Arteriovenous malformations of the brain: choosing embolic materials to enhance safety and ease of excision

1992 ◽  
Vol 77 (2) ◽  
pp. 217-222 ◽  
Author(s):  
Phillip D. Purdy ◽  
H. Hunt Batjer ◽  
Richard C. Risser ◽  
Duke Samson
Keyword(s):  
Arteriovenous Malformations ◽  
Arterial Occlusion ◽  
Technical Difficulty ◽  
Content Type ◽  
Feeding Vessels ◽  
Embolic Materials ◽  
Materials Used ◽  
Proximal Occlusion ◽  
Distal Occlusion ◽  
Fine Print

✓ The authors report their experience with surgical resection of 108 previously embolized arteriovenous malformations (AVM's). Embolization was performed via only transfemoral catheterization in 70 lesions and via the surgical exposure of feeding vessels in 32. The remaining six patients were referred for resection following silicone sphere embolization elsewhere. Materials used included polyvinyl alcohol (PVA) foam, platinum microcoils, detachable silicone balloons, surgical silk, a mixture of 33% ethanol and microfibrillar collagen, and isobutyl cyanoacrylate (IBCA). It is believed that proximal arterial occlusion with balloons is an inferior choice for preresection embolization, because the technical difficulty of placement is high and the nidus of the AVM is unaffected. Vascular coagulation and section and AVM retraction are more difficult with IBCA; therefore, this is also considered an inferior choice. Among the materials studied, the combination of PVA for distal occlusion and microcoils for proximal occlusion appears to be the superior choice. Fewer complications (stroke or hemorrhage) are seen when intraarterial Amytal (amobarbital) testing is used to guide the embolization. Data regarding toxicity, oncogenicity, and vascular metabolism or recanalization associated with PVA, IBCA, and n-butyl cyanoacrylate are reviewed.

Clinical significance of pedicle aneurysms on feeding vessels, especially those located in infratentorial arteriovenous malformations

2000 ◽  
Vol 92 (6) ◽  
pp. 995-1001 ◽  
Author(s):  
Manfred Westphal ◽  
Ulrich Grzyska
Keyword(s):  
Arteriovenous Malformations ◽  
Endovascular Techniques ◽  
Treatment Procedure ◽  
Major Hemorrhage ◽  
Content Type ◽  
Ruptured Aneurysms ◽  
Aggressive Management ◽  
Feeding Vessels ◽  
Fine Print ◽  
Feeding Vessel

Object. The diminishing threshold for the application of neuroimaging leads to an increasingly frequent diagnosis of previously asymptomatic arteriovenous malformations (AVMs). In such a context, it is warranted to define the criteria that make a lesion potentially hazardous so that neurosurgeons and patients reach a decision concerning how to manage the AVM. In addition to the proposed grading system for AVMs, which assesses the risk of an actual treatment procedure, several studies have been concerned with the evaluation of angioarchitectural features. The goal of the present study is to demonstrate the significance of feeding vessel pedicle aneurysms, especially those found in infratentorial AVMs.Methods. To determine the incidence of associated aneurysms, the authors reviewed an unselected cohort of 242 consecutive patients with AVMs managed between 1989 and 1999. Within this group were 240 patients who were treated by surgery, endovascular techniques, or a combination of both. Of these patients, 216 harbored a supratentorial and 24 an infratentorial AVM. Two additional patients with supratentorial AVMs underwent treatment of ruptured aneurysms without treatment of the AVMs. In six of the patients with supratentorial AVMs, proximal flow-related aneurysms were found on major feeding arteries, only one of which had caused hemorrhage. In only one patient were there additional distal feeding vessel pedicle aneurysms near the AVM, one of which had caused a major hemorrhage. In contrast, four of 24 patients with infratentorial AVMs had distal feeding artery pedicle aneurysms. Three of these aneurysms had caused hemorrhage.Conclusions. Pedicle aneurysms on feeding vessels are frequently associated with hemorrhage (four of five cases in this series). In our cohort of 242 treated patients (240 treated for AVM and two for an aneurysm), feeding vessel pedicle aneurysms appear to occur more frequently in conjunction with infratentorial AVMs, which justifies aggressive management to prevent incidences of morbidity associated with rupture of the aneurysm.

Dural arteriovenous malformations

1974 ◽  
Vol 40 (3) ◽  
pp. 322-329 ◽  
Author(s):  
Edward J. Kosnik ◽  
William E. Hunt ◽  
Carole A. Miller
Keyword(s):  
Surgical Treatment ◽  
Arteriovenous Malformations ◽  
Content Type ◽  
Venous Sinuses ◽  
Feeding Vessels ◽  
Physical Findings ◽  
Fine Print

✓ The history, physical findings, and treatment of dural arteriovenous malformations are reviewed. The importance of completely identifying and obliterating the fistula, even at the expense of obliterating major venous sinuses, is emphasized. Failure of surgical treatment usually is the result of mistaking the more obvious dilated feeding vessels for the lesion itself.

CO2 reactivity in arteriovenous malformations of the brain: a transcranial Doppler ultrasound study

1994 ◽  
Vol 80 (4) ◽  
pp. 624-630 ◽  
Author(s):  
Antônio A F. De Salles ◽  
Iñaki Manchola
Keyword(s):  
Carbon Dioxide ◽  
Doppler Ultrasound ◽  
Transcranial Doppler ◽  
Arteriovenous Malformations ◽  
Transcranial Doppler Ultrasound ◽  
Content Type ◽  
Control Subjects ◽  
Feeding Vessels ◽  
Carbon Dioxide Reactivity ◽  
Fine Print

✓ Arteriovenous malformations (AVM's) are congenital tangles of vessels that have a high blood flow through a low-resistance nidus. The vessels in the nidus may lack normal vasoreactivity in response to changes in PaCO2 or perfusion pressure (autoregulation). Arteriovenous malformation hemodynamics have been assessed based on the response of AVM feeding arteries to hypocapnia. Twenty-five AVM patients, aged 34 ± 11 years (mean ± standard deviation), were admitted to the Massachusetts General Hospital for proton-beam radiation therapy. Fourteen healthy volunteers aged 30 ± 7 years served as control subjects. Angiograms with calibrated markers permitting magnification correction were available for all patients. The limits of the middle cerebral artery, as determined by transcranial Doppler ultrasonography, were compared to measurements made on the angiograms. Hyperventilation was induced at a rate set by a metronome. Fixed bilateral Doppler probes allowed almost simultaneous sampling of two vessels. Volunteer control subjects were hyperventilated in two steps. The two PaCO2 step decreases were significant (mean resting PaCO2 40.6 ± 3.5 mm Hg, Step 1 level 29.4 ± 3.5 mm Hg and Step 2 level 23.8 ± 3.5 mm Hg; p < 0.01). These decreases induced a significant decrease in mean flow velocity (Vm) and an increase in the pulsatility index (p < 0.001). Mean carbon dioxide reactivity (%ΔVm/ΔPaCO2) was 2.74 ± 1.0 for Step 1 and 1.44 ± 1.8 for Step 2 (p < 0.003). The mean PaCO2 decrease in patients was from 39.5 ± 4.0 mm Hg to 27.0 ± 3.5 mm Hg. Carbon dioxide reactivity was 0.92 ± 1.12 for feeding vessels and 2.59 ± 1.78 for nonfeeding vessels (p < 0.001). Transcranial Doppler ultrasound and angiographic depth measurements correlated well. Hyperventilation induced significantly more hemodynamic changes in control and nonfeeding middle cerebral arteries than in feeding vessels. Impaired CO2 reactivity may help to identify AVM feeding vessels as well as the relative magnitude of the flow provided to the malformation.

Platelet aggregation within cerebral arteriovenous malformations

1988 ◽  
Vol 68 (2) ◽  
pp. 198-204 ◽  
Author(s):  
Garnette R. Sutherland ◽  
Martin E. King ◽  
Charles G. Drake ◽  
Sidney J. Peerless ◽  
William C. Vezina
Keyword(s):  
Platelet Aggregation ◽  
Arterial Thrombosis ◽  
Arteriovenous Malformations ◽  
Thrombus Formation ◽  
Short Interval ◽  
Arterial Occlusion ◽  
Blood Pool ◽  
Cerebral Arteriovenous Malformations ◽  
Content Type ◽  
Fine Print

✓ Turbulence within cerebral arteriovenous malformations (AVM's) may lead to endothelial disruption, platelet aggregation, and thrombus formation. This hypothesis would account for many of the pathological features in AVM's, including intimal hyperplasia and arterial thrombosis with or without organization. In this study, a dual-isotope method employing indium-111-labeled platelets and technetium-99m-labeled red blood cells was used to evaluate in vivo platelet aggregation in 20 patients with AVM's. The use of two isotopes allows subtraction of the blood-pool platelets and calculation of the ratio of the indium deposited:the indium in the blood pool (In(D)/In(BP)). After a 24-hour incubation period, eight of the 20 patients demonstrated platelet aggregation in their AVM's with a mean In(D)/In(BP) ratio of 0.71 ± 0.36 (± standard deviation). Seven of these AVM's were available for pathological study and all of them demonstrated evidence of arterial thrombosis of variable age. In the remaining 12 patients, the In(D)/In(BP) ratio was not significantly elevated (mean 0.02 ± 0.13), indicating the absence of active platelet aggregation during this short interval of study. Five of these AVM's were pathologically examined, four of which showed evidence of arterial occlusion. It is concluded that platelet aggregation is a common occurrence in cerebral AVM's and may account for the dynamic histopathology often seen in these lesions.

Management of extracranial congenital arteriovenous malformations of the head and neck

1973 ◽  
Vol 38 (5) ◽  
pp. 584-590 ◽  
Author(s):  
David G. Storrs ◽  
Robert B. King
Keyword(s):  
Head And Neck ◽  
Arteriovenous Malformations ◽  
Total Excision ◽  
Selective Angiography ◽  
Content Type ◽  
Selective Arteriography ◽  
Feeding Vessels ◽  
Definition Of ◽  
Contrast Studies ◽  
Fine Print

✓ Five cases of congenital extracranial arteriovenous malformations are reported. The need for careful preoperative definition of all feeding vessels by selective arteriography is stressed. The radiographic phenomenon of “washout” may preclude the recognition of some arterial feeders at the time of the initial contrast studies. The surgical management of these patients using repeated selective angiography, embolization, and ligation of the major arterial supply, followed by total excision of the malformation, is described.

Gamma knife radiosurgery as a single treatment modality for large cerebral arteriovenous malformations

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 113-119 ◽  
Author(s):  
D. Hung-Chi Pan ◽  
Wan-Yuo Guo ◽  
Wen-Yuh Chung ◽  
Cheng-Ying Shiau ◽  
Yue-Cune Chang ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Radiation Treatment ◽  
Gamma Knife Radiosurgery ◽  
Consecutive Series ◽  
Content Type ◽  
Obliteration Rate ◽  
Complete Obliteration ◽  
Fine Print

Object. A consecutive series of 240 patients with arteriovenous malformations (AVMs) treated by gamma knife radiosurgery (GKS) between March 1993 and March 1999 was evaluated to assess the efficacy and safety of radiosurgery for cerebral AVMs larger than 10 cm3 in volume. Methods. Seventy-six patients (32%) had AVM nidus volumes of more than 10 cm3. During radiosurgery, targeting and delineation of AVM nidi were based on integrated stereotactic magnetic resonance (MR) imaging and x-ray angiography. The radiation treatment was performed using multiple small isocenters to improve conformity of the treatment volume. The mean dose inside the nidus was kept between 20 Gy and 24 Gy. The margin dose ranged between 15 to 18 Gy placed at the 55 to 60% isodose centers. Follow up ranged from 12 to 73 months. There was complete obliteration in 24 patients with an AVM volume of more than 10 cm3 and in 91 patients with an AVM volume of less than 10 cm3. The latency for complete obliteration in larger-volume AVMs was significantly longer. In Kaplan—Meier analysis, the complete obliteration rate in 40 months was 77% in AVMs with volumes between 10 to 15 cm3, as compared with 25% for AVMs with a volume of more than 15 cm3. In the latter, the obliteration rate had increased to 58% at 50 months. The follow-up MR images revealed that large-volume AVMs had higher incidences of postradiosurgical edema, petechiae, and hemorrhage. The bleeding rate before cure was 9.2% (seven of 76) for AVMs with a volume exceeding 10 cm3, and 1.8% (three of 164) for AVMs with a volume less than 10 cm3. Although focal edema was more frequently found in large AVMs, most of the cases were reversible. Permanent neurological complications were found in 3.9% (three of 76) of the patients with an AVM volume of more than 10 cm3, 3.8% (three of 80) of those with AVM volume of 3 to 10 cm3, and 2.4% (two of 84) of those with an AVM volume less than 3 cm3. These differences in complications rate were not significant. Conclusions. Recent improvement of radiosurgery in conjunction with stereotactic MR targeting and multiplanar dose planning has permitted the treatment of larger AVMs. It is suggested that gamma knife radiosurgery is effective for treating AVMs as large as 30 cm3 in volume with an acceptable risk.

Factors related to complete occlusion of arteriovenous malformations after gamma knife radiosurgery

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 96-101 ◽  
Author(s):  
Jong Hee Chang ◽  
Jin Woo Chang ◽  
Yong Gou Park ◽  
Sang Sup Chung
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Maximum Diameter ◽  
Content Type ◽  
Complete Occlusion ◽  
Factors Associated ◽  
Martin Grade ◽  
Fine Print

Object. The authors sought to evaluate the effects of gamma knife radiosurgery (GKS) on cerebral arteriovenous malformations (AVMs) and the factors associated with complete occlusion. Methods. A total of 301 radiosurgical procedures for 277 cerebral AVMs were performed between December 1988 and December 1999. Two hundred seventy-eight lesions in 254 patients who were treated with GKS from May 1992 to December 1999 were analyzed. Several clinical and radiological parameters were evaluated. Conclusions. The total obliteration rate for the cases with an adequate radiological follow up of more than 2 years was 78.9%. In multivariate analysis, maximum diameter, angiographically delineated shape of the AVM nidus, and the number of draining veins significantly influenced the result of radiosurgery. In addition, margin radiation dose, Spetzler—Martin grade, and the flow pattern of the AVM nidus also had some influence on the outcome. In addition to the size, topography, and radiosurgical parameters of AVMs, it would seem to be necessary to consider the angioarchitectural and hemodynamic aspects to select proper candidates for radiosurgery.

A new rat model of chronic cerebral hypoperfusion associated with arteriovenous malformations

2002 ◽  
Vol 97 (5) ◽  
pp. 1198-1202 ◽  
Author(s):  
Jian Hai ◽  
Meixiu Ding ◽  
Zhilin Guo ◽  
Bingyu Wang
Keyword(s):  
Electron Microscopy ◽  
Animal Model ◽  
Arteriovenous Malformations ◽  
Perfusion Pressure ◽  
Chronic Cerebral Hypoperfusion ◽  
Cerebral Hypoperfusion ◽  
Model Group ◽  
Content Type ◽  
The Right ◽  
Fine Print

Object. A new experimental model of chronic cerebral hypoperfusion was developed to study the effects of systemic arterial shunting and obstruction of the primary vessel that drains intracranial venous blood on cerebral perfusion pressure (CPP), as well as cerebral pathological changes during restoration of normal perfusion pressure. Methods. Twenty-four Sprague—Dawley rats were randomly assigned to either a sham-operated group, an arteriovenous fistula (AVF) group, or a model group (eight rats each). The animal model was readied by creating a fistula through an end-to-side anastomosis between the right distal external jugular vein (EJV) and the ispilateral common carotid artery (CCA), followed by ligation of the left vein draining the transverse sinus and bilateral external carotid arteries. Systemic mean arterial pressure (MAP), draining vein pressure (DVP), and CPP were monitored and compared among the three groups preoperatively, immediately postoperatively, and again 90 days later. Following occlusion of the fistula after a 90-day interval, blood—brain barrier (BBB) disruption and water content in the right cortical tissues of the middle cerebral artery territory were confirmed and also quantified with transmission electron microscopy. Formation of a fistula resulted in significant decreases in MAP and CPP, and a significant increase in DVP in the AVF and model groups. Ninety days later, there were still significant increases in DVP and decreases in CPP in the model group compared with the other groups (p < 0.05). Damage to the BBB and brain edema were noted in animals in the model group during restoration of normal perfusion pressure by occlusion of the fistula. Electron microscopy studies revealed cerebral vasogenic edema and/or hemorrhage in various amounts, which correlated with absent astrocytic foot processes surrounding some cerebral capillaries. Conclusions. The results demonstrated that an end-to-side anastomosis between the distal EJV and CCA can induce a decrease in CPP, whereas a further chronic state of cerebral hypoperfusion may be caused by venous outflow restriction, which is associated with perfusion pressure breakthrough. This animal model conforms to the basic hemodynamic characteristics of human cerebral arteriovenous malformations.

scholarly journals Preoperative silk suture embolization of cerebral and dural arteriovenous malformations

2001 ◽  
Vol 11 (5) ◽  
pp. 1-6 ◽  
Author(s):  
Amir R. Dehdashti ◽  
Michel Muster ◽  
Alain Reverdin ◽  
Nicolas De Tribolet ◽  
Daniel A. Ruefenacht
Keyword(s):  
Arteriovenous Malformations ◽  
Histopathological Examination ◽  
Adverse Outcomes ◽  
Neurological Deficits ◽  
Grading System ◽  
Silk Suture ◽  
Long Term Follow Up ◽  
Feeding Vessels ◽  
A Minor ◽  
Proximal Occlusion

Object The aim of this study was to evaluate the use of silk sutures as a medical implant when applied for the embolization of cerebral and dural arteriovenous malformations (AVMs). The facility of surgery and the clinical significance of complications related to preoperative silk suture embolization were evaluated immediately after surgery and at long-term follow up. Methods Thirty-four patients harboring 29 cerebral and five dural AVMs underwent embolization in which silk alone or in association with other agents was used. Medical and radiological records obtained in these 34 patients were reviewed retrospectively. The cerebral AVMs were classified according to the Spetzler–Martin grading system and the dural AVMs to the Djindjian grading system. The facility of the resection and the adverse outcomes, including new neurological deficits, hemorrhage, and fever, as well as histopathological evidence of vessel inflammatory changes, were determined in each case. In all 23 surgical cases, the AVM could be easily manipulated and excised. New temporary neurological deficits occurred in three patients. A high Spetzler–Martin grade was not associated with a higher incidence of new neurological deficits. One delayed-onset hemorrhage was detected after embolization. Fever was present in 24% of the patients. No sign of significant vasculitis or perivascular inflammation was found on radiological or histopathological examination. Conclusions Silk sutures are safe embolic agents especially for proximal occlusion of AVM feeding vessels. New permanent neurological deficits were not encountered in this series. Fever was considered to be a minor, temporary side effect of silk suture embolization.

Cerebral angiography during operation for intracranial aneurysms and arteriovenous malformations

1971 ◽  
Vol 34 (5) ◽  
pp. 706-708 ◽  
Author(s):  
Martin L. Lazar ◽  
Clark C. Watts ◽  
Bassett Kilgore ◽  
Kemp Clark
Keyword(s):  
Cerebral Angiography ◽  
Arteriovenous Malformations ◽  
Intracranial Aneurysms ◽  
Operative Procedure ◽  
Superficial Temporal Artery ◽  
Technical Problem ◽  
Temporal Artery ◽  
Content Type ◽  
Actual Operation ◽  
Fine Print

✓ Angiography during the operative procedure is desirable, but is often difficult because of the problem of maintaining a needle or cannula in an artery for long periods of time. Cannulation of the superficial temporal artery avoids this technical problem. The artery is easily found, cannulation is simple, and obliteration of the artery is of no consequence. Cerebral angiography then provides a means for prompt evaluation of the surgical procedure at any time during the actual operation.

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