An analysis of the venous drainage system as a factor in hemorrhage from arteriovenous malformations

1992 ◽  
Vol 76 (2) ◽  
pp. 239-243 ◽  
Author(s):  
Yoshio Miyasaka ◽  
Kenzoh Yada ◽  
Takashi Ohwada ◽  
Takao Kitahara ◽  
Akira Kurata ◽  
...  
Keyword(s):  
Decision Making ◽  
Statistical Analysis ◽  
High Risk ◽  
Arteriovenous Malformations ◽  
Drainage System ◽  
Venous Drainage ◽  
Severe Stenosis ◽  
Content Type ◽  
Risk Of Hemorrhage ◽  
Fine Print

✓ The authors studied the venous drainage system and its impairment in relation to risk of hemorrhage in 108 cases of supratentorial arteriovenous malformation (AVM). The proportion of AVM's undergoing hemorrhage (hemorrhagic rate) was calculated in relation to: 1) the number of draining veins (one, two, or three or more); 2) the presence or absence of impairment in venous drainage (severe stenosis or occlusion in draining veins); and 3) the location of draining veins (deep venous drainage alone, superficial venous drainage alone, or a combination of the two). Statistical analysis demonstrated that AVM's with the following characteristics had a high risk of hemorrhage: 1) one draining vein (hemorrhagic rate 89% in 54 patients); 2) severely impaired venous drainage (hemorrhagic rate 94% in 18 patients); and 3) deep venous drainage alone (hemorrhagic rate 94% in 32 patients). The present study suggests that the venous drainage system of AVM's is significantly associated with the risk of hemorrhage of these lesions. Therefore, careful preoperative angiographic evaluation of the venous drainage system is mandatory for decision making in the management of patients with AVM's.

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

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

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

Long-term complications after gamma knife surgery for arteriovenous malformations

2005 ◽  
Vol 102 (Special_Supplement) ◽  
pp. 34-37 ◽  
Author(s):  
Masahiro Izawa ◽  
Motohiro Hayashi ◽  
Mikhail Chernov ◽  
Koutarou Nakaya ◽  
Taku Ochiai ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Cyst Formation ◽  
Gamma Knife Surgery ◽  
Content Type ◽  
Delayed Hemorrhage ◽  
Complete Obliteration ◽  
Risk Of Hemorrhage ◽  
Fine Print

Object. The authors analyzed of the long-term complications that occur 2 or more years after gamma knife surgery (GKS) for intracranial arteriovenous malformations (AVMs). Methods. Patients with previously untreated intracranial AVMs that were managed by GKS and followed for at least 2 years after treatment were selected for analysis (237 cases). Complete AVM obliteration was attained in 130 cases (54.9%), and incomplete obliteration in 107 cases (45.1%). Long-term complications were observed in 22 patients (9.3%). These complications included hemorrhage (eight cases), delayed cyst formation (eight cases), increase of seizure frequency (four cases), and middle cerebral artery stenosis and increased white matter signal intensity on T2-weighted magnetic resonance imaging (one case of each). The long-term complications were associated with larger nidus volume (p < 0.001) and a lobar location of the AVM (p < 0.01). Delayed hemorrhage was associated only with incomplete obliteration of the nidus (p < 0.05). Partial obliteration conveyed no benefit. Delayed cyst formation was associated with a higher maximal GKS dose (p < 0.001), larger nidus volume (p < 0.001), complete nidus obliteration (p < 0.01), and a lobar location of the AVM (p < 0.05). Conclusions. Incomplete obliteration of the nidus is the most important factor associated with delayed hemorrhagic complications. Partial obliteration does not seem to reduce the risk of hemorrhage. Complete obliteration can be complicated by delayed cyst formation, especially if high maximal treatment doses have been administered.

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.

Combining endovascular and neurosurgical treatments of high-risk dural arteriovenous fistulas in the lateral sinus and the confluence of the sinuses

1999 ◽  
Vol 90 (2) ◽  
pp. 289-299 ◽  
Author(s):  
Katsuya Goto ◽  
Prijo Sidipratomo ◽  
Noboru Ogata ◽  
Toru Inoue ◽  
Haruo Matsuno
Keyword(s):  
High Risk ◽  
Signs And Symptoms ◽  
Venous Drainage ◽  
Complex Nature ◽  
Lateral Sinus ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Diffuse Brain Swelling ◽  
Fine Print

Object. The authors describe the use of a systemic approach to treat dural arteriovenous fistulas (DAVFs) in the lateral sinus and the confluence of sinuses in 17 patients who presented with signs and symptoms related to intracranial hemorrhage, infarction, and diffuse brain swelling.Methods. Angiographic examination revealed three different types of DAVFs in these high-risk patients: 1) extremely high flow DAVF not associated with sinus occlusion or leptomeningeal retrograde venous drainage (LRVD); 2) localized DAVF with exclusive LRVD and without sinus occlusion; and 3) diffuse DAVF with sinus occlusion and LRVD. Because of the complex nature of these lesions, the authors adopted a staged protocol in which they combined endovascular and surgical treatments.Conclusions. The authors believe that by close collaboration between endovascular therapists and vascular neurosurgeons, high-risk DAVFs in the lateral sinus and the confluence of sinuses can be successfully managed without treatment-related morbidity and mortality.

Cerebral venous malformation—arteriovenous malformation transition forms

1996 ◽  
Vol 85 (1) ◽  
pp. 9-13 ◽  
Author(s):  
Sean Mullan ◽  
Saeid Mojtahedi ◽  
Douglas L. Johnson ◽  
R. Loch MacDonald
Keyword(s):  
Arteriovenous Malformation ◽  
Arteriovenous Malformations ◽  
Venous Malformation ◽  
Venous Drainage ◽  
Star Cluster ◽  
Cluster System ◽  
Content Type ◽  
Cerebral Venous Malformation ◽  
Fine Print

✓ Three cases of cerebral venous malformation (CVM) are presented to demonstrate the triad that characterizes CVM: abnormal surface venous drainage, a “star-cluster” system of deep collecting veins, and a deep draining vein. Four other cases are introduced that illustrate this triad and show an additional feature, namely arterial fistulization; these cases represent arteriovenous malformations (AVMs). A final case demonstrates a CVM within an AVM. Both of these structures have a common draining vein and an identical venous core. On the basis of the cases described and of others less suitable for illustration, it is postulated that an AVM is a fistulized CVM and that both relate to a failure in the development of the cortical venous mantle. This proposition is based on the authors' observations and their assessment of the “best possible fit.”

Multiplicity of dural arteriovenous fistulas

2002 ◽  
Vol 96 (1) ◽  
pp. 76-78 ◽  
Author(s):  
J. Marc C. Van Dijk ◽  
Karel G. TerBrugge ◽  
Robert A. Willinsky ◽  
M. Christopher Wallace
Keyword(s):  
Venous Drainage ◽  
Entire Group ◽  
Additional Risk ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Bilateral Involvement ◽  
Dural Arteriovenous Fistulas ◽  
Cortical Venous Drainage ◽  
Risk Of Hemorrhage ◽  
Fine Print

Object. Dural arteriovenous fistulas (AVFs) are a well-known pathoanatomical and clinical entity. Excluding bilateral involvement of the cavernous sinus, multiple dural AVFs are rare, with isolated reports in the literature. The additional risk associated with multiplicity is unknown, although it has been claimed that there is a greater risk of hemorrhage at presentation. In a group of 284 patients with dural AVFs consecutively treated at a single center, the occurrence of multiplicity is investigated and its risk factors for hemorrhage are identified. Methods. Among the 284 patients with both cranial and spinal dural AVFs, 20 patients with multiple fistulas were found. Nineteen (8.1%) of 235 patients with cranial AVFs had multiple cranial fistulas, and one (2%) of 49 patients with spinal AVFs harbored two spinal fistulas. Twelve patients were found to have a lesion at two separate sites, seven patients had them at three locations, and one patient had four fistulas, each at a different site. In the subgroup with multiple AVFs the percentage of hemorrhage at presentation was three times higher than in the entire group (p = 0.01). Cortical venous drainage in cranial fistulas was present in 84% of patients with multiple lesions compared with 46% of patients with solitary lesions (p < 0.005). Conclusions. Multiple dural AVFs are not rare. In this group of 284 patients it was found in 8.1% of all patients with cranial dural AVFs. Multiplicity was associated with a higher percentage of cortical venous drainage, a pattern of drainage reportedly yielding a higher risk for hemorrhage.

Theoretical comparison of surgery and radiosurgery in cerebral arteriovenous malformations

1999 ◽  
Vol 90 (4) ◽  
pp. 709-719 ◽  
Author(s):  
Han Soo Chang ◽  
Hiroshi Nihei
Keyword(s):  
Decision Making ◽  
Treatment Strategy ◽  
Arteriovenous Malformations ◽  
Treatment Plan ◽  
Survival Rates ◽  
Decision Making Process ◽  
Cerebral Arteriovenous Malformations ◽  
Conventional Surgery ◽  
Content Type ◽  
Fine Print

Object. Management of patients with cerebral arteriovenous malformations (AVMs) is controversial. Excellent surgical results are obtained in patients with low Spetzler—Martin grades, whereas radiosurgery offers a good alternative with its high obliteration rate. In the absence of randomized studies, physicians must choose a treatment plan based on the currently available data. To support this decision-making process, a mathematical model designed to describe patient survival rates after each treatment option was developed.Methods. The theoretical survival curve in patients undergoing conventional surgery, radiosurgery, or observation was calculated. Theoretical life expectancies in patients with AVMs who presented at various initial ages were calculated for each treatment strategy. A systematic method was also developed to compare the estimated risks of various treatment combinations.Conclusions. Conventional surgery and radiosurgery definitely produced better survival rates than observation. In the comparison of surgery with radiosurgery, radiosurgery was equivalent to surgery with a combined morbidity and mortality rate of approximately 7% for a 20-year-old patient with an unruptured cerebral AVM. Data for other patient ages and treatment combinations are tabulated for use in determining the best treatment strategy. The authors believe that their analysis will provide logical support for the decision-making process involved in the treatment of patients with cerebral AVMs.

Surgical resection of large incompletely treated intracranial arteriovenous malformations following stereotactic radiosurgery

1996 ◽  
Vol 84 (6) ◽  
pp. 920-928 ◽  
Author(s):  
Gary K. Steinberg ◽  
Steven D. Chang ◽  
Richard P. Levy ◽  
Michael P. Marks ◽  
Ken Frankel ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Arteriovenous Malformations ◽  
Venous Drainage ◽  
Endovascular Embolization ◽  
Content Type ◽  
Critical Areas ◽  
Endothelial Proliferation ◽  
Lower Success Rate ◽  
Complete Thrombosis ◽  
Fine Print

✓ Although radiosurgery is effective in obliterating small arteriovenous malformations (AVMs), it has a lower success rate for thrombosing larger AVMs. The authors surgically resected AVMs from 33 patients ranging in age from 7 to 64 years (mean 30.4 years) 1 to 11 years after radiosurgery. Initial AVM volumes were 0.8 to 117 cm3 (mean 21.6 cm3), and doses ranged from 4.6 to 45 GyE (mean 21.2 GyE). Of 27 AVMs in eloquent or critical areas, 10 were located in language, motor, sensory, or visual cortex, 11 in the basal ganglia/thalamus, one each in the brainstem, hypothalamus, and cerebellum, and three in the corpus callosum. Venous drainage was deep in 13, superficial in 12, or both in eight lesions. Spetzler—Martin grades were II in one, III in 12, IV in 16, and V in four patients. Eight patients experienced rebleeding after radiosurgery but prior to surgery. Three patients developed radiation necrosis and 25 underwent endovascular embolization prior to surgery. At surgery the AVMs were found to be markedly less vascular, partially thrombosed, and more easily resected, compared to those seen in patients who had not undergone radiosurgery. Pathological investigation showed endothelial proliferation with hyaline and calcium in vessel walls. There was partial or complete thrombosis of some AVM vessels and evidence of vessel and brain necrosis in many cases. Complete resection was achieved in 28 patients and partial resection in five. Clinical outcome was excellent or good in 31 cases, and two patients died of rebleeding from residual AVM. Four patients' conditions worsened following microsurgical resection. Final clinical outcome was largely related to the pretreatment grade. Radiosurgery several years prior to open microsurgery may prove to be a useful adjunct in treating unusually large and complex AVMs.

Retrospective analysis of a 10-year experience of stereotactic radiosurgery for arteriovenous malformations in children and adolescents

2002 ◽  
Vol 97 (4) ◽  
pp. 779-784 ◽  
Author(s):  
Masahiro Shin ◽  
Shunsuke Kawamoto ◽  
Hiroki Kurita ◽  
Masao Tago ◽  
Tomio Sasaki ◽  
...  
Keyword(s):  
Children And Adolescents ◽  
Arteriovenous Malformations ◽  
Univariate Analysis ◽  
Maximum Diameter ◽  
Content Type ◽  
Radiation Induced ◽  
Latency Interval ◽  
Risk Of Hemorrhage ◽  
Fine Print

Object. To obtain information essential to the decision to perform radiosurgery for arteriovenous malformations (AVMs) in children and adolescents, the authors retrospectively analyzed their experience with gamma knife surgery for AVMs in 100 patients ranging in age from 4 to 19 years. Methods. Follow-up periods ranged from 6 to 124 months (median 71 months), and the actuarial obliteration rates demonstrated by angiography were 84.1, 89.4, and 94.7% at 3, 4, and 5 years, respectively. Factors associated with better obliteration rates in univariate analysis included the following: a patient age of 12 years or younger; a mean nidus diameter of 2 cm or less; a nidus volume of 3.8 cm3 or less; a maximum diameter of the nidus less than 3 cm; and a Spetzler—Martin grade of III or less. Radiation-induced neuropathy was seen in four patients, and the risk factors were considered to be a nidus in the brainstem and a maximum radiation dose greater than 40 Gy. Hemorrhage developed during the latency interval in four patients, and one patient with a cerebellar AVM died of the hemorrhage. The annual bleeding rate was 1.5%. Feeding arteries located in the posterior cranial fossa and an AVM nidus located in the cerebellum were significantly associated with the risk of hemorrhage. After angiographically verified obliteration of the nidus, 51 patients continued to be observed from 1 to 110 months (median 67 months); hemorrhage developed in one patient 38 months after nidus obliteration. Conclusions. Radiosurgery is an acceptable treatment for small AVMs in children and adolescents in whom a higher obliteration rate can be achieved with lower risks of interval hemorrhage compared with the reported results in the general population. Careful follow-up observation seems to be required, however, even after angiographically verified obliteration.

Delayed neurological deterioration following resection of arteriovenous malformations of the brain

1999 ◽  
Vol 90 (4) ◽  
pp. 695-701 ◽  
Author(s):  
Michael K. Morgan ◽  
Lali H. S. Sekhon ◽  
Simon Finfer ◽  
Verity Grinnell
Keyword(s):  
Arteriovenous Malformations ◽  
Cerebral Arteries ◽  
Venous Drainage ◽  
Neurological Deficits ◽  
Grading System ◽  
Content Type ◽  
Drainage Networks ◽  
Middle Cerebral Arteries ◽  
The Brain ◽  
Fine Print

Object. The aim of this study was to analyze delayed neurological deficits following surgical resection of arteriovenous malformations (AVMs).Methods. The authors report on a consecutive series of 200 patients with angiographically proven AVMs of the brain that were surgically resected between January 1989 and June 1998. The 30-day mortality rate for patients in this series was 1%, with one death caused by AVM resection and one death attributed to basilar artery aneurysm repair following successful AVM resection. The Spetzler—Martin grading system correlated well with the difficulty of surgery. No permanent incidence of morbidity resulted from resection of Grade I or II AVMs; the percentage of patients with a significant neurological deficit due to resection was 7.8% for those with Grade III lesions and 33.3% for those with Grade IV or V AVMs. However, this grading system did not accurately predict the development of delayed neurological deficits.Ten patients (5%) developed delayed neurological deficits after recovering from anesthesia and surgery. The delayed deficit was due to hemorrhage in four of the 10 patients and all four had undergone resection of AVMs measuring at least 4 cm in diameter. An increase in blood pressure during the first 8 postoperative days precipitated hemorrhage in these patients. Edema arising as a consequence of propagated venous thrombosis (two patients) was associated with extensive venous drainage networks rather than large AVM niduses. Both hemorrhagic and edematous complications can be included under the umbrella term of “arterial-capillary-venous hypertensive syndrome” to describe the common underlying pathogenesis accurately. An additional four patients developed a delayed deficit as a result of vasospasm. Vasospasm occurred when resection had involved extensive dissection of proximal anterior and middle cerebral arteries; in such cases the incidence of vasospasm was 27%.Conclusions. On the basis of their analysis of these complications, the authors recommend strict blood pressure control for patients with lesions measuring 4 cm or more in diameter (particularly those with a deep arterial supply). Thromboprophylaxis with aspirin and heparin is prescribed for patients with extensive venous drainage networks, and prophylactic nimodipine therapy and angiographic surveillance for vasospasm are suggested for patients in whom extensive dissection of proximal anterior or middle cerebral arteries has been necessary.

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