Recurrent cerebral arteriovenous malformations after negative postoperative angiograms

1996 ◽  
Vol 85 (1) ◽  
pp. 14-18 ◽  
Author(s):  
Abraham Kader ◽  
James T. Goodrich ◽  
William J. Sonstein ◽  
Bennett M. Stein ◽  
Peter W. Carmel ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Surgical Removal ◽  
Cerebral Arteriovenous Malformations ◽  
Delayed Imaging ◽  
Humoral Factors ◽  
Content Type ◽  
Risk Of Hemorrhage ◽  
Success Of Treatment ◽  
Previous Location

✓ Angiography has been considered to be the gold standard to judge the success of treatment for cerebral arteriovenous malformations (AVMs). Patients without residual nidus or early draining veins on postoperative angiograms are considered cured, with the risk of hemorrhage eliminated. A series of five patients with recurrent AVMs after negative postoperative angiography is described. All patients had hemispheric AVMs, presented initially with hemorrhage, and were between 5 and 13 years of age. Recurrence was noted 1 to 9 years later (at 12–16 years of age); after a hemorrhage in three patients, seizures in one, and on follow-up magnetic resonance imaging in one. Four patients underwent angiography that showed recurrence of the AVM at or adjacent to the original site. Three years postsurgery, the fifth patient died from a large intracerebral and intraventricular hemorrhage originating in the previous location of the AVM; however, the patient did not undergo angiography at the time of recurrence. The initial negative angiograms obtained postoperatively in these patients may be explained by postoperative spasm or thrombosis of a small residual malformation. However, in the authors' cumulative experience with 808 patients who have undergone complete surgical removal of AVMs (of whom 667 were older than 18 years of age), no case of recurrent AVM has been observed in an adult. Therefore, actual regrowth of an AVM may occur in children and could be a consequence of their relatively immature cerebral vasculature and may involve active angiogenesis mediated by humoral factors. The present findings argue against the assumption that AVMs are strictly congenital lesions resulting from failure of capillary formation during early embryogenesis. It is concluded that delayed imaging studies should be considered in children at least 1 year after their initial negative postoperative arteriogram to exclude a recurrent AVM.

Arterial aneurysms associated with cerebral arteriovenous malformations: classification, incidence, and risk of hemorrhage

1998 ◽  
Vol 89 (4) ◽  
pp. 539-546 ◽  
Author(s):  
Gary Redekop ◽  
Karel TerBrugge ◽  
Walter Montanera ◽  
Robert Willinsky
Keyword(s):  
Arteriovenous Malformations ◽  
Clinical Presentation ◽  
Cerebral Arteriovenous Malformations ◽  
Content Type ◽  
Risk Of Bleeding ◽  
Risk Rate ◽  
Risk Of Hemorrhage ◽  
Arterial Aneurysms ◽  
Fine Print

Object. The goal of this study was to develop a classification system for aneurysms associated with arteriovenous malformations (AVMs) based on their anatomical and pathophysiological relationships and to determine the incidence and bleeding rates for these aneurysms as well as the effects of AVM treatment on their natural history. Methods. Of 632 patients with AVMs, intranidal aneurysms were found in 35 (5.5%) and flow-related aneurysms in 71 (11.2%). Patients with intranidal aneurysms presented more frequently with hemorrhage (72% compared with 40%, p < 0.001) and had a 9.8% per year risk rate of bleeding during follow-up review. Twelve (17%) of the patients with flow-related aneurysms associated with an AVM presented with hemorrhage from an aneurysm, whereas 15 (21%) bled from their AVM. Seventeen patients underwent angiography after AVM treatment (mean 2.25 years). Of 23 proximal aneurysms, 18 (78.3%) were unchanged, four (17.4%) were smaller, and one (4.3%) had disappeared, whereas four (80%) of five distal aneurysms regressed completely and one was unchanged. Sixteen patients underwent angiography after partial AVM treatment (mean 3.8 years). In cases with less than a 50% reduction in the AVM, no aneurysms regressed, although two enlarged and bled. In cases with greater than a 50% reduction in the AVM, two of three distal aneurysms disappeared and five proximal aneurysms were unchanged. Conclusions. Arterial aneurysms associated with cerebral AVMs may be classified as intranidal, flow-related, or unrelated to the AVM nidus. Intranidal aneurysms have a high correlation with hemorrhagic clinical presentation and a risk of bleeding during the follow-up period that considerably exceeds that which would be expected in their absence. Patients with flow-related aneurysms in association with an AVM may present with hemorrhage from either lesion. Aneurysms that arise on distal feeding arteries near the nidus have a high probability of regressing with substantial or curative AVM therapy.

Interhemispheric approach for the surgical removal of thalamocaudate arteriovenous malformations

1987 ◽  
Vol 66 (3) ◽  
pp. 345-351 ◽  
Author(s):  
Robert A. Solomon ◽  
Bennett M. Stein
Keyword(s):  
Corpus Callosum ◽  
Arteriovenous Malformations ◽  
Surgical Removal ◽  
Cerebral Arteriovenous Malformations ◽  
Total Removal ◽  
Recurrent Hemorrhage ◽  
Content Type ◽  
Interhemispheric Approach ◽  
Parinaud’S Syndrome ◽  
Fine Print

✓ A series of 250 surgically treated cerebral arteriovenous malformations (AVM's) is presented, in which 22 lesions were located primarily in the thalamus and caudate nucleus. A standardized interhemispheric approach through the posterior corpus callosum and into the atrium of the lateral ventricle was utilized for the surgical removal of these AVM's. Total removal was confirmed by angiography in 18 patients; removal was subtotal in four cases. There were no deaths in this group of patients. Disturbances of recent memory pre- and postoperatively were seen in half of the patients, but most of these deficits were temporary. Other complications included: postoperative homonymous hemianopsia (six cases), transient hemiparesis (three cases), hemisensory loss (two cases), Parinaud's syndrome (one case), and recurrent hemorrhage 2 years after surgery (one case). All 22 patients returned to their previous occupations and are leading independent lives. The results of this experience indicate that thalamocaudate AVM's can be effectively treated by resection.

Seizure control after surgery on cerebral arteriovenous malformations

1993 ◽  
Vol 78 (1) ◽  
pp. 12-18 ◽  
Author(s):  
Hwa-shain Yeh ◽  
John M. Tew ◽  
Maureen Gartner
Keyword(s):  
Arteriovenous Malformations ◽  
Seizure Control ◽  
Temporal Structure ◽  
Young Patients ◽  
Visual Field Defects ◽  
Cerebral Arteriovenous Malformations ◽  
Seizure Onset ◽  
Content Type ◽  
Fine Print

✓ Prediction of seizure control after surgery on cerebral arteriovenous malformations (AVM's) is currently unavailable. Between 1982 and 1990, 54 patients (30 males, 24 females) with epilepsy caused by a supratentorial cerebral AVM, without prior manifestation of intracranial hemorrhage, were surgically treated. Patients ranged in age from 11 to 59 years at seizure onset and from 13 to 70 years at surgery; the duration of seizure history ranged from several months to 27 years. The AVM's were located in the temporal (17 cases), frontal (15), parietal (10), rolandic (two), and occipital (two) regions; eight were multilobular. All patients underwent preoperative electroencephalography, intraoperative electrocorticography, and total excision of the AVM; additional cortical excision was performed in 25 cases. Remote seizure foci were identified in the ipsilateral mesial temporal structure in 10 patients with AVM's located in the lateral or posterior temporal lobe and in one with an AVM in the anterior frontal region. Two patients required a second operation to remove a remote seizure focus. Among the 54 patients, there were no operative deaths. After surgical treatment, two patients developed hemiparesis, one had contralateral paresthesia of limbs, two suffered partial visual field defects, and five experienced temporary speech disturbances. Postoperative results of seizure control during follow-up study (mean duration 4.8 years) were excellent in 38 patients (70.4%), good in 10 (18.5%), fair in five (9.3%), and poor in one (1.9%). Results appear to correlate with age at seizure onset, duration of seizures, location of lesions, and cortical excision. Excellent results were shown in 18 (60%) of 30 patients whose age at seizure onset was 30 years or less and in 20 (83.3%) of 24 whose age at seizure onset was greater than 30 years. Eighteen (90%) of 20 patients had excellent results when seizure duration was 1 year or less; only 25% of these underwent cortical excision. Twelve (71%) of the 17 temporal AVM's were associated with demonstrable epileptic foci. Secondary epileptogenesis can occur in humans with supratentorial cerebral AVM's; cortical excision in selected patients can improve the outcome of seizure control. Early surgery of a cerebral AVM in young patients presenting with epilepsy is an important consideration.

Development of multiple cerebral arteriovenous malformations documented in an adult by serial angiography

2003 ◽  
Vol 98 (1) ◽  
pp. 190-193 ◽  
Author(s):  
Yoshio Miyasaka ◽  
Kuniaki Nakahara ◽  
Hiroshi Takagi ◽  
Hiroyuki Hagiwara
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Angiography ◽  
Arteriovenous Malformations ◽  
Intracerebral Hematoma ◽  
Cerebral Arteriovenous Malformations ◽  
Content Type ◽  
Hematoma Evacuation ◽  
Cerebral Avms ◽  
Fine Print

✓ A 50-year-old woman with a parietal intracerebral hematoma was initially treated by hematoma evacuation. Initial preoperative and follow-up angiograms obtained 6 months later demonstrated no pial arteriovenous malformations (AVMs). She suffered a subarachnoid hemorrhage 8 years later. Results of follow-up cerebral angiography revealed the development of previously undetected multiple cerebral AVMs. This appears to be the first reported case of the development of multiple cerebral AVMs in an adult, demonstrated on serial angiography.

Dose—volume prediction of radiation-related complications after proton beam radiosurgery for cerebral arteriovenous malformations

2003 ◽  
Vol 99 (2) ◽  
pp. 254-263 ◽  
Author(s):  
Fred G. Barker ◽  
William E. Butler ◽  
Sue Lyons ◽  
Ethan Cascio ◽  
Christopher S. Ogilvy ◽  
...  
Keyword(s):  
Proton Beam ◽  
Arteriovenous Malformations ◽  
Cerebral Arteriovenous Malformations ◽  
Patient Age ◽  
Content Type ◽  
Complication Risk ◽  
Dose Volume ◽  
Treatment Dose ◽  
Fine Print

Object. The use of radiosurgery for the treatment of cerebral arteriovenous malformations (AVMs) and other lesions demands an accurate understanding of the risk of radiation-related complications. Some commonly used formulas for predicting risk are based on extrapolation from small numbers of animal experiments, pilot human treatment series, and theoretical radiobiological considerations. The authors studied the incidence of complications after AVM radiosurgery in relation to dose, volume, and other factors in a large patient series. Methods. A retrospective review was conducted in 1329 patients with AVM treated by Dr. Raymond Kjellberg at the Harvard Cyclotron Laboratory (HCL) between 1965 and 1993. Dose and volume were obtained from HCL records, and information about patient follow up was derived from concurrent clinical records, questionnaires, and contact with referring physicians. Multivariate logistic regression with bootstrapped confidence intervals was used. Follow up was available in 1250 patients (94%); the median follow-up duration was 6.5 years. The median radiation dose was 10.5 Gy and the median treatment volume was 33.7 cm3. Twenty-three percent of treated lesions were smaller than 10 cm3. Fifty-one permanent radiation-related deficits occurred (4.1%). Of 1043 patients treated with a dose predicted by the Kjellberg isoeffective centile curve to have a less than 1% complication risk, 1.8% suffered radiation-related complications. Actual complication rates were 4.7% for 128 patients treated at Kjellberg risk centile doses of 1 to 1.8%, and 34% for 61 patients treated at risk centile doses of 2 to 2.5%. The fitted logistic model showed that complication risk was related to treatment dose and volume, thalamic or brainstem location, and patient age. Conclusions. The Kjellberg isoeffective risk centile curve significantly underpredicted actual risks of permanent complications after proton beam radiosurgery for AVMs. Actual risks were best predicted using a model that accounted for treatment dose and volume, lesion location, and patient age.

Embolization and reduction of the “steal” syndrome in cerebral arteriovenous malformations

1974 ◽  
Vol 40 (3) ◽  
pp. 313-321 ◽  
Author(s):  
John A. Kusske ◽  
William A. Kelly
Keyword(s):  
Arteriovenous Malformations ◽  
Cerebral Perfusion ◽  
Clinical Syndrome ◽  
Normal Brain ◽  
Cerebral Arteriovenous Malformations ◽  
Content Type ◽  
Cerebral Steal ◽  
Steal Syndrome ◽  
Fine Print

✓ The authors report their experience with embolization of unresectable cerebral arteriovenous malformations in 10 patients; seven showed clinical improvement, two no change, and one became worse. Follow-up studies for up to 9 years suggest that partial obliteration of a lesion that shunts blood away from normal brain alleviates the clinical syndrome by enhancing cerebral perfusion. Thus, satisfactory results may be obtained without occlusion of malformations causing symptomatology on the basis of a cerebral steal.

Seizure outcome in patients with surgically treated cerebral arteriovenous malformations

1993 ◽  
Vol 78 (1) ◽  
pp. 5-11 ◽  
Author(s):  
David G. Piepgras ◽  
Thoralf M. Sundt ◽  
Ashvin T. Ragoonwansi ◽  
Lorna Stevens
Keyword(s):  
Arteriovenous Malformations ◽  
The United States ◽  
Seizure Disorder ◽  
Seizure Outcome ◽  
Cerebral Arteriovenous Malformations ◽  
Content Type ◽  
Follow Up Study ◽  
Significant Difference ◽  
Fine Print

✓ A series of 280 cases of cerebral arteriovenous malformations (AVM's) treated surgically between June, 1970, and June, 1989, is reviewed with particular focus on the preoperative seizure history and follow-up seizure status. Follow-up evaluation (mean duration 7.5 years) was achieved in 98% of cases and was accomplished through re-examinations, telephone interviews, and written questionnaires. Overall, 89% of the surviving patients with a follow-up period of greater than 2 years were free of seizures at last examination. Of the 280 patients in this series. 163 had experienced no seizures preoperatively. A recent follow-up study (with a minimum duration of 2 years or to death) was available in 157 of these 163 cases; 21 patients had died. Of the 136 surviving patients, only eight (6%) were having new ongoing seizures. In the 128 (94%) who had remained seizure-free, 73% were receiving no anticonvulsant agents while 27% were taking anticonvulsant prophylaxis. The 2-year minimum follow-up study in 110 of the 117 patients with preoperative seizures revealed that eight (7%) had died. Of the 102 surviving patients, 85 (83%) were seizure-free (with 48% no longer receiving anticonvulsant therapy), while 17 (17%) still suffered intermittent seizures. However, of these 17 patients, 13 reported their seizures to be improved compared to preoperatively; the seizures were the same in two patients and were worse in two patients. An actuarial analysis was conducted comparing the life expectancy of patients following surgery for AVM's with the expected survival of a general white population of the same age and sex in the West Northcentral region of the United States. No statistically significant difference was found. There were seven perioperative deaths (three from cerebral hemorrhage, two from pulmonary emboli, and two from obstruction of venous drainage) and 22 deaths during the follow-up period. Of these 22 deaths, the cause was unknown in four patients, apparently unrelated to the AVM in 13, and directly or indirectly related to the patient's neurological condition prior to surgery or due to surgery performed for resection of the AVM in five. There was a statistically significant relationship between the size and location of the AVM and the clinical presentation. Patients with small AVM's (< 3 cm) were more likely to present with hemorrhage whereas those with large AVM's were more likely to present with seizures. Conclusions from this study are: 1) there is a low incidence of a new seizure disorder following surgery: 2) chances for resolution or control of a pre-existing seizure disorder are good: 3) although resolution of seizures or seizure control was achieved postoperatively in AVM's of all sizes, this benefit was highest in smaller as opposed to larger AVM's; and 4) ultimately, there is a good capacity for recovery from pre-existing neurological deficits or those resulting from surgery.

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.

Surgical embolization of cerebral arteriovenous malformations through internal carotid and vertebral arteries

1975 ◽  
Vol 42 (4) ◽  
pp. 443-451 ◽  
Author(s):  
Alfred J. Luessenhop ◽  
John H. Presper
Keyword(s):  
Arteriovenous Malformations ◽  
Previous History ◽  
Surgical Excision ◽  
Clinical Results ◽  
Prior History ◽  
Cerebral Arteriovenous Malformations ◽  
Content Type ◽  
Progressive Neurological Deficit ◽  
History Of

✓ The authors describe the clinical results of surgical embolization in 55 patients with large cerebral arteriovenous malformations. Follow-up intervals ranged from 2 months to 14 years, averaging 4½ years. The authors believe the procedure is safe in properly selected patients and is useful as a preliminary to direct surgical excision. It relieves associated headaches, and usually reverses or stabilizes a progressive neurological deficit. The potential for seizures probably is not altered. The incidence of hemorrhage following embolization is low for patients with no previous history of hemorrhage; however, the procedure does not reduce the likelihood of recurrence in patients with a prior history of hemorrhage.

Intention-to-treat analysis of Spetzler—Martin Grades IV and V arteriovenous malformations: natural history and treatment paradigm

2003 ◽  
Vol 98 (1) ◽  
pp. 3-7 ◽  
Author(s):  
Patrick P. Han ◽  
Francisco A. Ponce ◽  
Robert F. Spetzler
Keyword(s):  
Natural History ◽  
Arteriovenous Malformations ◽  
Neurological Deficits ◽  
Surgical Removal ◽  
Content Type ◽  
Intention To Treat ◽  
Complete Treatment ◽  
Risk Of Hemorrhage ◽  
Treat Analysis ◽  
Fine Print

Object. In this study the authors quantified a subgroup of patients with Spetzler—Martin Grades IV and V arteriovenous malformations (AVMs) recommended for complete, partial, or no treatment, and calculated the retrospective hemorrhage rate for these lesions. Methods. Between July 1997 and May 2000, 73 consecutive patients with Grades IV and V AVMs were evaluated prospectively by the cerebrovascular team at Barrow Neurological Institute. Treatment recommendations given to the patients or referring physicians were classified as complete treatment, partial treatment, and no treatment. Retrospectively, the hemorrhage rates associated with these treatment groups were also calculated. In the prospective portion of the study (the intention-to-treat analysis), no treatment of the AVM, was recommended for 55 patients (75%) and partial treatment was recommended for seven patients (10%). Aneurysms associated with an AVM were obliterated by surgical or endovascular treatment in seven patients (10%), and complete surgical removal was recommended for four patients (5%). The overall hemorrhage rate for Grades IV and V AVMs was 1.5% per year. The annual risk of hemorrhage was 10.4% among patients who previously had received incomplete treatment, compared with patients without previous treatment. Conclusions. The hemorrhage risk of 1.5% per year, which was associated with Grades IV and V AVMs appears to be lower than that reported for Grades I through III AVMs. The authors recommend that no treatment be given for most Grades IV and V AVMs. No evidence indicates that partial treatment of an AVM reduces a patient's risk of hemorrhage. In fact, partial treatment may worsen the natural history of an AVM. The authors do not support palliative treatment of AVMs, except in the specific circumstances of arterial or intranidal aneurysms or progressive neurological deficits related to vascular steal. Complete treatment is warranted for patients with progressive neurological deficits caused by hemorrhage of the AVM. This selection process plays a significant role in the relatively low combined morbidity and mortality rates for Grade IV and Grade V AVMs (17 and 22%, respectively) reported by the cerebrovascular group in both retrospective and prospective studies.

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