Onyx embolization of intracranial arteriovenous malformations in pediatric patients

2013 ◽  
Vol 11 (4) ◽  
pp. 431-437 ◽  
Author(s):  
Maryam Soltanolkotabi ◽  
Samantha E. Schoeneman ◽  
Tord D. Alden ◽  
Michael C. Hurley ◽  
Sameer A. Ansari ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Pediatric Patients ◽  
Venous Drainage ◽  
Neurological Complications ◽  
Clinical Effects ◽  
Complication Rates ◽  
Intracranial Arteriovenous Malformations ◽  
Significant Difference ◽  
Complete Obliteration ◽  
Study Population

Object The authors undertook this study to assess the safety and efficacy of Onyx embolization in the treatment of intracranial arteriovenous malformations (AVMs) in pediatric patients. Methods All pediatric Onyx embolization of intracranial AVM cases performed consecutively at a single children's hospital over a 5-year period were collected and evaluated. Results Twenty-five patients (mean age 10.5 years) underwent a total of 38 procedures. An aggregate of 56 pedicles were embolized (mean 1.47 per session). The Spetzler-Martin grade was determined in all cases. Onyx embolization resulted in complete obliteration of the AVM in 3 cases (12%) and partial obliteration in 22 cases (88%). A total of 23 patients underwent surgical treatment. The mean preoperative AVM devascularization in these cases was 72%. One patient was treated with radiosurgery following Onyx embolization. Overall, 10 complications occurred in a total of 38 procedures (26.3%). None of the complications resulted in permanent neurological morbidity. The rate of transient neurological complications was 10.5% (4 of 38 procedures) and the rate of transient nonneurological complications was 5.3% (2 of 38 procedures). The remaining 4 complications were clinically silent (rate of 10.5%). There were no procedure-related deaths in this study population. There was no significant difference in patients with and without complications in terms of demographic characteristics, AVM grade, or embolization features (p ≥ 0.2). Deep venous drainage was associated with higher complication rates (p = 0.03). Conclusions Onyx utilization is feasible for preoperative or primary embolization in the treatment of pediatric intracranial AVMs; however, the spectrum of complications encountered is broad, and attention must be paid to the technical nuances of and indications for its use to avoid many potential dangerous effects. Although the overall complication rates were higher than expected, all were either clinically silent or had only transient clinical effects. Thus, this experience suggests that Onyx embolization can be performed safely with a low rate of permanent morbidity in pediatric patients harboring these difficult lesions.

scholarly journals Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: a systematic review

2015 ◽  
Vol 122 (2) ◽  
pp. 353-362 ◽  
Author(s):  
Ching-Jen Chen ◽  
Cheng-Chia Lee ◽  
Dale Ding ◽  
Robert M. Starke ◽  
Srinivas Chivukula ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Venous Drainage ◽  
Classification Systems ◽  
Complication Rates ◽  
Obliteration Rate ◽  
Arteriovenous Fistulas ◽  
Significant Difference ◽  
Dural Arteriovenous Fistulas ◽  
Complete Obliteration ◽  
Cortical Venous Drainage

OBJECT The goal of this study was to evaluate the obliteration rate of intracranial dural arteriovenous fistulas (DAVFs) in patients treated with stereotactic radiosurgery (SRS), and to compare obliteration rates between cavernous sinus (CS) and noncavernous sinus (NCS) DAVFs, and between DAVFs with and without cortical venous drainage (CVD). METHODS A systematic literature review was performed using PubMed. The CS DAVFs and the NCS DAVFs were categorized using the Barrow and Borden classification systems, respectively. The DAVFs were also categorized by location and by the presence of CVD. Statistical analyses of pooled data were conducted to assess complete obliteration rates in CS and NCS DAVFs, and in DAVFs with and without CVD. RESULTS Nineteen studies were included, comprising 729 patients harboring 743 DAVFs treated with SRS. The mean obliteration rate was 63% (95% CI 52.4%–73.6%). Complete obliteration for CS and NCS DAVFs was achieved in 73% and 58% of patients, respectively. No significant difference in obliteration rates between CS and NCS DAVFs was found (OR 1.72, 95% CI 0.66–4.46; p = 0.27). Complete obliteration in DAVFs with and without CVD was observed in 56% and 75% of patients, respectively. A significantly higher obliteration rate was observed in DAVFs without CVD compared with DAVFs with CVD (OR 2.37, 95% CI 1.07–5.28; p = 0.03). CONCLUSIONS Treatment with SRS offers favorable rates of DAVF obliteration with low complication rates. Patients harboring DAVFs that are refractory or not amenable to endovascular or surgical therapy may be safely and effectively treated using SRS.

Clinical Outcomes of Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations in Pediatric Patients: Systematic Review and Meta-Analysis

Neurosurgery ◽  
2019 ◽  
Vol 85 (4) ◽  
pp. E629-E640 ◽  
Author(s):  
Alp Özgün Börcek ◽  
Emrah Çeltikçi ◽  
Yiğit Aksoğan ◽  
Matthew John Rousseau
Keyword(s):  
Stereotactic Radiosurgery ◽  
Clinical Outcomes ◽  
Neurological Deficit ◽  
Arteriovenous Malformations ◽  
Pediatric Patients ◽  
Meta Analysis ◽  
Complication Rates ◽  
Single Session ◽  
Significant Difference ◽  
Year 2000

Abstract BACKGROUND Arteriovenous malformations (AVMs) in pediatric patients exhibit remarkable differences in terms of management and outcomes. Owing to a paucity of relevant data pertaining to AVMs in pediatric patients, special interest and investigation are required for an improved understanding of the available evidence by clinicians. OBJECTIVE To determine the clinical outcomes of single-session stereotactic radiosurgery (SRS) for AVMs in pediatric patients. METHODS A systematic literature review was performed to identify studies that reported the outcomes of SRS for AVMs in pediatric patients. Data pertaining to variables such as obliteration rate, post-SRS new hemorrhage rate, post-SRS new neurological deficit rate, and mortality rate were extracted and analyzed using meta-analysis techniques. RESULTS Based on pooled data from 20 studies with 1212 patients, single-session SRS resulted in complete obliteration in 65.9% (95% confidence interval [CI], 60.5%-71.1%; I2 = 66.5%) patients. Overall complication rate (including new hemorrhage, new neurodeficit, and mortality) was 8.0% (95% CI, 5.1%-11.5%; I2 = 66.4%). Post-SRS new neurological deficit rate was 3.1% (95% CI, 1.3%-5.4%; I2 = 59.7%), and post-SRS hemorrhage rate was 4.2% (95% CI, 2.5%-6.3%; I2 = 42.7%). There was no significant difference between studies disaggregated by treatment method (Gamma Knife [Elekta AB] vs other), treatment year (before year 2000 vs after year 2000), median AVM volume reported (≥3 vs <3 cm3), median dose reported (≥20 vs <20 Gy), or follow-up period (≥36 vs <36 mo). CONCLUSION Single-SRS is a safe treatment alternative that achieves high obliteration rates and acceptable complication rates for AVMs in pediatric patients.

scholarly journals Multimodal Treatment of Pediatric Ruptured Brain Arteriovenous Malformations: A Single-Center Study

Children ◽  
2021 ◽  
Vol 8 (3) ◽  
pp. 215
Author(s):  
Lukasz Antkowiak ◽  
Monika Putz ◽  
Marta Rogalska ◽  
Marek Mandera
Keyword(s):  
Medical Records ◽  
Arteriovenous Malformations ◽  
Pediatric Patients ◽  
Interventional Treatment ◽  
Digital Subtraction ◽  
Brain Arteriovenous Malformations ◽  
Single Center Study ◽  
Complete Obliteration ◽  
Multimodality Approach ◽  
Related Mortality

Bleeding from ruptured brain arteriovenous malformations (bAVMs) represents the most prevalent cause of pediatric intracranial hemorrhage, being also the most common initial bAVM manifestation. A therapeutic approach in these patients should aim at preventing rebleeding and associated significant morbidity and mortality. The purpose of this study was to determine the clinical outcomes of pediatric patients who initially presented at our institution with ruptured bAVMs and to review our experience with a multimodality approach in the management of pediatric ruptured bAVMs. We retrospectively reviewed pediatric patients’ medical records with ruptured bAVMs who underwent interventional treatment (microsurgery, embolization, or radiosurgery; solely or in combination) at our institution between 2011 and 2020. We identified 22 patients. There was no intraoperative and postoperative intervention-related mortality. Neither procedure-related complications nor rebleeding were observed after interventional treatment. Modified Rankin Scale (mRS) assessment at discharge revealed 19 patients (86.4%) with favorable outcomes (mRS 0–2) and 3 patients (13.6%) classified as disabled (mRS 3). Microsurgery ensured the complete obliteration in all patients whose postoperative digital subtraction angiography (DSA) was available. Management of high-grade bAVMs with radiosurgery or embolization can provide satisfactory outcomes without a high disability risk.

Multimodality treatment of posterior fossa arteriovenous malformations

2008 ◽  
Vol 108 (6) ◽  
pp. 1152-1161 ◽  
Author(s):  
Michael E. Kelly ◽  
Raphael Guzman ◽  
John Sinclair ◽  
Teresa E. Bell-Stephens ◽  
Regina Bower ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Multimodality Treatment ◽  
Neurological Complications ◽  
Cure Rate ◽  
Complete Obliteration ◽  
The Mean ◽  
Risk Of Hemorrhage ◽  
Negative Predictor

Object Posterior fossa arteriovenous malformations (AVMs) are relatively uncommon and often difficult to treat. The authors present their experience with multimodality treatment of 76 posterior fossa AVMs, with an emphasis on Spetzler–Martin Grades III–V AVMs. Methods Seventy-six patients with posterior fossa AVMs treated with radiosurgery, surgery, and endovascular techniques were analyzed. Results Between 1982 and 2006, 36 patients with cerebellar AVMs, 33 with brainstem AVMs, and 7 with combined cerebellar–brainstem AVMs were treated. Natural history data were calculated for all 76 patients. The risk of hemorrhage from presentation until initial treatment was 8.4% per year, and it was 9.6% per year after treatment and before obliteration. Forty-eight patients had Grades III–V AVMs with a mean follow-up of 4.8 years (range 0.1–18.4 years, median 3.1 years). Fifty-two percent of patients with Grades III–V AVMs had complete obliteration at the last follow-up visit. Three (21.4%) of 14 patients were cured with a single radiosurgery treatment, and 4 (28.6%) of 14 with 1 or 2 radiosurgery treatments. Twenty-one (61.8%) of 34 patients were cured with multimodality treatment. The mean Glasgow Outcome Scale (GOS) score after treatment was 3.8. Multivariate analysis performed in the 48 patients with Grades III–V AVMs showed radiosurgery alone to be a negative predictor of cure (p = 0.0047). Radiosurgery treatment alone was not a positive predictor of excellent clinical outcome (GOS Score 5; p > 0.05). Nine (18.8%) of 48 patients had major neurological complications related to treatment. Conclusions Single-treatment radiosurgery has a low cure rate for posterior fossa Spetzler–Martin Grades III–V AVMs. Multimodality therapy nearly tripled this cure rate, with an acceptable risk of complications and excellent or good clinical outcomes in 81% of patients. Radiosurgery alone should be used for intrinsic brainstem AVMs, and multimodality treatment should be considered for all other posterior fossa AVMs.

Long-term Outcomes of Patients With Giant Intracranial Arteriovenous Malformations

Neurosurgery ◽  
2015 ◽  
Vol 79 (1) ◽  
pp. 116-124 ◽  
Author(s):  
Wuyang Yang ◽  
Zhikui Wei ◽  
Joanna Y. Wang ◽  
Alice L. Hung ◽  
Justin M. Caplan ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Conservative Management ◽  
Arteriovenous Malformations ◽  
Intervention Group ◽  
Intracranial Arteriovenous Malformations ◽  
Cerebrovascular Lesions ◽  
Significant Difference ◽  
Hemorrhagic Risk ◽  
Interventional Therapies

Abstract BACKGROUND: Giant intracranial arteriovenous malformations (AVMs) are rare cerebrovascular lesions that pose management challenges. OBJECTIVE: To further clarify outcomes in patients with giant cerebral AVMs managed with conservative or interventional therapies. METHODS: We performed a retrospective review of all patients diagnosed with AVMs evaluated at our institution from 1990 to 2013. Patients with a single intracranial AVM &gt;6 cm were included. Patients were divided into 2 groups: conservative management or intervention (microsurgery, radiosurgery, or embolization). Functional outcome was assessed with the modified Rankin Scale (mRS) and compared between the 2 groups. RESULTS: A total of 55 patients with giant AVMs were included, and 35 patients (63.6%) had clinical follow-up with a mean of 11.8 years. Spetzler-Martin grades were as follows: grade III, n = 2 (3.6%); grade IV, n = 15 (27.3%); and grade V, n = 38 (69.1%). Twenty-four patients (43.6%) were conservatively managed. The patients in the conservatively managed group had larger AVMs (P &lt; .05) with more frequent involvement of the temporal lobe (P = .02). Five patients (26.3%) in the conservatively managed group and 5 (31.3%) in the intervention group experienced hemorrhage during follow-up, translating to an annualized risk of 2.7% and 4.1%, respectively. No significant difference in risk of first subsequent hemorrhage was observed (P = .78). Despite comparable mRS scores at presentation, we observed a trend toward better outcomes (mRS &lt; 2) in patients undergoing conservative management (P = .06) compared with the intervention group at last follow-up. CONCLUSION This study suggests that interventions for giant AVMs should be considered cautiously because hemorrhagic risk is similar regardless of management strategy and functional outcome is likely to be same or better in the conservatively managed population.

A proposed scheme for grading intracranial arteriovenous malformations

1986 ◽  
Vol 65 (4) ◽  
pp. 484-489 ◽  
Author(s):  
Yu-quan Shi ◽  
Xian-cheng Chen
Keyword(s):  
Arteriovenous Malformations ◽  
Surgical Excision ◽  
Venous Drainage ◽  
Morbidity And Mortality ◽  
Intracranial Arteriovenous Malformations ◽  
Surgical Morbidity ◽  
Operative Morbidity ◽  
Content Type ◽  
Grade Classification ◽  
Grading Scale

✓ A four-grade classification scheme for intracranial arteriovenous malformations (AVM's) is proposed. Grading is based on 1) the size of the AVM; 2) its location and depth; 3) its arterial supply; and 4) its venous drainage. Each of these aspects is divided into four grades with respect to the difficulty it poses for surgical excision. A description of the grading system and its application is given. This grading scale has been correlated with the operative morbidity and mortality in 100 cases of excised intracranial AVM's. The results show that the higher the grade of AVM, the greater the risk of surgical morbidity and mortality. This grading scale is simple and easy to apply. It can guide neurosurgeons in selecting AVM patients suitable for operation, in determining the best type of operation to perform, and in predicting operative difficulties as well as postoperative results.

Dural arteriovenous malformation of the skull base with intraosseous vascular nidus

1994 ◽  
Vol 81 (4) ◽  
pp. 620-623 ◽  
Author(s):  
Ghaus M. Malik ◽  
Asim Mahmood ◽  
Bharat A. Mehta
Keyword(s):  
Arteriovenous Malformation ◽  
Skull Base ◽  
Arteriovenous Malformations ◽  
Venous Drainage ◽  
Dural Arteriovenous Malformation ◽  
Intracranial Arteriovenous Malformations ◽  
Content Type ◽  
Small Subgroup ◽  
Fine Print ◽  
Dural Venous Sinuses

✓ Intracranial arteriovenous malformations (AVM's) have been classified as pure pial, pure dural, and mixed pial and dural. Dural AVM's are relatively uncommon, with 377 cases documented up to 1990. These lesions were believed to be situated within the walls of the sinuses, but during the last decade researchers discovered a small subgroup of dural AVM's in extrasinusal locations such as the skull base and tentorium. Two of the 17 patients who were studied between 1976 and 1993 had dural AVM's that were entirely intraosseous except for their venous drainage, which was via the dural venous sinuses. Although such intraosseous dural AVM's have not been previously described, the authors elected to group these malformations with dural AVM's because their venous drainage was intracranial and angiograms revealed identical features.

scholarly journals International multicenter cohort study of pediatric brain arteriovenous malformations. Part 1: Predictors of hemorrhagic presentation

2017 ◽  
Vol 19 (2) ◽  
pp. 127-135 ◽  
Author(s):  
Dale Ding ◽  
Robert M. Starke ◽  
Hideyuki Kano ◽  
David Mathieu ◽  
Paul P. Huang ◽  
...  
Keyword(s):  
Cohort Study ◽  
Arteriovenous Malformations ◽  
Pediatric Patients ◽  
Management Strategies ◽  
Multivariate Logistic Regression Analysis ◽  
Venous Drainage ◽  
Study Cohort ◽  
Multicenter Cohort Study ◽  
Brain Arteriovenous Malformations ◽  
Occipital Lobes

OBJECTIVE Brain arteriovenous malformations (AVMs) are the most common cause of spontaneous intracranial hemorrhage in pediatric patients (age < 18 years). Since the cumulative lifetime risk of AVM hemorrhage is considerable in children, an improved understanding of the risk factors influencing hemorrhagic presentation may aid in the management of pediatric AVMs. The aims of this first of a 2-part multicenter, retrospective cohort study are to evaluate the incidence and determine the predictors of hemorrhagic presentation in pediatric AVM patients. METHODS The authors analyzed pooled AVM radiosurgery data from 7 institutions participating in the International Gamma Knife Research Foundation (IGKRF). Patients younger than 18 years at the time of radiosurgery and who had at least 12 months of follow-up were included in the study cohort. Patient and AVM characteristics were compared between unruptured and ruptured pediatric AVMs. RESULTS A total of 357 pediatric patients were eligible for analysis, including 112 patients in the unruptured and 245 patients in the ruptured AVM cohorts (69% incidence of hemorrhagic presentation). The annual hemorrhage rate prior to radiosurgery was 6.3%. Hemorrhagic presentation was significantly more common in deep locations (basal ganglia, thalamus, and brainstem) than in cortical locations (frontal, temporal, parietal, and occipital lobes) (76% vs 62%, p = 0.006). Among the factors found to be significantly associated with hemorrhagic presentation in the multivariate logistic regression analysis, deep venous drainage (OR 3.2, p < 0.001) was the strongest independent predictor, followed by female sex (OR 1.7, p = 0.042) and smaller AVM volume (OR 1.1, p < 0.001). CONCLUSIONS Unruptured and ruptured pediatric AVMs have significantly different patient and nidal features. Pediatric AVM patients who possess 1 or more of these high-risk features may be candidates for relatively more aggressive management strategies.

THE PROTECTIVE STATUS OF SUBTOTAL OBLITERATION OF ARTERIOVENOUS MALFORMATIONS AFTER RADIOSURGERY

Neurosurgery ◽  
2009 ◽  
Vol 65 (4) ◽  
pp. 709-718 ◽  
Author(s):  
Zuair Abu-Salma ◽  
François Nataf ◽  
May Ghossoub ◽  
Michel Schlienger ◽  
Jean-François Meder ◽  
...  
Keyword(s):  
Comparative Analysis ◽  
Arteriovenous Malformations ◽  
Statistical Difference ◽  
Bleeding Rate ◽  
Significant Statistical Difference ◽  
Significant Difference ◽  
Complete Obliteration

Abstract OBJECTIVE Arteriovenous malformations (AVMs) treated by radiosurgery with complete obliteration of the nidus but a persisting early draining vein on follow-up angiography can be termed subtotally obliterated. However, these are persistent circulating AVMs. The significance of these lesions, their hemorrhage rate, and their management are analyzed. METHODS In a series of 862 consecutive patients with AVMs treated by radiosurgery, 121 patients (14%) achieved subtotal obliteration (STO). The angiographic evolution and rate of obliteration were studied. The pretreatment angiographic features, dosimetric parameters, and postradiosurgery hemorrhage rate were compared with those in the rest of the treated population. Finally, the options for follow-up and treatment were analyzed. RESULTS Of 121 subtotally obliterated AVMs, the bleeding rate was 0%; 53% of patients achieved complete obliteration. This occurred in 71% of those who had STO at 1 year. In the cases in which STO was detected at 2, 3, and 4 years, total obliteration eventually occurred in 43%, 28.5%, and 0%, respectively. Comparative analysis with AVMs in which a part of the nidus persisted showed a significant difference in the bleeding rate. Except for volume, no significant statistical difference in angiographic and dosimetric parameters was found between the STO group and the rest of the studied population with residual nidus. Six cases received further treatment, resulting in 2 cures and 2 treatment-related complications. CONCLUSION Subtotally obliterated AVMs are different from other partially obliterated AVMs, with a 0% bleeding rate. Their complete obliteration is a function of delay of appearance on follow-up angiography. Invasive follow-up and further treatment of these AVMs do not seem warranted.

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