Microsurgery for cerebral arteriovenous malformations: postoperative outcomes and predictors of complications in 264 cases

Object The authors conducted a study to assess the safety and efficacy of microsurgical resection of arteriovenous malformations (AVMs) and determine predictors of complications. Methods A total of 264 patients with cerebral AVMs were treated with microsurgical resection between 1994 and 2010 at the Jefferson Hospital for Neuroscience. A review of patient data was performed, including initial hemorrhage, clinical presentation, Spetzler-Martin (SM) grade, treatment modalities, clinical outcomes, and obliteration rates. Univariate and multivariate analyses were used to determine predictors of operative complications. Results Of the 264 patients treated with microsurgery, 120 (45%) patients initially presented with hemorrhage. There were 27 SM Grade I lesions (10.2%), 101 Grade II lesions (38.3%), 96 Grade III lesions (36.4%), 31 Grade IV lesions (11.7%), and 9 Grade V lesions (3.4%). Among these patients, 102 (38.6%) had undergone prior endovascular embolization. In all patients, resection resulted in complete obliteration of the AVM. Complications occurred in 19 (7.2%) patients and resulted in permanent neurological deficits in 5 (1.9%). In multivariate analysis, predictors of complications were increasing AVM size (OR 3.2, 95% CI 1.5–6.6; p = 0.001), increasing number of embolizations (OR 1.6, 95% CI 1.1–2.2; p = 0.01), and unruptured AVMs (OR 2.7, 95% CI 1–7.2; p = 0.05). Conclusions Microsurgical resection of AVMs is highly efficient and can be undertaken with low rates of morbidity at high-volume neurovascular centers. Unruptured and larger AVMs were associated with higher complication rates.

Download Full-text

A challenging entity of endovascular embolization with ONYX for brainstem arteriovenous malformation: Experience from 13 cases

Interventional Neuroradiology ◽

10.1177/1591019917711679 ◽

2017 ◽

Vol 23 (5) ◽

pp. 497-503 ◽

Cited By ~ 5

Author(s):

Hengwei Jin ◽

Zhan Liu ◽

Qing Chang ◽

Chang Chen ◽

Huijian Ge ◽

...

Keyword(s):

Postoperative Complications ◽

Intracranial Hemorrhage ◽

Arteriovenous Malformations ◽

Clinical Presentation ◽

Gamma Knife Radiosurgery ◽

Endovascular Embolization ◽

Treatment Modalities ◽

Patient Demographics ◽

Partially Occluded

Objective Brainstem arteriovenous malformations (AVMs) are rare lesions with a high risk of intracranial hemorrhage and are challenging to treat. We present our experience of endovascular embolization with Onyx in these aggressive lesions. Materials and methods Between 2007 and 2016, 13 patients with brainstem AVMs were embolized with Onyx at our center. Twelve patients presented with intracranial hemorrhage and one with headache. Retrospective examinations of patient demographics, clinical presentation, angiographic features, treatment modalities, postoperative complications and outcomes were carried out. Results The AVMs were in the midbrain in 10 patients (one anterior and nine posterior or dorsal), in the posterior pons in two and pontomedullary in one. Complete occlusion was achieved in three patients. Gamma knife radiosurgery was performed in six patients who were near-completely or partially embolized. Postoperative complications, including five cases of ischemia and one case of hemorrhage, resulted in four cases of neurological deterioration and two deaths. Clinical follow-up was obtained in 10 patients at a mean period of 45.2 months (range 3 to 93 months). During the follow-up, good clinical outcomes were observed in seven patients with posterior or dorsal midbrain AVMs, and one patient with a posterior pons AVM that was partially occluded died of intracranial hemorrhage. Conclusion Endovascular embolization for brainstem AVM with Onyx is a technical challenge and the reflux of Onyx may cause severe complications. Individualized treatment is needed based on the specific subtype of brainstem AVM.

Download Full-text

Embolization of brain arteriovenous malformations with intent to cure: a systematic review

Journal of Neurosurgery ◽

10.3171/2018.10.jns181791 ◽

2020 ◽

Vol 132 (2) ◽

pp. 388-399 ◽

Cited By ~ 5

Author(s):

Eva M. Wu ◽

Tarek Y. El Ahmadieh ◽

Cameron M. McDougall ◽

Salah G. Aoun ◽

Nikhil Mehta ◽

...

Keyword(s):

Complication Rate ◽

Treatment Strategy ◽

Arteriovenous Malformations ◽

Endovascular Embolization ◽

Definitive Treatment ◽

Complication Rates ◽

Brain Arteriovenous Malformations ◽

Complete Obliteration ◽

Complete Treatment ◽

Entire Patient Cohort

OBJECTIVEEndovascular embolization has been established as an adjuvant treatment strategy for brain arteriovenous malformations (AVMs). A growing body of literature has discussed curative embolization for select lesions. The transition of endovascular embolization from an adjunctive to a definitive treatment modality remains controversial. Here, the authors reviewed the literature to assess the lesional characteristics, technical factors, and angiographic and clinical outcomes of endovascular embolization of AVMs with intent to cure.METHODSElectronic databases—Ovid MEDLINE, Ovid Embase, and PubMed—were searched for studies in which there was evidence of AVMs treated using endovascular embolization with intent to cure. The primary outcomes of interest were angiographic obliteration immediately postembolization and at follow-up. The secondary outcomes of interest were complication rates. Descriptive statistics were used to calculate rates and means.RESULTSFifteen studies with 597 patients and 598 AVMs treated with intent-to-cure embolization were included in this analysis. Thirty-four percent of AVMs were Spetzler-Martin grade III. Complete obliteration immediately postembolization was reported in 58.3% of AVMs that had complete treatment and in 45.8% of AVMs in the entire patient cohort. The overall clinical complication rate was 24.1%. The most common complication was hemorrhage, occurring in 9.7% of patients. Procedure-related mortality was 1.5%.CONCLUSIONSWhile endovascular embolization with intent to cure can be an option for select AVMs, the reported complication rates appear to be increased compared with those in studies in which adjunctive embolization was the goal. Given the high complication rate related to a primary embolization approach, the risks and benefits of such a treatment strategy should be discussed among a multidisciplinary team. Curative embolization of AVMs should be considered an unanticipated benefit of such therapy rather than a goal.

Download Full-text

Transvenous embolization of brain arteriovenous malformations: a review of techniques, indications, and outcomes

Neurosurgical FOCUS ◽

10.3171/2018.3.focus18113 ◽

2018 ◽

Vol 45 (1) ◽

pp. E13 ◽

Cited By ~ 12

Author(s):

Ching-Jen Chen ◽

Pedro Norat ◽

Dale Ding ◽

George A. C. Mendes ◽

Petr Tvrdik ◽

...

Keyword(s):

Arteriovenous Malformations ◽

Small Diameter ◽

Endovascular Embolization ◽

Complication Rates ◽

Transvenous Embolization ◽

Efficacy And Safety ◽

Brain Arteriovenous Malformations ◽

Complete Obliteration ◽

Transvenous Approach ◽

Technical Considerations

Endovascular embolization of brain arteriovenous malformations (AVMs) is conventionally performed from a transarterial approach. Transarterial AVM embolization can be a standalone treatment or, more commonly, used as a neoadjuvant therapy prior to microsurgery or stereotactic radiosurgery. In contrast to the transarterial approach, curative embolization of AVMs may be more readily achieved from a transvenous approach. Transvenous embolization is considered a salvage therapy in contemporary AVM management. Proposed indications for this approach include a small (diameter < 3 cm) and compact AVM nidus, deep AVM location, hemorrhagic presentation, single draining vein, lack of an accessible arterial pedicle, exclusive arterial supply by perforators, and en passage feeding arteries. Available studies of transvenous AVM embolization in the literature have reported high complete obliteration rates, with reasonably low complication rates. However, evaluating the efficacy and safety of this approach is challenging due to the limited number of published cases. In this review the authors describe the technical considerations, indications, and outcomes of transvenous AVM embolization.

Download Full-text

Microsurgical treatment for cerebellomesencephalic fissure arteriovenous malformations after multiple sessions of endovascular treatment

Surgical Neurology International ◽

10.25259/sni_187_2021 ◽

2021 ◽

Vol 12 ◽

pp. 214

Author(s):

Silvio Sarmento Lessa ◽

Juan Alberto Paz-Archilla ◽

Bruno Loof Amorim ◽

Jose Maria Campos Filho ◽

Christiane Monteiro de Siqueira Campos ◽

...

Keyword(s):

Endovascular Treatment ◽

Posterior Fossa ◽

Arteriovenous Malformations ◽

Therapeutic Strategy ◽

Endovascular Embolization ◽

Female Adolescent ◽

Neurological Deficits ◽

High Incidence ◽

Microsurgical Resection

Background: Arteriovenous malformations (AVMs) are relatively uncommon congenital vascular anomalies, and only 7–15% of AVMs occur in the posterior fossa. Most posterior fossa AVMs clinically present with hemorrhage and are associated with a high risk of neurological deficits and mortality. These malformations are associated with a high incidence of flow-related aneurysms. Endovascular treatment of infratentorial AVMs is challenging in pediatric patients. Case Description: We describe an 11-year-old female adolescent with cerebellar syndrome [Video 1], who was diagnosed with a cerebellomesencephalic fissure AVM. We observed a sequential increase in the size of the AVM after multiple sessions of endovascular treatment and performed successful microsurgical resection of the lesion. Conclusion: This illustrative video highlights the role of microsurgery as a feasible therapeutic strategy for complete resection of cerebellar AVMs after endovascular embolization.

Download Full-text

Comparison of Endovascular Embolization Plus Simultaneous Microsurgical Resection vs. Primary Microsurgical Resection for High-Grade Brain Arteriovenous Malformations

Frontiers in Neurology ◽

10.3389/fneur.2021.756307 ◽

2021 ◽

Vol 12 ◽

Author(s):

Mingze Wang ◽

Fa Lin ◽

Hancheng Qiu ◽

Yong Cao ◽

Shuo Wang ◽

...

Keyword(s):

Blood Loss ◽

Arteriovenous Malformations ◽

Endovascular Embolization ◽

Neurological Deficits ◽

High Grade ◽

Neurological Outcomes ◽

Brain Arteriovenous Malformations ◽

Hybrid Operation ◽

Microsurgical Resection ◽

The One

Aim: It remains a challenge in surgical treatments of brain arteriovenous malformations (AVMs) in Spetzler-Martin Grade (SMG) IV and V to achieve both optimal neurological outcomes and complete obliteration. The authors reported a series of patients with AVMs in SMG IV and V who underwent a surgical paradigm of endovascular embolization and simultaneous microsurgical resection based on the one-staged hybrid operation.Methods: Participants in the multicenter prospective clinical trial (NCT 03774017) between January 2016 and December 2019 were enrolled. Patients who received endovascular embolization plus microsurgical resection (EE+MRS) and those who received intraoperative digital subtraction angiography plus microsurgical resection (iDSA+MRS) were divided into two groups. Information on clinical features, operative details, and clinical outcomes were extracted from the database. Deterioration of neurological deficits (DNDs) was defined as the primary outcome, which represented neurological outcomes. The time of microsurgical operation and blood loss were defined as the secondary outcomes representing microsurgical risks and difficulties. Outcomes and technical details were compared between groups.Results: Thirty-eight cases (male: female = 23:15) were enrolled, with 24 cases in the EE+MRS group and 14 in the iDSA+MRS group. Five cases (13.2%) were in SMG V and 33 cases (86.8%) were in SMG IV. Fourteen cases (36.8%) underwent the paradigm of microsurgical resection plus intraoperative DSA. Twenty-four cases (63.2%, n = 24) underwent the paradigm of endovascular embolization plus simultaneous microsurgical resection. Degradations of SMG were achieved in 15 cases. Of the cases, two cases got the residual nidus detected via intraoperative DSA and resected. Deterioration of neurological deficits occurred in 23.7% of cases (n = 9) when discharged, and in 13.5, 13.5, 8.1% of cases at the follow-ups of 3, 6, and 12 months, respectively, without significant difference between groups (P > 0.05). Intracranial hemorrhagic complications were reported in three cases (7.9%) of the EE+MRS group only. The embolization did not significantly affect the surgical time and intraoperative blood loss. The subtotal embolization or the degradation of size by 2 points resulted in no DNDs.Conclusions: The paradigms based on the one-staged hybrid operation were practical and effective in treating high-grade AVMs. Appropriate intraoperative embolization could help decrease operative risks and difficulties and improve neurological outcomes.

Download Full-text

Combined endovascular embolization and stereotactic radiosurgery in the treatment of large arteriovenous malformations

Journal of Neurosurgery ◽

10.3171/2011.1.jns10571 ◽

2011 ◽

Vol 114 (6) ◽

pp. 1758-1767 ◽

Cited By ~ 59

Author(s):

Spiros L. Blackburn ◽

William W. Ashley ◽

Keith M. Rich ◽

Joseph R. Simpson ◽

Robert E. Drzymala ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Ct Angiography ◽

Arteriovenous Malformations ◽

Mr Angiography ◽

Endovascular Embolization ◽

Neurological Deficits ◽

Maximum Diameter ◽

Complication Rates ◽

Catheter Angiography

Object Large cerebral arteriovenous malformations (AVMs) are often not amenable to direct resection or stereotactic radiosurgery (SRS) treatment. An alternative treatment strategy is staged endovascular embolization followed by SRS (Embo/SRS). The object of this study was to examine the experience at Washington University in St. Louis with Embo/SRS for large AVMs and review the results in earlier case series. Methods Twenty-one cases involving patients with large AVMs treated with Embo/SRS between 1994 and 2006 were retrospectively evaluated. The AVM size (before and after embolization), procedural complications, radiological outcome, and neurological outcome were examined. Radiological success was defined as AVM obliteration as demonstrated by catheter angiography, CT angiography, or MR angiography. Radiological failure was defined as residual AVM as demonstrated by catheter angiography, CT angiography, or MR angiography performed at least 3 years after SRS. Results The maximum diameter of all AVMs in this series was > 3 cm (mean 4.2 cm); 12 (57%) were Spetzler-Martin Grade IV or V. Clinical follow-up was available in 20 of 21 cases; radiological follow-up was available in 19 of 21 cases (mean duration of follow-up 3.6 years). Forty-three embolization procedures were performed; 8 embolization-related complications occurred, leading to transient neurological deficits in 5 patients (24%), minor permanent neurological deficits in 3 patients (14%), and major permanent neurological deficits in none (0%). Twenty-one SRS procedures were performed; 1 radiation-induced complication occurred (5%), leading to a permanent minor neurological deficit. Of the 20 patients with clinical follow-up, none experienced cerebral hemorrhage. In the 19 patients with radiological follow-up, AVM obliteration was confirmed by catheter angiography in 13, MR angiography in 2, and CT angiography in 1. Residual nidus was found in 3 patients. In patients with follow-up catheter angiography, the AVM obliteration rate was 81% (13 of 16 cases). Conclusions Staged endovascular embolization followed by SRS provides an effective means of treating large AVMs not amenable to standard surgical or SRS treatment. The outcomes and complication rates reported in this series compare favorably to the results of other reported therapeutic strategies for this very challenging patient population.

Download Full-text

Morbidity and mortality associated with sequential flow reduction embolization technique of cerebral arteriovenous malformations using n-butyl cyanoacrylate

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016223 ◽

2020 ◽

pp. neurintsurg-2020-016223

Author(s):

Alfred P See ◽

Mahmoud H Mohammaden ◽

Mark Rizko ◽

Christopher J Stapleton ◽

Sepideh Amin-Hanjani ◽

...

Keyword(s):

Arteriovenous Malformations ◽

Endovascular Embolization ◽

Morbidity And Mortality ◽

Treatment Modalities ◽

Cerebral Arteriovenous Malformations ◽

Major Morbidity ◽

Factors Affecting ◽

Flow Reduction ◽

Ruptured Avm ◽

Targeting Strategy

BackgroundEndovascular embolization of cerebral arteriovenous malformations (AVM) with liquid n-butyl cyanoacrylate (n-BCA) serves multiple purposes including AVM occlusion and flow reduction in preparation for other treatment modalities. The objective was to study the clinical, structural, and angiographic factors affecting complications associated with AVM treatment by sequential n-BCA embolizations for nidal occlusion versus quantitative flow reduction in preparation for surgical resection or radiosurgery.MethodsWe performed a retrospective review of all patients who underwent endovascular embolization of cerebral AVM at our institution between 1998 and 2019, during which time the technique of traditional embolization evolved to a strategy of targeted sequential flow reduction guided by serial flow imaging based on quantitative magnetic resonance angiography, in conjunction with a shift away from nidal penetration.ResultsAmong 251 patients, 47.8% of patients presented with ruptured AVM. On average, each patient underwent 2.4 embolizations, for a total of 613 sessions. Major morbidity related to embolization occurred in 18 (7.2%) patients, but this occurred disproportionately in the traditional embolization strategy (n=16, 8%) in contrast with the flow-targeting strategy (n=2, 3.8%). Four patients (1.6%) died in the overall group, and these all occurred with the traditional embolization strategy (2% of 199 patients); no deaths occurred in the flow-targeting strategy (n=52).ConclusionEmbolization with n-BCA targeted to sequential flow reduction and feeder occlusion with limited nidal penetration prior to definitive surgical or radiosurgical treatment can be safely performed with low overall morbidity and mortality.

Download Full-text

Microsurgical Treatment of Recurrent Conus Medullaris Arteriovenous Malformation: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opy180 ◽

2018 ◽

Vol 16 (2) ◽

pp. E44-E44

Author(s):

M Neil Woodall ◽

Robert F Spetzler

Keyword(s):

Arteriovenous Malformations ◽

Treatment Options ◽

Conus Medullaris ◽

Endovascular Embolization ◽

Spinal Angiography ◽

Microsurgical Treatment ◽

Complete Obliteration ◽

Retrospective Nature ◽

Posterior Spinal Arteries

Abstract Arteriovenous malformations (AVMs) involving the conus medullaris have a unique angioarchitecture due to their involvement of the arterial basket of the conus medullaris, which represents an arterial anastomotic network between the anterior spinal artery (ASA) and posterior spinal arteries (PSAs) at the level of the conus medullaris.1 These lesions consist of a combination of a true AVM nidus, which is usually extramedullary, and direct shunts between the ASA, PSAs, and the venous system. Patients may present with radiculopathy, myelopathy, or subarachnoid hemorrhage.2 A 40-yr-old woman status post T11-L1 laminoplasty for resection of a ruptured conus AVM 6 yr prior presented with routine follow-up angiography suggestive of an arteriovenous fistula. She was counseled regarding treatment options including endovascular embolization and microsurgical ligation or resection, and she elected to proceed with surgical treatment. At the time of surgery, a recurrent AVM was noted. A 2-dimensional intraoperative video illustrates the microsurgical treatment of her recurrent conus AVM. The patient recovered well postoperatively. Spinal angiography demonstrated complete obliteration of the lesion. The patient experienced transient urinary retention that was self-limited but otherwise was without any new neurological deficit. Due to the retrospective nature of this report, informed consent was not required. Video used with permission from Barrow Neurological Institute, all rights reserved.

Download Full-text

Complication Analysis of 469 Brain Arteriovenous Malformations Treated with N-Butyl Cyanoacrylate

Interventional Neuroradiology ◽

10.1177/159101990501100204 ◽

2005 ◽

Vol 11 (2) ◽

pp. 141-148 ◽

Cited By ~ 14

Author(s):

T. L. Li ◽

B. Fang ◽

X. Y. He ◽

C. Z. Duan ◽

Q. J. Wang ◽

...

Keyword(s):

Arteriovenous Malformations ◽

Endovascular Procedures ◽

Endovascular Embolization ◽

Neurological Deficits ◽

Embolization Therapy ◽

Brain Arteriovenous Malformations ◽

Ischemic Complications ◽

Brain Avms ◽

Special Strategy ◽

Low Rate

We independently assessed the frequency, severity and determinants of neurological deficits after endovascular embolization with NBCA of brain arteriovenous malformations (BAVMs) to have a better basis for making treatment decisions. All the charts of 469 BAVMs patients who underwent embolization with NBCA were reviewed. We analyzed the complications and their relation to angiographic features. The 469 patients were treated with 1108 endovascular procedures. Each met one to eight times, average 2.3 times. Eleven patients showed treatment-related complications, including four haemorrhagic and seven ischemic complications. Of these 11 cases, two died, two had persistent disabling deficits, and another seven suffered transient neurological deficits. Our finding suggests a low rate of disabling treatment complications for embolization of brain AVMs with NBCA in this center. The management of AVM patients who have high risk of embolization therapy should be treated by special strategy.

Download Full-text

Stereotactic radiosurgery for arteriovenous malformations of the brain

Journal of Neurosurgery ◽

10.3171/jns.1991.75.4.0512 ◽

1991 ◽

Vol 75 (4) ◽

pp. 512-524 ◽

Cited By ~ 508

Author(s):

L. Dade Lunsford ◽

Douglas Kondziolka ◽

John C. Flickinger ◽

David J. Bissonette ◽

Charles A. Jungreis ◽

...

Keyword(s):

Magnetic Resonance ◽

Stereotactic Radiosurgery ◽

Arteriovenous Malformations ◽

Neurological Deficits ◽

Content Type ◽

Complete Obliteration ◽

Latency Interval ◽

Subtotal Removal ◽

The Brain ◽

Fine Print

✓ Stereotactic radiosurgery successfully obliterates carefully selected arteriovenous malformations (AVM's) of the brain. In an initial 3-year experience using the 201-source cobalt-60 gamma knife at the University of Pittsburgh, 227 patients with AVM's were treated. Symptoms at presentation included prior hemorrhage in 143 patients (63%), headache in 104 (46%), and seizures in 70 (31%). Neurological deficits were present in 102 patients (45%). Prior surgical resection (resulting in subtotal removal) had been performed in 36 patients (16%). In 47 selected patients (21%), embolization procedures were performed in an attempt to reduce the AVM size prior to radiosurgery. The lesions were classified according to the Spetzler grading system: 64 (28%) were Grade VI (inoperable), 22 (10%) were Grade IV, 90 (40%) were Grade III, 43 (19%) were Grade II, and eight (4%) were Grade I. With the aid of computer imaging-integrated isodose plans for single-treatment irradiation, total coverage of the AVM nidus was possible in 216 patients (95%). The location and volume of the AVM were the most important factors for the selection of radiation dose. Magnetic resonance (MR) imaging was performed at 6-month intervals in 161 patients. Seventeen patients who had MR evidence of complete obliteration underwent angiography within 3 months of imaging: in 14 (82%) complete obliteration was confirmed. Complete angiographic obliteration was confirmed in 37 (80%) of 46 patients at 2 years, the earliest confirmation being 4 months (mean 17 months) after radiosurgery. The 2-year obliteration rates according to volume were: all eight (100%) AVM's less than 1 cu cm; 22 (85%) of 26 AVM's of 1 to 4 cu cm; and seven (58%) of 12 AVM's greater than 4 cu cm. Magnetic resonance imaging revealed postirradiation changes in 38 (24%) of 161 patients at a mean interval of 10.2 months after radiosurgery; only 10 (26%) of those 38 patients were symptomatic. In the entire series, two patients developed permanent new neurological deficits believed to be treatment-related. Two patients died of repeat hemorrhage at 6 and 23 months after treatment during the latency interval prior to obliteration. Stereotactic radiosurgery is an important method to obliterate AVM's, especially those previously considered inoperable. Success and complication risks are related to the AVM location and the volume treated.

Download Full-text