Deep central arteriovenous malformations of the brain: the role of endovascular treatment

1995 ◽  
Vol 82 (2) ◽  
pp. 190-195 ◽  
Author(s):  
Robert W. Hurst ◽  
Alex Berenstein ◽  
Mark J. Kupersmith ◽  
Mary Madrid ◽  
Eugene S. Flamm
Keyword(s):  
Endovascular Treatment ◽  
Arteriovenous Malformations ◽  
Signs And Symptoms ◽  
Neurological Deficits ◽  
Considerable Difficulty ◽  
Content Type ◽  
Complete Obliteration ◽  
Endovascular Methods ◽  
The Brain

✓ Cerebral deep central arteriovenous malformations (AVMs) are uncommon lesions associated with considerable difficulty in treatment. The authors report a series of 14 deep central AVMs treated by endovascular methods and examine the present role of endovascular treatment. This treatment used alone resulted in complete obliteration of AVMs in approximately 15% of cases and reduction in 50% to a size permitting treatment by means of radiosurgery. Reversal of previous neurological signs and symptoms occurred in 35.7% of embolized patients. Overall, nearly 80% of patients had either complete obliteration of the lesion, reduction to a size allowing radiosurgical treatment, or reversal of previous neurological deficits. There were treatment complications in 14.3% of the cases. Endovascular treatment methods may make a significant contribution to the therapy of AVMs that have a particularly poor course and are difficult to treat by other means.

Stereotactic radiosurgery for arteriovenous malformations of the brain

1991 ◽  
Vol 75 (4) ◽  
pp. 512-524 ◽  
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.

Stereotactic craniotomy in the resection of small arteriovenous malformations

1991 ◽  
Vol 75 (1) ◽  
pp. 40-44 ◽  
Author(s):  
Michael B. Sisti ◽  
Robert A. Solomon ◽  
Bennett M. Stein
Keyword(s):  
Arteriovenous Malformations ◽  
Complete Removal ◽  
Neurological Deficits ◽  
Content Type ◽  
Neurological Improvement ◽  
Stereotactic Frame ◽  
Microsurgical Resection ◽  
The Brain ◽  
Radiological Studies ◽  
Fine Print

✓ Surgical resection of 10 obscure arteriovenous malformations (AVM's) was accomplished with craniotomy guided by computerized tomography (CT) or angiography and the use of the Brown-Roberts-Wells stereotactic frame. Stereotactic craniotomy was invaluable for resection of the following types of AVM's: 1) AVM's with a nidus less than 2 cm in diameter, 2) AVM's located in an eloquent area of the brain, and 3) AVM's located deep in the brain. Stereotactic localization of these AVM's on preoperative radiological studies provides a precise route to the nidus, often avoiding important areas of the brain. This series included six male and four female patients with a mean age of 32 years. All patients presented with an intracerebral hemorrhage, from which eight made a complete neurological recovery prior to surgery. Two AVM's were located on the cortex, three were found subcortically, and five were situated near the ventricles or in the deep white matter. As a guide, angiography was used in six cases and CT in four cases. In each instance, the study providing the best image of the AVM nidus was employed. Postoperatively, no neurological deficits were found in eight patients and, in the two patients with preoperative deficits, neurological improvement was observed after recovery from surgery. Postoperative studies revealed complete removal of the AVM in all patients, and all lesions were confirmed histologically. The authors conclude that stereotactic craniotomy provides the optimum operative approach for the localization and microsurgical resection of AVM's that are either obscure or located deep in the brain.

Endovascular treatment of intracerebral arteriovenous malformations: experience in 49 cases

1991 ◽  
Vol 75 (2) ◽  
pp. 228-233 ◽  
Author(s):  
Dominique Fournier ◽  
Karel G. TerBrugge ◽  
Robert Willinsky ◽  
Pierre Lasjaunias ◽  
Walter Montanera
Keyword(s):  
Endovascular Treatment ◽  
Arteriovenous Malformations ◽  
Multidisciplinary Treatment ◽  
Treatment Protocol ◽  
Therapeutic Embolization ◽  
The Other ◽  
Neurological Deficits ◽  
Content Type ◽  
Results Of Treatment ◽  
Delayed Hemorrhage

✓ The authors report the results of treatment in 49 consecutive patients with brain arteriovenous malformations (AVM's) who underwent therapeutic embolization with liquid adhesive agents between 1984 and 1988 at the Toronto Western Hospital. Thirty-three patients had no other treatment and were followed up with angiography at 2 years and clinically from 2 to 6 years. Of the other 16 patients, 10 had adjunctive radiosurgery and six underwent surgical resection following embolization. Seven (14%) of the 49 patients had a morphological cure effected by embolization as evidenced on their 2-year follow-up angiograms; these have remained clinically stable. Twelve patients developed neurological deficits after embolization; eight (16% of the series) were transient and four (8%) were permanent. Two patients (4%) had a delayed hemorrhage after incomplete obliteration of their malformations. Endovascular treatment resulted in clinical improvement in 15 (33%) of the other 46 patients. None of the patients who initially presented with hemorrhage had a rebleed following embolization. It is concluded that endovascular treatment with liquid embolic material can be an integral part of the multidisciplinary treatment protocol for patients with brain AVM's.

scholarly journals Hemodynamic Simulation Study of Cerebral Arteriovenous Malformations. Part 2. Effects of Impaired Autoregulation and Induced Hypotension

1996 ◽  
Vol 16 (1) ◽  
pp. 162-169 ◽  
Author(s):  
Shiro Nagasawa ◽  
Masahiro Kawanishi ◽  
Susumu Kondoh ◽  
Sachiko Kajimoto ◽  
Kazunobu Yamaguchi ◽  
...  
Keyword(s):  
Simulation Study ◽  
Arteriovenous Malformations ◽  
Flow Model ◽  
Perfusion Pressure ◽  
Hemodynamic Changes ◽  
Induced Hypotension ◽  
Complete Obliteration ◽  
Hemodynamic Simulation ◽  
The Brain

The hemodynamic changes occurring during obliteration procedures for arteriovenous malformations (AVM) have not been fully elucidated. Therefore, we undertook a simulation study using a compartmental flow model to investigate the role of altered autoregulatory conditions in the development of hyperperfusion during obliteration of large high-flow AVM. Induced hypotension was also simulated to evaluate its usefulness in reducing the incidence and severity of the event. As the AVM flow was decreased during the obliteration procedures, feeder pressure increased and drainer pressure decreased, with a concomitant increase in the perfusion pressure in the brain tissue surrounding the AVM. Cerebral blood flow (CBF) remained constant at 50 ml 100 g−1 min−1 in the presence of autoregulation and increased to 67 ml 100 g−1 min−1 in its absence. When the lower limit of the autoregulatory pressure range (LAR) was shifted from 60 to 50 or 40 mm Hg, the flow volume increased markedly from 67 to 77 ml 100 g−1 min−1 or to 92 ml 100 g−1 min−1 after complete obliteration. Decrease in LAR would be a cause of the hyperperfusion. Induced systemic hypotension was found to be effective in reducing the magnitude of these hemodynamic changes, when induction was appropriately performed in a stepwise fashion. A simulation study is useful in clarifying the various hemodynamic changes that develop during the treatment of AVM.

Cerebral arteriovenous malformations

1984 ◽  
Vol 60 (1) ◽  
pp. 14-22 ◽  
Author(s):  
Alfred J. Luessenhop ◽  
Louis Rosa
Keyword(s):  
Arteriovenous Malformations ◽  
Neurological Dysfunction ◽  
Cerebral Arteriovenous Malformations ◽  
Natural Risk ◽  
Surgical Risk ◽  
Content Type ◽  
Mortality And Morbidity ◽  
The Brain ◽  
Fine Print

✓ To address the problems of surgical risk versus natural risk associated with cerebral arteriovenous malformations (AVM's), and the role of the intravascular operative approach, the authors have assessed a 20-year experience with 450 patients. Results of direct surgery in 90 patients indicate that for the smaller AVM's (Grades I and II), mortality and morbidity rates are lower than a reasonably projected natural risk. Hence, these patients are candidates for surgery in most instances. However, for more extensive AVM's (Grades III and IV), consideration of anticipated future years of exposure to natural risk and the location of the AVM in the brain are necessary for determining operability. In general, neither seizures nor incipient focal neurological dysfunction alone are indications for surgery, and the risks of disability or death from hemorrhage after the fifth decade of life are probably less than the surgical risks by present operative techniques. Considering the usual age of patients at the time of diagnosis, it is estimated that surgical risk is currently less than the natural risk for about 65% to 70% of all AVM patients. The categories of AVM's in which the angiographic effectiveness of the intravascular approach is the greatest correspond to the same categories of AVM's that can be surgically removed with low risk. The intravascular approach is most useful for management of large AVM's causing progressive neurological dysfunction or as a preliminary step to surgery in selected cases in which access to major feeding arteries is difficult. The authors believe that the future of the intravascular approach should be directed toward transforming large inoperable AVM's into operable ones, but that the overall capability for this with acceptable risk is uncertain at present.

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.

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

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.

Management of arteriovenous malformations of the brain stem

1986 ◽  
Vol 64 (6) ◽  
pp. 857-864 ◽  
Author(s):  
Robert A. Solomon ◽  
Bennett M. Stein
Keyword(s):  
Radiation Therapy ◽  
Brain Stem ◽  
Arteriovenous Malformations ◽  
Treated Group ◽  
Intracranial Arteriovenous Malformations ◽  
Content Type ◽  
Embolization Therapy ◽  
Complete Obliteration ◽  
The Brain ◽  
Fine Print

✓ In a series of 250 intracranial arteriovenous malformations (AVM's), 12 malformations involved the brain stem. Nine of these lesions were treated surgically, with complete obliteration in eight. There were no operative deaths, and only two patients were made worse by surgery. In the nonsurgically treated group, one patient had embolization therapy and two patients underwent radiation therapy. Results in these three patients have not been satisfactory. These data indicate that brain-stem AVM's can be surgically removed with acceptable morbidity.

Interim report on the radiosurgical treatment of cerebral arteriovenous malformations

1995 ◽  
Vol 83 (5) ◽  
pp. 832-837 ◽  
Author(s):  
Yoshihiro Yamamoto ◽  
Robert J. Coffey ◽  
Douglas A. Nichols ◽  
Edward G. Shaw
Keyword(s):  
Arteriovenous Malformations ◽  
Time Course ◽  
Gamma Knife Radiosurgery ◽  
Average Diameter ◽  
Neurological Deficits ◽  
Direct Result ◽  
Cerebral Arteriovenous Malformations ◽  
Content Type ◽  
Complete Obliteration ◽  
Fine Print

✓ During the authors' initial 4-year experience with radiosurgery using the Leksell cobalt-60 gamma unit, they treated 121 patients with cerebral arteriovenous malformations (AVMs). The radiosurgical dose to the margin of the nidus was 20 Gy for lesions less than 2.0 cm in diameter (volume ≤ 4.2 cm3); 18 Gy for malformations 2.1 to 3.0 cm in diameter (volume 4.2–14.1 cm3); and 16 Gy for malformations greater than 3.0 cm (volume > 14.1 cm3). Fifty-one patients underwent follow-up angiography between 1 and 3 years after treatment, and complete obliteration of the nidus was confirmed in 38 (74.5%) of these patients. Thirty-two (74.4%) of 43 AVMs with volumes of 10 cm3 or less and six (75%) of eight larger AVMs (volume 11–30 cm3) showed complete obliteration. Analysis of the time course of AVM nidus shrinkage and obliteration showed that most of the radiosurgically induced effect had occurred by 36 months after treatment. Retrospective analysis of the dose plans for 10 AVMs that were not obliterated by 36 months after gamma knife radiosurgery at the authors' institution (eight cases) or elsewhere (two cases) revealed that six AVMs had not been covered completely by the prescribed isodose. Six (5%) of the 121 patients developed neurological deficits as a direct result of radiosurgical treatment. The authors infer from these data that malformations up to 30 cm3 in volume (approximately 4.0 cm in average diameter) can be treated effectively with an acceptably low complication rate using a radiosurgical dose of 16 Gy to the margin of the nidus. The obliteration rate for the larger malformations that were treated with a dose of 16 to 18 Gy appears to be similar to that for smaller ones treated with 18 to 20 Gy. As more experience accrues using radiosurgery to treat AVMs, patient selection criteria and the variables associated with successful obliteration of the nidus should become more clearly defined.

Surgical removal of arteriovenous malformations from the brain stem and cerebellopontine angle

1975 ◽  
Vol 43 (6) ◽  
pp. 661-670 ◽  
Author(s):  
Charles G. Drake
Keyword(s):  
Arteriovenous Malformation ◽  
Brain Stem ◽  
Arteriovenous Malformations ◽  
Cerebellopontine Angle ◽  
Neurological Deficits ◽  
Surgical Removal ◽  
Surgical Experience ◽  
Content Type ◽  
The Brain ◽  
Fine Print

✓ The author reports his surgical experience with five cases of arteriovenous malformation of the brain stem and cerebellopontine angle causing multiple hemorrhages and severe neurological deficits. Surgical removal of the lesions had good results in four cases; there was one death.

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