Petrov ◽

Arkady Ivanov ◽

Larisa Rozhchenko ◽

Anna Petrova ◽

Pervinder Bhogal ◽

...

Keyword(s):

Endovascular Treatment ◽

Complete Resolution ◽

Middle Meningeal Artery ◽

Endovascular Embolization ◽

Neurological Deficits ◽

Embolic Agent ◽

Ethylene Vinyl Alcohol ◽

Arteriovenous Fistulas ◽

Subdural Hematomas

Objective: Endovascular embolization using non-adhesive agents (e.g., ethylene vinyl alcohol copolymer with suspended micronized tantalum dissolved in dimethyl sulfoxide; Squid, Balt Extrusion) is an established treatment of brain arteriovenous malformations, dural arteriovenous fistulas, and hypervascular neoplasms. Middle meningeal artery (MMA) embolization is a relatively new concept for treating chronic subdural hematomas (CSDH). This study aimed to evaluate the safety and effectiveness of the use of Squid in the endovascular treatment of CSDH. Methods: Embolization was offered to patients with CSDH with minimal or moderate neurological deficits and patients who had previously undergone open surgery to evacuate their CSDH without a significant effect. Distal catheterization of the MMA was followed by embolization of the hematoma capsule with Squid 12 or Squid 18. Safety endpoints were ischemic or hemorrhagic stroke and any other adverse event of the endovascular procedure. Efficacy endpoints were the feasibility of the intended procedure and a ≥ 50% reduction of the maximum depth of the CSDH confirmed by follow-up computed tomography (CT) after >3 months. Results: Between November 2019 and July 2021, 10 patients (3 female and 7 male, age range 42–89 years) were enrolled. Five patients had bilateral hematomas, and five patients had previously been operated on with no significant effect and recurrent hematoma formation. The attempted embolization was technically possible in all patients. No technical or clinical complication was encountered. During a post-procedural follow-up (median 90 days), 10 patients improved clinically. A complete resolution of the CSDH was observed in 10 patients. The clinical condition of all enrolled patients during the so-far last contact was rated mRS 0 or 1. Conclusion: A distal catheterization of the MMA for the endovascular embolization of CSDH with Squid allowed for the devascularization of the MMA and the dependent vessels of the hematoma capsule. This procedure resulted in a partial or complete resolution of the CSDH. Procedural complications were not encountered.

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Superselective Arterial Chemotherapy for Inoperable Metastases in the Dura Mater and Cranium

Interventional Neuroradiology ◽

10.1177/159101990200800203 ◽

2002 ◽

Vol 8 (2) ◽

pp. 121-125 ◽

Cited By ~ 1

Author(s):

S. Suzuki ◽

A. Kurata ◽

H. Takagi ◽

K. Nakahara ◽

H. Oka ◽

...

Keyword(s):

Carotid Artery ◽

Mr Imaging ◽

Dura Mater ◽

Surgical Intervention ◽

External Carotid Artery ◽

External Carotid ◽

Skull Bone ◽

Minimal Dose ◽

Mass Lesions

Diffuse metastases to the cranium and dura mater of the bilateral hemisphere do not allow surgical intervention. We describe an excellent case which was treated by intra-arterial chemotherapy using Epirubicine (Farumorbicine). A 58-year-old woman treated for breast cancer ten years ago was admitted to our hospital with headache and frontal mass lesions. Magnetic resonance (MR) imaging on admission revealed a remarkable enhanced lesion of the bilateral dura mater and cranium, and bilateral brain edema in the frontal lobe. Angiography disclosed a vascular rich tumour supplied by bilateral external carotid artery branches. We successfully treated the lesion using superselective intra-arterial chemotherapy with a minimal dose of Epirubicine followed by embolization of bilateral external carotid artery branches. Follow-up MR imaging two years after the endovascular treatment showed disappearance of the enhanced lesion and remodeling of the skull bone. The patient is neurologically free of symptoms.

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Intracerebral Arteriovenous Fistulas Associated with Intraparenchymal Varix in Childhood: Case Reports

Neurosurgery ◽

10.1227/00006123-199001000-00017 ◽

1990 ◽

Vol 26 (1) ◽

pp. 122-125 ◽

Cited By ~ 30

Author(s):

Stanley L. Barnwell ◽

Samuel F. Ciricillo ◽

Van V. Halbach ◽

Michael S. B. Edwards ◽

Philip H. Cogen

Keyword(s):

Developmental Delay ◽

Head Circumference ◽

Clinical Symptoms ◽

Case Reports ◽

Endovascular Embolization ◽

Vein Of Galen ◽

Arteriovenous Fistulas ◽

Complete Closure ◽

Venous Varix

Abstract This report describes three children, each of whom developed an unusual malformation consisting of one or more intracerebral arteriovenous fistulas and a large intraparenchymal venous varix. Their clinical symptoms were similar to those produced by aneurysms of the vein of Galen: increasing head circumference, seizures, hemorrhage, and developmental delay. We treated each child with endovascular embolization and/or surgery and obtained complete closure of all fistulas without mortality. (Neurosurgery 26:122-125, 1990)

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Stereotactic radiosurgery for the treatment of dural arteriovenous fistulas involving the transverse—sigmoid sinus

Journal of Neurosurgery ◽

10.3171/jns.2002.96.5.0823 ◽

2002 ◽

Vol 96 (5) ◽

pp. 823-829 ◽

Cited By ~ 59

Author(s):

David Hung-chi Pan ◽

Wen-yuh Chung ◽

Wan-yuo Guo ◽

Hsiu-mei Wu ◽

Kang-du Liu ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Neurological Complication ◽

Endovascular Embolization ◽

Sigmoid Sinus ◽

Type I ◽

Content Type ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Fine Print

Object. The aim of this study was to assess the efficacy and safety of radiosurgery for the treatment of dural arteriovenous fistulas (DAVFs) located in the region of the transverse—sigmoid sinus. Methods. A series of 20 patients with DAVFs located in the transverse—sigmoid sinus, who were treated with gamma knife surgery between June 1995 and June 2000, was evaluated. According to the Cognard classification, the DAVF was Type I in four patients, Type IIa in seven, Type IIb in two, and combined Type IIa+b in seven. Nine patients had previously been treated with surgery and/or embolization, whereas 11 patients underwent radiosurgery alone. Radiosurgery was performed using multiple-isocenter irradiation of the delineated DAVF nidus. The target volume ranged from 1.7 to 40.7 cm3. The margin dose delivered to the nidus ranged from 16.5 to 19 Gy at a 50 to 70% isodose level. Nineteen patients were available for follow-up review, the duration of which ranged from 6 to 58 months (median 19 months). Of the 19 patients, 14 (74%) were cured of their symptoms. At follow up, magnetic resonance imaging and/or angiography demonstrated complete obliteration of the DAVF in 11 patients (58%), subtotal obliteration (95% reduction of the nidus) in three (16%), and partial obliteration in another five (26%). There was no neurological complication related to the treatment. One patient experienced a recurrence of the DAVF 18 months after angiographic confirmation of total obliteration, and underwent a second course of radiosurgery. Conclusions. Stereotactic radiosurgery provides a safe and effective option for the treatment of DAVFs involving the transverse and sigmoid sinuses. For some aggressive DAVFs with extensive retrograde cortical venous drainage, however, a combination of endovascular embolization and surgery may be necessary.

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Percutaneous Transvenous Embolization of Intracranial Dural Arteriovenous Fistulas with Detachable Coils and/or in Combination with Onyx

Interventional Neuroradiology ◽

10.1177/159101990801400407 ◽

2008 ◽

Vol 14 (4) ◽

pp. 415-427 ◽

Cited By ~ 10

Author(s):

Xianli Lv ◽

Chuhan Jiang ◽

Youxiang Li ◽

Xinjian Yang ◽

Zhongxue Wu

Keyword(s):

Cavernous Sinus ◽

Clinical Results ◽

Sigmoid Sinus ◽

Anterior Cranial Fossa ◽

Transvenous Embolization ◽

Arteriovenous Fistulas ◽

Detachable Coils ◽

Cranial Fossa ◽

Age Range

This study evaluated angiographic and clinical results in patients with a dural arteriovenous fistula (DAVF) who underwent percutaneous transvenous embolization. Retrospective chart analysis and radiographic studies were performed in 23 patients (aged 11–70 yrs) with a DAVF treated with percutaneous transvenous embolization in the past five years. Lesions were located in the anterior cranial fossa, cerebellar tentorium, transverse-sigmoid sinus and cavernous sinus. All procedures were analyzed with regard to presentation, delivery, angiographical and clinical outcome. Data for 23 patients (age range, 11–70 yrs, mean age 49.5 yrs) with DAVFs (cavernous sinus[CS], n=17; transverse-sigmoid sinus, n=3; anterior cranial fossa, n=2; cerebellar tentorium, n=1) were retrospectively reviewed. The DAVFs were treated with coils or a combination with Onyx via different transvenous approaches, in 28 procedures. Cerebral angiography was performed to confirm the treatment. The mean clinical follow-up period was 22.1 months. Transvenous treatment of intracranial DAVFs can be safe and effective if various transvenous approaches are attempted. Percutaneous transvenous embolization with detachable platinum coils or a combination with Onyx is effective in the treatment of DAVFs.

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Outcome and complications of endovascular embolization for vein of Galen malformations: a systematic review and meta-analysis

Journal of Neurosurgery ◽

10.3171/2014.12.jns141249 ◽

2015 ◽

Vol 123 (4) ◽

pp. 872-890 ◽

Cited By ~ 35

Author(s):

Jun Yan ◽

Jing Wen ◽

Roodrajeetsing Gopaul ◽

Chao-Yuan Zhang ◽

Shao-wen Xiao

Keyword(s):

Large Scale ◽

Meta Analysis ◽

Clinical History ◽

Endovascular Embolization ◽

Research Literature ◽

Vein Of Galen ◽

Efficacy And Safety ◽

Treatment Mortality ◽

Leg Ischemia

OBJECT There have been many multidisciplinary approaches to the treatment of vein of Galen malformations. Endovascular embolization is the first option for treatment. However, the effects of the treatment remain controversial. The aim of this study is to assess the efficacy and safety of endovascular embolization to treat patients with vein of Galen malformations. METHODS This paper includes a retrospective analysis of a sample of 667 patients who underwent endovascular embolization to treat vein of Galen malformations. The data were obtained through a literature search of PubMed databases. The authors also evaluate the efficacy and safety of the treatment. Mortality within the follow-up period is analyzed. Pooled estimates of proportions with corresponding 95% CIs were calculated using raw (i.e., untransformed) proportions (PRAW). RESULTS In the 34 studies evaluated, neonates accounted for 44% of the sample (95% CI 31%-57%; I2 = 92.5%), infants accounted for 41% (95% CI 30%–51%; I2 = 83.3%), and children and adults accounted for 12% (95% CI 7%–16%; I2 = 52.9%). The meta-analysis revealed that complete occlusion was performed in 57% (95% CI 48%–65%; I2 = 68.2%) of cases, with partial occlusion in 43% (95% CI 34%–51%; I2 = 70.7%). The pooled proportion of patients showing a good outcome was 68% (95% CI 61%–76%; I2 = 77.8%), while 31% showed a poor outcome (95% CI 24%–38%; I2 = 75.6%). The proportional meta-analysis showed that postembolization mortality and complications were reported in 10% (95% CI 8%–12%; I2 = 42.8%) and 37% (95% CI 29%–45%; I2 = 79.1%), respectively. Complications included cerebral hemorrhage, cerebral ischemia, hydrocephalus, leg ischemia, and vessel perforation. CONCLUSIONS The successful treatment of vein of Galen malformations remains a complex therapeutic challenge. The authors’ analysis of clinical history and research literature suggests that vein of Galen malformations treated with endovascular embolization can result in an acceptable mortality rate, complications, and good clinical outcome. Future large-scale, multicenter, randomized trials are necessary to confirm these findings.

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Vein of Galen Malformation

Pediatric Neurosurgery ◽

10.1093/med/9780190617073.003.0018 ◽

2019 ◽

pp. 157-164

Author(s):

Lissa C. Baird

Keyword(s):

Cardiac Failure ◽

Transarterial Embolization ◽

Interdisciplinary Approach ◽

Organ Damage ◽

Vein Of Galen ◽

Arteriovenous Fistulas ◽

Arterial Blood ◽

Optimal Intervention ◽

Complete Obliteration

Vein of Galen malformations consist of multiple arteriovenous fistulas shunting arterial blood into the persistent embryonic prosencephalic vein of Markowski. The mural type are characterized by fewer fistulas and commonly present with progressive hydrocephalus. The choroidal type malformations have more complex and numerous fistulas, have higher flow, and commonly present with severe high-output cardiac failure. Transfemoral transarterial embolization at the fistula sites of the malformation for complete obliteration of arteriovenous shunting is the optimal intervention. An interdisciplinary approach is critical from the time of diagnosis through the post-treatment follow-up period. Sequelae of cardiac failure and end-organ damage may be minimized with early endovascular intervention when indicated and complete embolization when feasible.

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Gamma Knife Radiosurgery for Dural Arteriovenous Fistulas

Neurosurgery ◽

10.1227/neu.0b013e3181eff6f7 ◽

2010 ◽

Vol 67 (5) ◽

pp. 1230-1235 ◽

Cited By ~ 36

Author(s):

Christopher P Cifarelli ◽

George Kaptain ◽

Chun-Po Yen ◽

David Schlesinger ◽

Jason P Sheehan

Keyword(s):

Gamma Knife ◽

Medical Center ◽

Demographic Data ◽

Gamma Knife Radiosurgery ◽

Clinical History ◽

Endovascular Embolization ◽

Neurological Deficits ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas

Abstract BACKGROUND: The current management of intracranial dural arteriovenous fistulas (dAVFs) incorporates a multimodal approach involving microneurosurgery, endovascular embolization, and radiosurgery. OBJECTIVE: To explore the role of Gamma Knife radiosurgery for dAVFs. METHODS: The series includes patients with dAVFs who had Gamma Knife radiosurgery at the University of Virginia Medical Center between 1989 and 2005 with clinical follow-up through 2008. Medical records were reviewed to obtain clinical history, demographic data, and dosimetry. Radiographic records provided the location and anatomy of the dAVFs. Follow-up angiography was performed 2 to 3 years after treatment, with cure defined as complete obliteration of fistulous flow. Follow-up for clinical symptomology and quality of life was obtained from direct patient and primary physician questionnaires. RESULTS: Fifty-five patients underwent Gamma Knife radiosurgery for dAVFs during the study period. Twenty patients (36%) presented with intracranial hemorrhage before radiosurgery. Gamma Knife radiosurgery was preceded by craniotomy for microneurosurgical ablation in 11 patients (20%) or endovascular embolization in 36 patients (65%). Follow-up angiography was performed on 46 patients (83%) with documented obliteration in 30 patients (65%). Patients lost to follow-up were classified as treatment failures, adjusting the range of efficacy from 65% to 54%. Three patients (5%) suffered a posttreatment hemorrhage during the follow-up period, but no new permanent neurological deficits resulted from these events. CONCLUSION: Gamma Knife radiosurgery is an effective adjunct therapy for dAVFs with persistence of flow after open neurosurgical resection or endovascular treatment while still maintaining a role in nonaggressive dAVFs not amenable to either surgery or embolization.

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Vein of Galen Aneurysmal Malformations in Pediatric Patients Submitted to Endovascular Treatment: Report of 3 Cases

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0041-1730372 ◽

2021 ◽

Author(s):

Amanda Cristina Zimmermann ◽

Bernardo Przysiezny ◽

Evelyn Della Giustina ◽

Guilherme Voltolini Staedele ◽

Leandro José Haas ◽

...

Keyword(s):

Endovascular Treatment ◽

Pediatric Patients ◽

Clinical Presentation ◽

Endovascular Embolization ◽

High Morbidity ◽

Vein Of Galen ◽

Neurological Damage ◽

Vascular Abnormalities ◽

Neonatal Stage

Abstract Objective To report three cases of vein of Galen aneurysmal malformation (VGAM) in pediatric patients treated at the hemodynamics lab of Hospital Santa Isabel (HSI) in Blumenau, state of Santa Catarina, Brazil, from 2006 to 2020. Clinical presentation, endovascular treatment, and postprocedure evolution to date are included. Case description Three children aged 5 to 12 months with cardiac, respiratory, or neurological damage in the neonatal stage, were referred to the neurosurgery service and diagnosed with VGAM. The three patients underwent endovascular embolization of the malformation, with different clinical evolution throughout outpatient follow-up. Conclusion Vein of Galen aneurysmal malformations are uncommon vascular abnormalities that, until the advent of endovascular embolization, were associated with high morbidity and mortality rates. Its prognosis is linked with initial clinic, early diagnosis, and timely surgical correction.

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