Functional and topographical considerations in the surgical management of cerebral vascular malformations

Cerebral vascular malformations with potential surgical consequences mainly consist of arteriovenous malformations (AVM) and cavernous malformations. The standard preoperative workup of these lesions includes basic neuroradiological investigation, such as computed tomography, magnetic resonance imaging (MRI), and magnetic resonance angiography, and conventional angiography, to assess the exact neurotopographical relationships of the nidus, arterial feeding pedicles, and venous drainage. In cases where lesions are located near or within eloquent areas, precise documentation of the anatomy can be obtained using various functional tests including functional MRI, activated positron emission tomoqraphy, and magnetoencephalography (MEG), which may then be integrated into a neuronavigational system allowing for selective, image-guided surgery, thus potentially reducing surgical morbidity. Preoperative embolization may in certain cases improve the surqical excision by reducinq blood flow throuqh the AVM. Cavernous malformations may also be removed with minimally invasive and highly selective techniques.

Download Full-text

Unexpected Binding of Tozuleristide “Tumor Paint” to Cerebral Vascular Malformations: A Potentially Novel Application of Fluorescence-Guided Surgery

Neurosurgery ◽

10.1093/neuros/nyab106 ◽

2021 ◽

Author(s):

Andrew J Kobets ◽

David Nauen ◽

Amy Lee ◽

Alan R Cohen

Keyword(s):

Near Infrared ◽

Vascular Malformations ◽

Cns Tumors ◽

Matrix Metalloproteinase 2 ◽

Cerebrovascular Lesions ◽

Cavernous Malformations ◽

Guided Surgery ◽

Fluorescence Guided Surgery ◽

Cerebral Vascular Malformations ◽

Cerebral Vascular

Abstract BACKGROUND Fluorescence-guided surgery (FGS) is under investigation as a means to improve the extent of resection for primary central nervous system (CNS) tumors. Tozuleristide, known also as “Tumor Paint,” is an investigational tumor-targeting agent covalently conjugated to a derivative of the fluorescent dye indocyanine green. OBJECTIVE To report the finding of avid intraoperative fluorescence of tozuleristide on cerebral vascular malformations. METHODS Our institution is participating in a phase 2/3 study of intraoperative near-infrared fluorescence detection of pediatric primary CNS tumors in patients receiving intravenous tozuleristide and imaged with the Canvas system. Our site enrolled 2 patients with intracranial lesions, suspected preoperatively of possibly being gliomas that proved to be cavernous vascular malformations after resection. RESULTS Each lesion had a dark blue mulberry appearance and each fluoresced avidly with tozuleristide. Each was completely resected, and the patients recovered without deficit. Pathological assessment showed cavernous angioma for both cases. Tozuleristide fluorescence is postulated to result from binding to matrix metalloproteinase-2 and annexin A2, and literature review demonstrates expression of both these ligands on multiple cerebrovascular lesions, including cavernous malformations. CONCLUSION This finding deserves further investigation to determine if tozuleristide “Tumor Paint” may have a wider role in the identification of non-neoplastic intracranial pathologies.

Download Full-text

Diagnostic Accuracy of SWAN in the Diagnosis of Low-Flow Brain Vascular Malformations in Childhood

Journal of Pediatric Neurology ◽

10.1055/s-0041-1736554 ◽

2021 ◽

Author(s):

Nazlı Gülsüm Akyel ◽

Ayşe Gül Alımlı ◽

Mesut Sivri ◽

Havva Akmaz Ünlü ◽

Mehmet Tiftik

Keyword(s):

Diagnostic Accuracy ◽

Vascular Malformations ◽

False Negative ◽

Vascular Anomaly ◽

Low Flow ◽

Developmental Venous Anomaly ◽

Cavernous Malformations ◽

Capillary Telangiectasia ◽

Cerebral Vascular Malformations ◽

Cerebral Vascular

Abstract Purpose The main objective of this study is to demonstrate the diagnostic accuracy of susceptibility-weighted angiography (SWAN) in the diagnosis of slow-flow cerebral vascular malformations, especially developmental venous anomaly (DVA). We also aimed to determine the prevalence of DVAs identified by SWAN at 1.5 T. Methods We retrospectively evaluated 1,760 axial SWAN images for the diagnosis of low-flow vascular anomaly. Among them were 305 patients who underwent contrast-enhanced examination due to different indications. Postcontrast images were analyzed by different radiologists who were blinded to patients. The presence of DVA and other features such as location, length, depth, and direction of drainage vein was evaluated. Results Twenty-six patients with DVA had both SWAN and postcontrast images. There were four false-negative patients with SWAN. The sensitivity of the SWAN sequence was 84.6%. In addition, totally 77 DVA (4.36%), 2 capillary telangiectasia (0.11%), and 2 cavernous malformations (0.11%) were detected in 1,760 patients. Conclusion SWAN is an effective method for the diagnosis of developmental venous anomalies and other low-flow cerebral vascular malformations. Especially in the pediatric age, susceptibility-weighted imaging sequences are useful to limit contrast use.

Download Full-text

Neurosurgical Issues in Pregnancy

Seminars in Neurology ◽

10.1055/s-0037-1607430 ◽

2017 ◽

Vol 37 (06) ◽

pp. 689-693 ◽

Cited By ~ 5

Author(s):

Anil Can ◽

Rose Du

Keyword(s):

Arteriovenous Malformations ◽

Intracranial Aneurysms ◽

Vascular Malformations ◽

Significant Risk ◽

Unborn Child ◽

Cavernous Malformations ◽

Life Threatening ◽

Ruptured Intracranial Aneurysms ◽

Cerebral Vascular Malformations ◽

Cerebral Vascular

AbstractAlthough rare, intracranial hemorrhage due to rupture of cerebral vascular malformations or intracranial aneurysms during pregnancy is a potentially devastating and life-threatening disorder, posing a diagnostic and therapeutic challenge to a multidisciplinary team of neurosurgeons, neurologists, obstetricians, and anesthesiologists. Despite the significant risk of morbidity and mortality affecting both the mother and the unborn child, knowledge of the natural history, epidemiology, and appropriate management of cerebral vascular malformations and intracranial aneurysms in pregnant women is limited. Although emergent neurosurgical concerns usually outweigh obstetric considerations, and treatment of these disorders is generally similar in pregnant and nonpregnant women, any necessary and feasible modifications to protect the unborn child should be made. This article reviews the management of ruptured intracranial aneurysms and cerebral vascular malformations, including arteriovenous malformations, cavernous malformations, and moyamoya disease, in women during pregnancy, partus, and puerperium.

Download Full-text