|
1
|
Karadimas SK, Silva MA, Starke RM. Occipital Interhemispheric Transtentorial Approach for Microsurgical Treatment of Posterior Midbrain Arteriovenous Malformation: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2025; 28:445-446. [PMID: 38995048 DOI: 10.1227/ons.0000000000001273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/20/2024] [Indexed: 07/13/2024] Open
Affiliation(s)
- Spyridon K Karadimas
- Department of Neurosurgey, Miami Miller School of Medicine, Jackson Memorial Hospital, Miami , Florida , USA
- Department of Neurosurgery, University of Texas Health Science Center Houston, Houston , Texas , USA
| | - Michael A Silva
- Department of Neurosurgey, Miami Miller School of Medicine, Jackson Memorial Hospital, Miami , Florida , USA
| | - Robert M Starke
- Department of Neurosurgey, Miami Miller School of Medicine, Jackson Memorial Hospital, Miami , Florida , USA
| |
Collapse
|
|
2
|
Golub D, Lynch DG, Mehta SH, Donaldson H, Shah KA, White TG, Quach ET, Papadimitriou K, Kuffer AF, Woo HH, Link TW, Patsalides A, Dehdashti AR. The role of surgical disconnection for posterior fossa pial arteriovenous fistulas and dural fistulas with pial supply: an illustrative case series. Neurosurg Rev 2024; 47:189. [PMID: 38658425 DOI: 10.1007/s10143-024-02407-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/26/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Pial arteriovenous fistulas (pAVFs) are rare vascular malformations characterized by high-flow arteriovenous shunting involving a cortical arterial supply directly connecting to venous drainage without an intermediate nidus. Dural arteriovenous fistulas (dAVFs) can infrequently involve additional pial feeders which can introduce higher flow shunting and increase the associated treatment risk. In the posterior fossa, arteriovenous fistula (AVF) angioarchitecture tends to be particularly complex, involving either multiple arterial feeders-sometimes from both dural and pial origins-or small caliber vessels that are difficult to catheterize and tend to be intimately involved with functionally critical brainstem or upper cervical cord structures. Given their rarity, published experience on microsurgical or endovascular treatment strategies for posterior fossa pAVFs and dAVFs with pial supply remains limited. METHODS Retrospective chart review from 2019-2023 at a high-volume center identified six adult patients with posterior fossa pAVFs that were unable to be fully treated endovascularly and required microsurgical disconnection. These cases are individually presented with a technical emphasis and supported by comprehensive angiographic and intraoperative images. RESULTS One vermian (Case 1), three cerebellopontine angle (Cases 2-4) and two craniovertebral junction (Cases 5-6) posterior fossa pAVFs or dAVFs with pial supply are presented. Three cases involved mixed dural and pial arterial supply (Cases 1, 4, and 6), and one case involved a concomitant microAVM (Case 2). Endovascular embolization was attempted in four cases (Cases 1-4): The small caliber and tortuosity of the main arterial feeder prevented catheterization in two cases (Cases 1 and 3). Partial embolization was achieved in Cases 2 and 4. In Cases 5 and 6, involvement of the lateral spinal artery or anterior spinal artery created a prohibitive risk for endovascular embolization, and surgical clip ligation was pursued as primary management. In all cases, microsurgical disconnection resulted in complete fistula obliteration without evidence of recurrence on follow-up imaging (mean follow-up 27.1 months). Two patients experienced persistent post-treatment sensory deficits without significant functional limitation. CONCLUSIONS This illustrative case series highlights the technical difficulties and anatomical limitations of endovascular management for posterior fossa pAVFs and dAVFs with pial supply and emphasizes the relative safety and utility of microsurgical disconnection in this context. A combined approach involving partial preoperative embolization-when the angioarchitecture is permissive-can potentially decrease surgical morbidity. Larger studies are warranted to better define the role for multimodal intervention and to assess associated long-term AVF obliteration rates in the setting of pial arterial involvement.
Collapse
Affiliation(s)
- Danielle Golub
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA.
| | - Daniel G Lynch
- Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, USA
| | - Shyle H Mehta
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Hayley Donaldson
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Kevin A Shah
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Timothy G White
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Eric T Quach
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | | | | | - Henry H Woo
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Thomas W Link
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Athos Patsalides
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| | - Amir R Dehdashti
- Department of Neurosurgery, Northwell Health, Manhasset, NY, USA
| |
Collapse
|
|
3
|
Stanishevskiy A, Babichev K, Svistov D, Savello A. Sporadic multiple cerebral arteriovenous malformations: case report and systematic review of additional 80 cases. J Neurosurg Sci 2024; 68:225-231. [PMID: 37184633 DOI: 10.23736/s0390-5616.23.06028-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
INTRODUCTION In absence of hereditary diseases multiple brain arteriovenous malformations are extremely rare. The case series that would include more than 13 patients are unlikely to be found, which causes an obstacle to comprehensively analyzing the peculiarities of epidemiology, symptoms and treatment options for this disorder. We describe patent with two independent arteriovenous malformations in frontal and parietal lobes that have been treated with combination of preoperative embolization, surgical excision and stereotactic radiosurgery. Systematic review of literature was also performed, focusing on epidemiology of sporadic multiple arteriovenous malformations, niduses location, clinical presentation, treatment and outcomes. EVIDENCE ACQUISITION We systematically analyzed relevant literature using the PubMed database, encompassing studies in English (published between 1956 and 2023) reporting incidence, epidemiological features, symptomatology and treatment of sporadic multiple brain arteriovenous malformations. EVIDENCE SYNTHESIS Forty-eight studies with a total of 80 sporadic multiple cerebral arteriovenous malformations were extracted from the literature. Twenty-two papers reported incidence of multiple brain arteriovenous malformations. The average incidence (including our data) was 2.4%, varying significantly between children and adults. Hemorrhage from one AVM was the most frequent debut of multiple cerebral arteriovenous malformations. Surgical removal of niduses remains a valuable treatment option even considering the enhancement of embolization techniques and the development of radiosurgery. CONCLUSIONS Sporadic multiple cerebral arteriovenous malformations represent a difficult problem to solve. The possibility of persistence of multiple brain arteriovenous malformations should be taken into account when diagnosing and following-up.
Collapse
Affiliation(s)
- Artem Stanishevskiy
- Department of Neurosurgery, Military Medical Academy, Saint-Petersburg, Russia -
| | - Konstantin Babichev
- Department of Neurosurgery, Military Medical Academy, Saint-Petersburg, Russia
| | - Dmitriy Svistov
- Department of Neurosurgery, Military Medical Academy, Saint-Petersburg, Russia
| | - Alexander Savello
- Department of Neurosurgery, Military Medical Academy, Saint-Petersburg, Russia
| |
Collapse
|
|
4
|
Alfter M, Albiña-Palmarola P, Cimpoca A, Díaz-Peregrino R, Jans P, Ganslandt O, Kühne D, Henkes H. Multi-Stage Treatment for Spetzler-Martin Grades III, IV, and V Arteriovenous Malformations: Preoperative Embolization and Microsurgical Resection in a Consecutive Series of 250 Patients. J Clin Med 2023; 12:5990. [PMID: 37762930 PMCID: PMC10531818 DOI: 10.3390/jcm12185990] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
PURPOSE The treatment of high-grade brain AVMs is challenging and has no guidelines available to date. This study was aimed at reporting the experience of two centers in treating these AVMs through a multi-stage approach consisting of preoperative embolization and microsurgical resection. METHODS A retrospective review was performed for 250 consecutive patients with a diagnosis of high-grade brain AVM (Spetzler-Martin grades III, IV, and V) treated in two centers in Germany between January 1989 and February 2023. The analyzed data included demographic, clinical, morphological, and neurological data. RESULTS A total of 150 cases (60%) were classified as Spetzler-Martin grade III, 82 cases (32.8%) were classified as grade IV, and 18 cases (7.2%) were classified as grade V. Eighty-seven cases (34.8%) presented with hemorrhage. The devascularization percentages achieved were <50% in 24 (9.6%), 50-80% in 55 (22%), and >80% in 171 (68.4%) cases. The average number of sessions was 5.65 ± 5.50 and 1.11 ± 0.32 endovascular and surgical procedures, respectively, and did not significantly differ by rupture status. Death or dependency (mRS score ≥ 3) after the last follow-up was observed in 18.8% of patients and was significantly associated with age > 80 years and poor baseline neurological condition. The complete resection rate was 82.3% and was significantly associated with age > 80 years, large nidus, and deep venous drainage. Permanent disabling neurological deficit after at least 3 months of follow-up was diagnosed in 13.2% of patients and was significantly associated with age > 80 years and infratentorial locations. CONCLUSION A multi-stage treatment for high-grade AVMs is feasible for selected cases but comes at a functional cost. The devascularization percentage was not associated with the investigated outcomes. Age > 80 years was associated with poor safety and effectiveness outcomes; consequently, this treatment should be offered only in exceptional circumstances.
Collapse
Affiliation(s)
- Marcel Alfter
- Neuroradiological Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany; (P.A.-P.); (H.H.)
- Medical Faculty, University Duisburg-Essen, 47057 Duisburg, Germany
| | - Pablo Albiña-Palmarola
- Neuroradiological Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany; (P.A.-P.); (H.H.)
- Medical Faculty, University Duisburg-Essen, 47057 Duisburg, Germany
- Department of Anatomy, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Alexandru Cimpoca
- Neuroradiological Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany; (P.A.-P.); (H.H.)
| | - Roberto Díaz-Peregrino
- Department of Neurosurgery, University Hospital Heidelberg, Ruprecht-Karls-University Heidelberg, 69117 Heidelberg, Germany
| | - Paul Jans
- Clinic for Neurosurgery, Alfried Krupp Krankenhaus, 45131 Essen, Germany
| | - Oliver Ganslandt
- Neurosurgical Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Dietmar Kühne
- Clinic for Radiology and Neuroradiology, Alfried Krupp Krankenhaus, 45131 Essen, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Klinikum Stuttgart, 70174 Stuttgart, Germany; (P.A.-P.); (H.H.)
- Medical Faculty, University Duisburg-Essen, 47057 Duisburg, Germany
| |
Collapse
|
|
5
|
Dória-Neto HL, Agyemang K, Rodríguez RG, Ahumada-Vizcaíno JC, Riechelmann GS, Rose A, Chaddad-Neto F. The Microsurgical Management of a Cerebellar Vermian Arteriovenous Malformations Associated With High-Flow Fistulae: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e175-e176. [PMID: 37345927 DOI: 10.1227/ons.0000000000000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/17/2023] [Indexed: 06/23/2023] Open
Affiliation(s)
- Hugo Leonardo Dória-Neto
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil
| | - Kevin Agyemang
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Rony Gomez Rodríguez
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | | | - Anna Rose
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Feres Chaddad-Neto
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
- Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil
| |
Collapse
|
|
6
|
Agyemang K, Paganelli SL, de Oliveira Silva J, Korotkov D, Bryce A, Ahumada Vizcaino JC, Mikue JME, Riechelmann GS, Rodríguez RG, Hernandez MM, de Campos Filho JM, Dória-Netto HL, Wuo-Silva R, Chaddad-Neto F. Resection of a Midbrain AVM-A Combined Microsurgical and Endovascular Strategy: 3-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e368-e369. [PMID: 36716000 DOI: 10.1227/ons.0000000000000587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/18/2022] [Indexed: 01/31/2023] Open
Affiliation(s)
- Kevin Agyemang
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil.,School of Medicine, University of Glasgow, Glasgow, United Kingdom
| | | | | | - Dimitriy Korotkov
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil.,Department of Neurosurgery, National Children Medical Center, Tashkent Uzbekistan
| | - Adam Bryce
- School of Medicine, University of Glasgow, Glasgow, United Kingdom
| | | | - José Mayo Elo Mikue
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Rony Gómes Rodríguez
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Manuel Moreno Hernandez
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - José Maria de Campos Filho
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil.,Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Hugo Leonardo Dória-Netto
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil.,Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Raphael Wuo-Silva
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Feres Chaddad-Neto
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil.,Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| |
Collapse
|
|
7
|
Merchant K, Corso O, Schammel CMG, Ward ME, Fulcher J. Brainstem Malformation Causes Sudden Death. Am J Forensic Med Pathol 2022; 43:e23-e25. [PMID: 35900219 DOI: 10.1097/paf.0000000000000781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Krupa Merchant
- From the University of South Carolina School of Medicine-Greenville
| | | | | | | | | |
Collapse
|
|
8
|
Surgical Management of Cranial and Spinal Arteriovenous Malformations. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00074-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
|
9
|
Piao J, Luan T, Wang Y, Yu J. Imaging characteristics and endovascular treatment strategy for cerebellar arteriovenous malformations. MEDICINE INTERNATIONAL 2021; 1:5. [PMID: 36698869 PMCID: PMC9855278 DOI: 10.3892/mi.2021.6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/22/2021] [Indexed: 01/28/2023]
Abstract
Cerebellar arteriovenous malformations (CAVMs) have increased probabilities of rupture and bleeding compared with arteriovenous malformations (AVMs) in other locations of the brain. Endovascular treatment (EVT) for CAVMs is difficult; as the angioarchitecture of CAVMs is complex, EVT may be associated with complications, due to the involvement of crucial structures, such as the brainstem. The present study aimed to determine the efficacy of EVT for CAVMS. For this purpose, 33 cases of CAVMs treated with EVT from January, 2015 to January, 2020 were retrospectively analyzed. The 33 patients were aged 8 to 73 years (mean age, 40.4±17.8 years) and 21 were female (63%, 21/33). Rupture and bleeding occurred in 29 patients (87.9%, 29/33). Among the 33 CAVM cases, 15 (45.5%, 15/33) were fed by a single artery, and 18 (54.5%, 18/33) were fed by multiple arteries. In total, 27 patients (81.8%, 27/33) had superficial vein drainage alone. Among the 33 cases, 15 were complicated by 16 aneurysms, including 14 prenidal aneurysms and 2 intranidal aneurysms. Among the 33 cases, the nidus of the CAVM (87.9%, 29/33) was treated with Onyx™ casting in 29 patients: 8 cases (27.6%, 8/29) had an embolization volume of <1/3 of the nidus, 11 cases had a volume of 1/3-2/3 of the nidus (37.9%, 11/29) and 10 cases had a volume >2/3 of the nidus (34.5%, 10/29). Among the EVT complications, there were 3 cases (9.1%, 3/33) of intraoperative and post-operative bleeding, which resulted in two deaths (on the 1st and 7th days). The length of hospital stay was 10.7±5.4 days. In total, 27 patients (81.7%, 27/33) had a Glasgow Outcome Scale (GOS) score of 5 at discharge. On the whole, the present study demonstrates that overall, EVT is a feasible treatment for CAVM and may be used to obtain acceptable therapeutic effects.
Collapse
Affiliation(s)
- Jianmin Piao
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Tengfei Luan
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Yiheng Wang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| |
Collapse
|
|
10
|
Ai X, Xu J. The predictors of clinical outcomes in brainstem arteriovenous malformations after stereotactic radiosurgery. Medicine (Baltimore) 2021; 100:e26203. [PMID: 34087891 PMCID: PMC8183693 DOI: 10.1097/md.0000000000026203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 05/11/2021] [Indexed: 02/05/2023] Open
Abstract
The brainstem arteriovenous malformations (BS-AVMs) have a high morbidity and mortality and stereotactic radiosurgery (SRS) has been widely used to treat BS-AVMs. However, no consensus is reached in the explicit predictors of obliteration for BS-AVMs after SRS.To identify the predictors of clinical outcomes for BS-AVMs treated by SRS, we performed a retrospective observational study of BS-AVMs patients treated by SRS at our institution from 2006 to 2016. The primary outcomes were obliteration of nidus and favorable outcomes (AVM nidus obliteration with mRS score ≤2). For getting the outcomes more accurate, we also pooled the results of previous studies as well as our study by meta-analysis.A total of 26 patients diagnosed with BS-AVMs, with mean volume of 2.6 ml, were treated with SRS. Hemorrhage presentation accounted for 69% of these patients. Overall obliteration rate was 42% with mean follow-up of more than five years and two patients (8%) had a post-SRS hemorrhage. Favorable outcomes were observed in 8 patients (31%). Higher margin dose (>15Gy) was associated with higher obliteration (P = .042) and small volume of nidus was associated with favorable outcomes (P = .036). After pooling the results of 7 studies and present study, non-prior embolization (P = .049) and higher margin dose (P = .04) were associated with higher obliteration rate, in addition, the lower Virginia Radiosurgery AVM Scale (VRAS) was associated with favorable outcomes (P = .02) of BS-AVMs after SRS.In the BS-AVMs patients treated by SRS, higher margin dose (19-24Gy) and non-prior embolization were the independent predictors of higher obliteration rate. In addition, smaller volume of nidus and lower VRAS were the potential predictors of long-term favorable outcomes for these patients.
Collapse
Affiliation(s)
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
|
11
|
Tominaga S, Kugai M, Matsuda K, Yamazato K, Inui T, Kitano M, Hasegawa H. Usefulness of the middle cerebellar peduncle approach for microsurgical resection of lateral pontine arteriovenous malformation. NEUROSURGICAL FOCUS: VIDEO 2021; 4:V11. [PMID: 36284622 PMCID: PMC9542488 DOI: 10.3171/2020.10.focvid2063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 10/15/2020] [Indexed: 12/02/2022]
Abstract
Surgical treatment of brainstem arteriovenous malformation (AVM) is challenging and associated with a higher risk of complications and a lower rate of gross-total resection. The authors present their experience with the surgical management of lateral pontine AVM using the middle cerebellar peduncle approach. All cases presented with neurological deficits that were caused by hemorrhage before surgery. In all cases, the AVM was not visualized on postoperative angiography, and there was no deterioration of neurological symptoms. In this video, the authors report the treatment results of one case and describe the technique with a review of the literature. The video can be found here: https://youtu.be/bFvEMtMnrKw
Collapse
|
|
12
|
Lefevre E, Robert T, Escalard S, Fahed R, Smajda S, Ciccio G, Desilles JP, Mazighi M, Blanc R, Piotin M. Presence of direct vertebrobasilar perforator feeders in posterior fossa arteriovenous malformations and association with poor outcomes after endovascular treatment. J Neurosurg 2020; 133:1802-1810. [PMID: 31703199 DOI: 10.3171/2019.8.jns191971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 08/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Treatment of posterior fossa arteriovenous malformations (PFAVMs) remains controversial as it is always challenging and may lead to major complications. Nonetheless, these lesions are more likely to bleed and generate poorer outcomes than other brain AVMs. The aim of this study was to evaluate the effect of endovascular treatment on long-term outcomes and identify the patient subgroups that might benefit from endovascular treatment. METHODS The authors performed a retrospective analysis of all consecutive cases of PFAVM managed at the Fondation Rothschild Hospital between 1995 and 2018. Clinical, imaging, and treatment data were prospectively gathered; these data were analyzed with respect to long-term outcomes. RESULTS Among the 1311 patients with brain AVMs, 114 (8.7%) had a PFAVM, and 88 (77.2%) of these patients had a history of bleeding. Of the 114 PFAVMs, 101 (88.6%) were treated (83 ruptured and 18 unruptured). The mean duration of follow-up was 47.6 months (range 0-240 months). Good neurological outcome at last follow-up was achieved in 79 cases (78.2%). Follow-up angiography showed obliteration of the PFAVM in 68.3% of treated cases. The presence of direct vertebrobasilar perforator feeders was associated with neurological deterioration (OR 5.63, 95% CI 11.15-30.76) and a lower obliteration rate (OR 15.69, 95% CI 2.52-304.03) after endovascular treatment. Other predictors of neurological deterioration and obliteration rate were consistent with the Spetzler-Martin grading system. CONCLUSIONS Advances in endovascular techniques have enabled higher obliteration rates in the treatment of PFAVMs, but complication rates are still high. Subgroups of patients who might benefit from treatment must be carefully selected and the presence of direct vertebrobasilar perforator feeders must call into question the indication for endovascular treatment.
Collapse
Affiliation(s)
- Etienne Lefevre
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Thomas Robert
- 2Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Ticino, Switzerland
| | - Simon Escalard
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Robert Fahed
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Stanislas Smajda
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Gabriele Ciccio
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Jean-Philippe Desilles
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Mikael Mazighi
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Raphaël Blanc
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Michel Piotin
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| |
Collapse
|
|
13
|
Tjahjadi M, Wijaya V, Serrone J, Caropeboka MS. Trigeminal Neuralgia Secondary to Cerebellar Arteriovenous Malformation: A Report of Two Cases. Asian J Neurosurg 2020; 15:745-749. [PMID: 33145245 PMCID: PMC7591222 DOI: 10.4103/ajns.ajns_229_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/14/2020] [Accepted: 07/04/2020] [Indexed: 11/28/2022] Open
Abstract
Trigeminal neuralgia (TN) secondary to cerebellar arteriovenous malformation (cAVM) is a rare condition with only few reports existing in the literatures. Given to its rarity, the treatment armamentarium is still controversial. We reported our experiences treated two cases of TN secondary to cAVM using different strategies. The first case was successfully treated by a combination of gamma knife radiosurgery and microvascular decompression (MVD) of the trigeminal nerve. The second case was successfully treated by one-step microsurgical AVM resection and MVD of the trigeminal nerve. Postoperative immediate pain relief was achieved in both patients. Microsurgical procedure is still playing an important role in treating TN secondary to cAVM.
Collapse
Affiliation(s)
- Mardjono Tjahjadi
- Department of Surgery, Universitas Pembangunan Nasional Veteran Jakarta/Pasar Minggu Regional Hospital, Jakarta, Indonesia.,Department of Surgery, Universitas Katolik Indonesia Atmajaya, Jakarta, Indonesia
| | - Vincent Wijaya
- Department of Surgery, Universitas Katolik Indonesia Atmajaya, Jakarta, Indonesia
| | - Joseph Serrone
- Department of Neurosurgery, Loyola University Medical Center, Chicago, Illinois, USA
| | | |
Collapse
|
|
14
|
Chen Y, Li R, Ma L, Meng X, Yan D, Wang H, Ye X, Jin H, Li Y, Gao D, Sun S, Liu A, Wang S, Chen X, Zhao Y. Long-term outcomes of brainstem arteriovenous malformations after different management modalities: a single-centre experience. Stroke Vasc Neurol 2020; 6:65-73. [PMID: 32928999 PMCID: PMC8005895 DOI: 10.1136/svn-2020-000407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 07/13/2020] [Accepted: 07/29/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The aims of this study are to clarify the long-term outcomes of brainstem arteriovenous malformations (AVMs) after different management modalities. METHODS The authors retrospectively reviewed 61 brainstem AVMs in their institution between 2011 and 2017. The rupture risk was represented by annualised haemorrhagic rate. Patients were divided into five groups: conservation, microsurgery, embolisation, stereotactic radiosurgery (SRS) and embolisation+SRS. Neurofunctional outcomes were evaluated by the modified Rankin Scale (mRS). Subgroup analysis was conducted between different management modalities to compare the long-term outcomes in rupture or unruptured cohorts. RESULTS All of 61 brainstem AVMs (12 unruptured and 49 ruptured) were followed up for an average of 4.5 years. The natural annualised rupture risk was 7.3%, and the natural annualised reruptured risk in the ruptured cohort was 8.9%. 13 cases were conservative managed and 48 cases underwent intervention (including 6 microsurgery, 12 embolisation, 21 SRS and 9 embolisation+SRS). In the selection of interventional indication, diffuse nidus were often suggested conservative management (p=0.004) and nidus involving the midbrain were more likely to be recommended for intervention (p=0.034). The risk of subsequent haemorrhage was significantly increased in partial occlusion compared with complete occlusion and conservative management (p<0.001, p=0.036, respectively). In the subgroup analysis, the follow-up mRS scores of different management modalities were similar whether in the rupture cohort (p=0.064) or the unruptured cohort (p=0.391), as well as the haemorrhage-free survival (p=0.145). In the adjusted Bonferroni correction analysis of the ruptured cohort, microsurgery and SRS could significantly improve the obliteration rate compared with conservation (p<0.001, p=0.001, respectively) and SRS may have positive effect on avoiding new-onset neurofunctional deficit compared with microsurgery and embolisation (p=0.003, p=0.003, respectively). CONCLUSIONS Intervention has similar neurofunctional outcomes as conservation in these brainstem AVM cohorts. If intervention is adopted, partial obliteration should be avoided because of the high subsequent rupture risk. TRIAL REGISTRATION NUMBER NCT04136860.
Collapse
Affiliation(s)
- Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiangyu Meng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Debin Yan
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Dezhi Gao
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Beijing, China
| | - Shibin Sun
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Beijing, China
| | - Ali Liu
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China .,Department of Neurosurgery, Peking University International Hospital, Beijing, China
| |
Collapse
|
|
15
|
Lehrer EJ, Snyder MH, Desai BD, Li CE, Narayan A, Trifiletti DM, Schlesinger D, Sheehan JP. Clinical and radiographic adverse events after Gamma Knife radiosurgery for brainstem lesions: A dosimetric analysis. Radiother Oncol 2020; 147:200-209. [PMID: 32413528 DOI: 10.1016/j.radonc.2020.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/30/2020] [Accepted: 05/08/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To analyze the association between dosvolume relationships and adverse events in brainstem lesions treated with Gamma Knife radiosurgery (GKRS). METHODS Treatment plans were generated on BrainLab Elements and GammaPlan software. Dosimetric data were analyzed as continuous variables for patients who received GKRS to brain metastases or arteriovenous malformations (AVM) within or abutting the brainstem. Adverse events were classified as clinical and/or radiographic. Logistic and cox regression were used to assess the relationship between dosimetric variables and adverse events. RESULTS Sixty-one patients who underwent single fraction GKRS for brain metastases or AVM were retrospectively analyzed. Median age was 62 years (range: 12-92 years) and the median prescription dose was 18 Gy (range: 13-25 Gy). Median follow-up was 6months. Clinical and radiographic complications were seen in ten (16.4%) and 17 (27.9%) patients, respectively. On logistic regression, increasing D05% was found to be associated with an increased probability of developing a clinical complication post-GKRS (OR: 1.18; 95% CI: 1.01-1.39; p = 0.04). Furthermore, mean brainstem dose (HR: 1.43; 95% CI: 1.05-1.94; p < 0.02), D05% (HR: 1.09; 95% CI: 1.01-1.18; p = 0.03), and D95% (HR: 2.37; 95% CI: 0.99-5.67; p = 0.05) were associated with an increased hazard of experiencing post-GKRS complications over time. CONCLUSIONS Increasing D05% to the brainstem is associated with an increased risk of developing clinical complications. Clinicians may consider this parameter in addition to fractionated stereotactic radiation therapy when well-established dose constraints are not met in this patient population. Additional data are needed to further validate these findings.
Collapse
Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - M Harrison Snyder
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Bhargav D Desai
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Chelsea E Li
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Aditya Narayan
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | | | - David Schlesinger
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| |
Collapse
|
|
16
|
Nisson PL, Fard SA, Walter CM, Johnstone CM, Mooney MA, Meybodi AT, Lang M, Kim H, Jahnke H, Roe DJ, Dumont TM, Lemole GM, Spetzler RF, Lawton MT. A novel proposed grading system for cerebellar arteriovenous malformations. J Neurosurg 2020; 132:1105-1115. [PMID: 30849761 PMCID: PMC6856412 DOI: 10.3171/2018.12.jns181677] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 12/03/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the existing Spetzler-Martin (SM), Spetzler-Ponce (SP), and Lawton-Young (LY) grading systems for cerebellar arteriovenous malformations (AVMs) and to propose a new grading system to estimate the risks associated with these lesions. METHODS Data for patients with cerebellar AVMs treated microsurgically in two tertiary medical centers were retrospectively reviewed. Data from patients at institution 1 were collected from September 1999 to February 2013, and at institution 2 from October 2008 to October 2015. Patient outcomes were classified as favorable (modified Rankin Scale [mRS] score 0-2) or poor (mRS score 3-6) at the time of discharge. Using chi-square and logistic regression analysis, variables associated with poor outcomes were assigned risk points to design the proposed grading system. The proposed system included neurological status prior to treatment (poor, +2 points), emergency surgery (+1 point), age > 60 years (+1 point), and deep venous drainage (deep, +1 point). Risk point totals of 0-1 comprised grade 1, 2-3 grade 2, and 4-5 grade 3. RESULTS A total of 125 cerebellar AVMs of 1328 brain AVMs were reviewed in 125 patients, 120 of which were treated microsurgically and included in the study. With our proposed grading system, we found poor outcomes differed significantly between each grade (p < 0.001), while with the SM, SP, and LY grading systems they did not (p = 0.22, p = 0.25, and p = 1, respectively). Logistic regression revealed grade 2 had 3.3 times the risk of experiencing a poor outcome (p = 0.008), while grade 3 had 9.9 times the risk (p < 0.001). The proposed grading system demonstrated a superior level of predictive accuracy (area under the receiver operating characteristic curve [AUROC] of 0.72) compared with the SM, SP, and LY grading systems (AUROC of 0.61, 0.57, and 0.51, respectively). CONCLUSIONS The authors propose a novel grading system for cerebellar AVMs based on emergency surgery, venous drainage, preoperative neurological status, and age that provides a superior prognostication power than the formerly proposed SM, SP, and LY grading systems. This grading system is clinically predictive of patient outcomes and can be used to better guide vascular neurosurgeons in clinical decision-making.
Collapse
Affiliation(s)
- Peyton L. Nisson
- College of Medicine, University of Arizona, Tucson, Arizona
- Department of Neurosurgery, University of California, San Francisco, California
| | - Salman A. Fard
- College of Medicine, University of Arizona, Tucson, Arizona
| | | | | | - Michael A. Mooney
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael Lang
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Helen Kim
- Department of Neurosurgery, University of California, San Francisco, California
| | - Heidi Jahnke
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Denise J. Roe
- Epidemiology and Biostatistics, College of Public Health, University of Arizona, Tucson, Arizona
| | - Travis M. Dumont
- Division of Neurosurgery, Banner-University Medical Center, Tucson, Arizona
| | - G. Michael Lemole
- Division of Neurosurgery, Banner-University Medical Center, Tucson, Arizona
| | - Robert F. Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael T. Lawton
- Department of Neurosurgery, University of California, San Francisco, California
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| |
Collapse
|
|
17
|
Dinc N, Platz J, Tritt S, Quick-Weller J, Eibach M, Wolff R, Berkefeld J, Seifert V, Marquardt G. Posterior fossa AVMs: Increased risk of bleeding and worse outcome compared to supratentorial AVMs. J Clin Neurosci 2018; 53:171-176. [DOI: 10.1016/j.jocn.2018.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 02/07/2018] [Accepted: 04/08/2018] [Indexed: 10/14/2022]
|
|
18
|
Sarikaya H, Steinlin M. Cerebellar stroke in adults and children. HANDBOOK OF CLINICAL NEUROLOGY 2018; 155:301-312. [DOI: 10.1016/b978-0-444-64189-2.00020-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
|
19
|
Madhugiri VS, Teo MKC, Vavao J, Bell-Stephens T, Steinberg GK. Brainstem arteriovenous malformations: lesion characteristics and treatment outcomes. J Neurosurg 2018; 128:126-136. [DOI: 10.3171/2016.9.jns16943] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVEBrainstem arteriovenous malformations (AVMs) are rare lesions that are difficult to diagnose and treat. They are often more aggressive in their behavior when compared with their supratentorial counterparts. The consequence of a brainstem hemorrhage is often devastating, and many patients are in poor neurological status at presentation. The authors examine the factors associated with angiographically confirmed cure and those affecting management outcomes for these complex lesions.METHODSThis was a retrospective analysis of data gathered from the prospectively maintained Stanford AVM database. Lesions were grouped based on their location in the brainstem (medulla, pons, or midbrain) and the quadrant they occupied. Angiographic cure was dichotomized as completely obliterated or not, and functional outcome was dichotomized as either independent or not independent at last follow-up.RESULTSOver a 23-year period, 39 lesions were treated. Of these, 3 were located in the medulla, 14 in the pons, and 22 in the midbrain. At presentation, 92% of the patients had hemorrhage, and only 43.6% were functionally independent. Surgery resulted in the best radiographic cure rates, with a morbidity rate of 12.5%. In all, 53% of patients either improved or remained stable after surgery. Absence of residual nidus and female sex correlated with better outcomes.CONCLUSIONSBrainstem AVMs usually present with hemorrhage. Surgery offers the best chance of cure, either in isolation or in combination with other modalities as appropriate.
Collapse
|
|
20
|
Hasegawa H, Hanakita S, Shin M, Sugiyama T, Kawashima M, Takahashi W, Nomoto AK, Shojima M, Nakatomi H, Saito N. Does Advanced Age Affect the Outcomes of Stereotactic Radiosurgery for Cerebral Arteriovenous Malformation? World Neurosurg 2017; 109:e715-e723. [PMID: 29066317 DOI: 10.1016/j.wneu.2017.10.071] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is generally considered a minimally invasive treatment modality. However, definitive evidence of the efficacy of SRS in the elderly population is still not available. METHODS The outcomes of 561 elderly and nonelderly patients who underwent SRS for AVM at our institution between 1990 and 2013 were reviewed, analyzed, and compared. Elderly patients were defined as those age ≥60 years at the time of SRS. RESULTS The elderly cohort comprised 55 patients; the nonelderly cohort, 506. In the elderly cohort, the median age was 65 years, and the duration of follow-up was 91 months. The actuarial obliteration rates were 47% at 3 years, 70% at 4 years, and 76% at 5 years in the elderly cohort, and 57% at 3 years, 76% at 4 years, and 83% at 5 years in the nonelderly cohort. In the elderly cohort, the hemorrhage rates during the post-SRS latent phase were 5.2%/year in patients with hemorrhagic onset and 0%/year in those with nonhemorrhagic onset, and event-free survival (EFS) was 93% at 6 years and 89% at 12 years. The obliteration rate, mortality, and EFS rate were not significantly different between the 2 cohorts, whereas the rate of perifocal edema was significantly lower (P = 0.021) in the elderly cohort. The pre-SRS and post-SRS hemorrhage rates were slightly higher in the elderly cohort, albeit without statistical significance. CONCLUSIONS Therapeutic effects and outcomes of SRS are similar in elderly and nonelderly patients. Treatment-related neurologic deficits are rare, and longer EFS can be expected.
Collapse
Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan.
| | - Shunya Hanakita
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Masahiro Shin
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan; Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Wataru Takahashi
- Department of Radiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Akihiro K Nomoto
- Department of Radiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Masaaki Shojima
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Tokyo Medical University Hospital, Tokyo, Japan
| |
Collapse
|
|
21
|
Jin H, Liu Z, Chang Q, Chen C, Ge H, Lv X, Li Y. A challenging entity of endovascular embolization with ONYX for brainstem arteriovenous malformation: Experience from 13 cases. Interv Neuroradiol 2017; 23:497-503. [PMID: 28614989 PMCID: PMC5624407 DOI: 10.1177/1591019917711679] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 04/29/2017] [Indexed: 02/05/2023] Open
Abstract
Objective Brainstem arteriovenous malformations (AVMs) are rare lesions with a high risk of intracranial hemorrhage and are challenging to treat. We present our experience of endovascular embolization with Onyx in these aggressive lesions. Materials and methods Between 2007 and 2016, 13 patients with brainstem AVMs were embolized with Onyx at our center. Twelve patients presented with intracranial hemorrhage and one with headache. Retrospective examinations of patient demographics, clinical presentation, angiographic features, treatment modalities, postoperative complications and outcomes were carried out. Results The AVMs were in the midbrain in 10 patients (one anterior and nine posterior or dorsal), in the posterior pons in two and pontomedullary in one. Complete occlusion was achieved in three patients. Gamma knife radiosurgery was performed in six patients who were near-completely or partially embolized. Postoperative complications, including five cases of ischemia and one case of hemorrhage, resulted in four cases of neurological deterioration and two deaths. Clinical follow-up was obtained in 10 patients at a mean period of 45.2 months (range 3 to 93 months). During the follow-up, good clinical outcomes were observed in seven patients with posterior or dorsal midbrain AVMs, and one patient with a posterior pons AVM that was partially occluded died of intracranial hemorrhage. Conclusion Endovascular embolization for brainstem AVM with Onyx is a technical challenge and the reflux of Onyx may cause severe complications. Individualized treatment is needed based on the specific subtype of brainstem AVM.
Collapse
Affiliation(s)
- Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, China
- Beijing Engineering Research Center for Interventional Neuroradiology, China
| | - Zhan Liu
- Department of Neurosurgery, Traditional Chinese Medicine Hospital of Laiwu City, China
| | - Qing Chang
- Department of Neurosurgery, Weifang Yidu Hospital, Qingzhou, China
| | - Chang Chen
- Department of Neurosurgery, Xintai Hospital of Traditional Chinese Medicine, China
| | - Huijian Ge
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, China
- Beijing Engineering Research Center for Interventional Neuroradiology, China
| | - Xianli Lv
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, China
- Beijing Engineering Research Center for Interventional Neuroradiology, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, China
- Beijing Engineering Research Center for Interventional Neuroradiology, China
| |
Collapse
|
|
22
|
Cohen-Inbar O, Starke RM, Lee CC, Kano H, Huang P, Kondziolka D, Grills IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic Radiosurgery for Brainstem Arteriovenous Malformations: A Multicenter Study. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx189] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
The management of brainstem arteriovenous malformations (bAVMs) is a formidable challenge. bAVMs harbor higher morbidity and mortality compared to other locations.
OBJECTIVE
To review the outcomes following stereotactic radiosurgery (SRS) of bAVMs in a multicenter study.
METHODS
Six medical centers contributed data from 205 patients through the International Gamma Knife Research Foundation. Median age was 32 yr (6-81). Median nidus volume was 1.4 mL (0.1-69 mL). Favorable outcome (FO) was defined as AVM obliteration and no post-treatment hemorrhage or permanent symptomatic radiation-induced complications.
RESULTS
Overall obliteration was reported in 65.4% (n = 134) at a mean follow-up of 69 mo. Obliteration was angiographically proven in 53.2% (n = 109) and on MRA in 12.2% (n = 25). Actuarial rate of obliteration at 2, 3, 5, 7, and 10 yr after SRS was 24.5%, 43.3%, 62.3%, 73%, and 81.8% respectively. Patients treated with a margin dose >20 Gy were more likely to achieve obliteration (P = .001). Obliteration occurred earlier in patients who received a higher prescribed margin dose (P = .05) and maximum dose (P = .041). Post-SRS hemorrhage occurred in 8.8% (n = 18). Annual postgamma knife latency period hemorrhage was 1.5%. Radiation-induced complications were radiologically evident in 35.6% (n = 73), symptomatic in 14.6% (n = 30), and permanent in 14.6% (n = 30, which included long-tract signs and new cranial nerve deficits). FO was achieved in 64.4% (n = 132). Predictors of an FO were a higher Virginia radiosurgery AVM scale score (P = .003), prior hemorrhage (P = .045), and a lower prescribed maximum dose (P = .006).
CONCLUSION
SRS for bAVMs results in obliteration and avoids permanent complications in the majority of patients.
Collapse
Affiliation(s)
- Or Cohen-Inbar
- Department of Neurosurgery and Gam-ma-Knife center, University of Virginia, Charlottesville, Virginia
- Department of Neurosurgery, Rambam Health Care Center Haifa Israel, Technion Israel Institute of Technology, Haifa, Israel
| | - Robert M Starke
- Department of Neurosurgery and Gam-ma-Knife center, University of Virginia, Charlottesville, Virginia
| | - Cheng-Chia Lee
- Department of Neurological Surgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Hideyuki Kano
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Paul Huang
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Danilo Silva
- Rose-Ella Burkhardt Brain Tumor and Neuro-oncology center, Cleveland Clinic, Cleveland, Ohio
| | - Mohmoud Abbassy
- Rose-Ella Burkhardt Brain Tumor and Neuro-oncology center, Cleveland Clinic, Cleveland, Ohio
| | - Symeon Missios
- Rose-Ella Burkhardt Brain Tumor and Neuro-oncology center, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Rose-Ella Burkhardt Brain Tumor and Neuro-oncology center, Cleveland Clinic, Cleveland, Ohio
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- Department of Neurosurgery and Gam-ma-Knife center, University of Virginia, Charlottesville, Virginia
| |
Collapse
|
|
23
|
Hung AL, Yang W, Braileanu M, Garzon-Muvdi T, Caplan JM, Colby GP, Coon AL, Tamargo RJ, Huang J. Risk Assessment of Hemorrhage of Posterior Inferior Cerebellar Artery Aneurysms in Posterior Fossa Arteriovenous Malformations. Oper Neurosurg (Hagerstown) 2017; 14:359-366. [DOI: 10.1093/ons/opx120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/18/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Posterior fossa arteriovenous malformations (AVMs) are associated with increased risk of rupture and severe consequences from such rupture. The hemorrhagic risk of prenidal aneurysms (anr) on the posterior inferior cerebellar artery (PICA) may exceed that of the AVM in posterior fossa AVMs fed by PICA (PICA-AVM).
OBJECTIVE
To characterize the relative risks of aneurysm and AVM hemorrhage in patients with posterior fossa AVMs.
METHODS
We retrospectively reviewed patients diagnosed with AVM. Patients with posterior fossa AVMs were divided into 3 groups: PICA-AVM with prenidal aneurysm (PICA-AVM-anr group), PICA-AVM without prenidal aneurysm (PICA-AVM group), and AVMs without PICA feeder with/without aneurysm (AVM-only group). Patient and lesion characteristics and treatment outcomes were compared. ANOVA and chi squared tests were used for statistical analyses.
RESULTS
Our cohort included 85 patients. Mean age was 45.3 ± 18.1 yr, with 43(50.6%) female patients. Fifty-one patients (60.0%) had hemorrhagic presentation, and 27 (31.8%) experienced acute hydrocephalus. Patients in the PICA-AVM-anr group (n = 11) were more likely to present with aneurysmal subarachnoid hemorrhage (SAH; P = .005) and less likely to have AVM rupture (P < .001). Ten (90.9%) patients presented with hemorrhage, 6 (60.0%) of which resulted from aneurysm rupture. Of these 6, 5 (83.3%) had acute hydrocephalus. No patients with AVM rupture had hydrocephalus. Eight (72.7%) received aneurysm treatment prior to AVM treatment. There were no significant differences in post-treatment outcomes dependent on treatment order.
CONCLUSION
In addition to relatively higher risk of AVM rupture from infratentorial location and prenidal aneurysm, a higher risk of aneurysm rupture rather than AVM rupture was observed in patients with PICA-AVM-anr complex.
Collapse
Affiliation(s)
- Alice L Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Maria Braileanu
- Department of Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Tomas Garzon-Muvdi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Geoffrey P Colby
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
|
24
|
Long-Term Outcomes of Single-Session Stereotactic Radiosurgery for Cerebellar Arteriovenous Malformation, with a Median Follow-Up of 10 Years. World Neurosurg 2017; 98:314-322. [DOI: 10.1016/j.wneu.2016.10.137] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/27/2016] [Accepted: 10/28/2016] [Indexed: 11/20/2022]
|
|
25
|
Yang W, Porras JL, Garzon-Muvdi T, Xu R, Caplan JM, Hung AL, Braileanu M, Rong X, Colby GP, Coon AL, Tamargo RJ, Huang J. Management Outcome of Brainstem Arteriovenous Malformations: The Role of Radiosurgery. World Neurosurg 2016; 94:64-72. [DOI: 10.1016/j.wneu.2016.06.082] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/17/2016] [Accepted: 06/20/2016] [Indexed: 11/29/2022]
|
|
26
|
Tong X, Wu J, Lin F, Cao Y, Zhao Y, Wang S, Zhao J. Microsurgical Outcome of Cerebellar Arteriovenous Malformations: Single-Center Experience. World Neurosurg 2016; 95:469-479. [PMID: 27567580 DOI: 10.1016/j.wneu.2016.08.059] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 08/12/2016] [Accepted: 08/13/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We aimed to describe our single-center experience in treating cerebellar arteriovenous malformations (AVMs) with microsurgical resection. METHODS During a 16-year period, 181 patients with cerebellar AVMs were surgically treated at the Department of Neurosurgery in Beijing Tiantan Hospital. Patient functional status was evaluated using modified Rankin Scale (mRS) scores both before treatment and at the last follow-up. The mRS scores at the last follow-up were dichotomized as good outcome (mRS <3) and poor outcome (mRS ≥3). The treatment modalities, post-treatment complications, obliteration rate, and follow-up outcomes were analyzed. RESULTS Of the 181 patients, 172 (95%) patients presented with initial hemorrhage and 62 (34%) patients experienced rehemorrhage before microsurgical treatment. Complete obliteration of the AVMs was achieved in 177 (97.8%) patients. Good functional outcome was achieved in 144 (80%) of the patients. The surgical mortality rate was 4.4% (8/181), and overall mortality rate was 6.6% (12/181). Poor outcome was significantly associated with increasing age (P = 0.035; odds ratio [OR], 1.030; 95% CI 1.002-1.060), presurgical mRS ≥3 (P = 0.029; OR, 2.563; 95% CI 1.101-5.968), eloquent AVM location (P = 0.015; OR, 3.058; 95% CI 1.244-7.516), and presurgical rehemorrhage (P = 0.008; OR, 3.266; 95% CI 1.358-7.858). CONCLUSION Good outcome can be achieved by microsurgical resection in most patients with cerebellar AVMs. Increasing age at surgery, poor presurgical functional status, eloquent AVM location, and presurgical rehemorrhage are independent predictors of poor outcomes after AVM resection. We recommend early surgical resection for all surgically accessible cerebellar AVMs to prevent subsequent hemorrhage and resultant poor neurologic outcomes.
Collapse
Affiliation(s)
- Xianzeng Tong
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Fuxin Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China.
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China.
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| |
Collapse
|
|
27
|
Lai LF, Chen JX, Zheng K, He XY, Li XF, Zhang X, Wang QJ, Duan CZ, Chen M. Posterior fossa brain arteriovenous malformations. Clin Neuroradiol 2016; 28:17-24. [DOI: 10.1007/s00062-016-0514-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 04/11/2016] [Indexed: 11/28/2022]
|
|
28
|
Yang W, Hung AL, Caplan JM, Braileanu M, Wang JY, Colby GP, Coon AL, Tamargo RJ, Huang J. Delayed Hemorrhage After Treatment of Brain Arteriovenous Malformations (AVMs). World Neurosurg 2016; 87:98-109. [DOI: 10.1016/j.wneu.2015.11.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/09/2015] [Accepted: 11/12/2015] [Indexed: 10/22/2022]
|
|
29
|
Robert T, Blanc R, Ciccio G, Gilboa B, Fahed R, Boissonnet H, Redjem H, Pistocchi S, Bartolini B, Piotin M. Endovascular treatment of posterior fossa arteriovenous malformations. J Clin Neurosci 2016; 25:65-8. [PMID: 26549679 DOI: 10.1016/j.jocn.2015.05.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/07/2015] [Accepted: 05/09/2015] [Indexed: 11/28/2022]
Affiliation(s)
- T Robert
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, 25 Rue Manin, 75019 Paris, France.
| | - R Blanc
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, 25 Rue Manin, 75019 Paris, France
| | - G Ciccio
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, 25 Rue Manin, 75019 Paris, France
| | - B Gilboa
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, 25 Rue Manin, 75019 Paris, France
| | - R Fahed
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, 25 Rue Manin, 75019 Paris, France
| | - H Boissonnet
- Department of Neurosurgery, Rothschild Foundation Hospital, Paris, France
| | - H Redjem
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, 25 Rue Manin, 75019 Paris, France
| | - S Pistocchi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, 25 Rue Manin, 75019 Paris, France
| | - B Bartolini
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, 25 Rue Manin, 75019 Paris, France
| | - M Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, 25 Rue Manin, 75019 Paris, France
| |
Collapse
|
|
30
|
Cohen-Inbar O, Ding D, Chen CJ, Sheehan JP. Stereotactic radiosurgery for deep intracranial arteriovenous malformations, part 1: Brainstem arteriovenous malformations. J Clin Neurosci 2016; 24:30-6. [DOI: 10.1016/j.jocn.2015.11.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 11/21/2015] [Indexed: 11/30/2022]
|
|
31
|
Stereotactic radiosurgery for deep intracranial arteriovenous malformations, part 2: Basal ganglia and thalamus arteriovenous malformations. J Clin Neurosci 2016; 24:37-42. [DOI: 10.1016/j.jocn.2015.11.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 11/21/2015] [Indexed: 11/24/2022]
|
|
32
|
Surgical Management of Cranial and Spinal Arteriovenous Malformations. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00072-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
|
33
|
Crimmins M, Gobin YP, Patsalides A, Knopman J. Therapeutic management of cerebral arteriovenous malformations: a review. Expert Rev Neurother 2015; 15:1433-44. [PMID: 26567441 DOI: 10.1586/14737175.2015.1079129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The therapeutic management of cerebral arteriovenous malformations has undergone significant change over the past 40 years. Embolization, radiosurgery, advanced imaging modalities, neuropsychological testing and advances in surgical technique has both significantly improved our ability to treat patients, as well as confounding the landscape as to what constitutes best medical practice. Variability in natural history provides additional challenges in that it is challenging to determine an accurate estimate of the risk of hemorrhage, morbidity and mortality. It is clear that the complexity of the treatment of these lesions demands a multidisciplinary approach. The need for a team of neurosurgeons, interventional and diagnostic neuroradiologists, neurologists, radiation oncologists and neuropsychologists will improve outcomes and aid in determining best therapy for patients.
Collapse
Affiliation(s)
- Michael Crimmins
- a Weill Cornell Medical Center - Neurosurgery , 525 East 68th Street Starr Pavilion, 10065 , NY , USA
| | - Y Pierre Gobin
- a Weill Cornell Medical Center - Neurosurgery , 525 East 68th Street Starr Pavilion, 10065 , NY , USA
| | - Athos Patsalides
- a Weill Cornell Medical Center - Neurosurgery , 525 East 68th Street Starr Pavilion, 10065 , NY , USA
| | - Jared Knopman
- a Weill Cornell Medical Center - Neurosurgery , 525 East 68th Street Starr Pavilion, 10065 , NY , USA
| |
Collapse
|
|
34
|
Robert T, Blanc R, Ciccio G, Redjem H, Fahed R, Smajda S, Piotin M. Anatomic and angiographic findings of cerebellar arteriovenous malformations: Report of a single center experience. J Neurol Sci 2015; 358:357-61. [PMID: 26412159 DOI: 10.1016/j.jns.2015.09.361] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 09/10/2015] [Accepted: 09/21/2015] [Indexed: 11/28/2022]
Abstract
Cerebellar arteriovenous malformations (AVM) are rare and comprise only 5-10% of cerebral AVM. The concentration of eloquent neurological systems and the high rate of bleeding presentation of AVMs particularly in this location complicate the management of such lesions. New therapeutic options, especially in endovascular neurosurgery, have fundamentally modified the strategy and, also, the outcome of cerebellar AVMs. Between 1995 and 2013, demographic, clinical and angiographic data of cerebral AVMs have been prospectively collected. We analyzed data of patients treated for a cerebellar AVM, focusing on the angiographic anatomy. Fifty-nine patients (mean age : 35 years, male to female ratio : 2) were consecutively treated for a cerebellar AVM. 81.4% of them presented bleeding at admission. 20 AVMs (33.9%) were in eloquent areas. The Spetzler-Martin grade was I or II in 36 cases (51%). An associated aneurysm was noted in more than 40% of cases and a venous drainage anomaly in 70%. The vast majority of cases of this series presented an anatomical risk factor of bleeding. Patients with cerebellar AVMs presented with bleeding more often than patients with supratentorial AVMs, justifying an aggressive management. The analysis of angio-architecture highlighted the high rate of associated aneurysm and/or venous drainage anomalies that could explain the tendency to bleed of such lesion.
Collapse
Affiliation(s)
- Th Robert
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France.
| | - R Blanc
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - G Ciccio
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - H Redjem
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - R Fahed
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - S Smajda
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - M Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| |
Collapse
|
|
35
|
Tucker A, Tsuji M, Yamada Y, Hanabusa K, Ukita T, Miyake H, Ohmura T. Arteriovenous malformation of the vestibulocochlear nerve. World J Clin Cases 2015; 3:661-670. [PMID: 26244159 PMCID: PMC4517342 DOI: 10.12998/wjcc.v3.i7.661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/14/2014] [Accepted: 04/20/2015] [Indexed: 02/05/2023] Open
Abstract
We describe a rare case of an arteriovenous malformation (AVM) embedded in the vestibulocochlear nerve presenting with subarachnoid hemorrhage (SAH) treated by microsurgical elimination of the main feeding artery and partial nidus volume reduction with no permanent deficits. This 70-year-old woman was incidentally diagnosed 4 years previously with two small unruptured tandem aneurysms (ANs) on the right anterior inferior cerebral artery feeding a small right cerebellopontine angle AVM. The patient was followed conservatively until she developed sudden headache, nausea and vomiting and presented to our outpatient clinic after several days. Magnetic resonance imaging demonstrated findings suggestive of early subacute SAH in the quadrigeminal cistern. A microsurgical flow reduction technique via clipping between the two ANs and partial electrocoagulation of the nidus buried within the eighth cranial nerve provided radiographical devascularization of the ANs with residual AVM shunt flow and no major deficits during the 2.5 year follow-up. This is only the second report of an auditory nerve AVM. In the event of recurrence, reoperation or application of alternative therapies may be considered.
Collapse
|
|
36
|
Torné R, Rodríguez-Hernández A, Arikan F, Romero-Chala F, Cicuéndez M, Vilalta J, Sahuquillo J. Posterior fossa arteriovenous malformations: Significance of higher incidence of bleeding and hydrocephalus. Clin Neurol Neurosurg 2015; 134:37-43. [PMID: 25938563 DOI: 10.1016/j.clineuro.2015.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 03/03/2015] [Accepted: 04/05/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Ramon Torné
- Department of Neurological Surgery, Vall d'Hebron University Hospital, Paseo Vall D'Hebron 119-129, 08035 Barcelona, Spain; Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain.
| | - Ana Rodríguez-Hernández
- Department of Neurological Surgery, Vall d'Hebron University Hospital, Paseo Vall D'Hebron 119-129, 08035 Barcelona, Spain
| | - Fuat Arikan
- Department of Neurological Surgery, Vall d'Hebron University Hospital, Paseo Vall D'Hebron 119-129, 08035 Barcelona, Spain; Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| | - Fabián Romero-Chala
- Department of Neurological Surgery, Vall d'Hebron University Hospital, Paseo Vall D'Hebron 119-129, 08035 Barcelona, Spain; Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| | - Marta Cicuéndez
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| | - Jordi Vilalta
- Department of Neurological Surgery, Vall d'Hebron University Hospital, Paseo Vall D'Hebron 119-129, 08035 Barcelona, Spain; Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| | - Juan Sahuquillo
- Department of Neurological Surgery, Vall d'Hebron University Hospital, Paseo Vall D'Hebron 119-129, 08035 Barcelona, Spain; Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain
| |
Collapse
|
|
37
|
Abla AA, Nelson J, Rutledge WC, Young WL, Kim H, Lawton MT. The natural history of AVM hemorrhage in the posterior fossa: comparison of hematoma volumes and neurological outcomes in patients with ruptured infra- and supratentorial AVMs. Neurosurg Focus 2015; 37:E6. [PMID: 25175444 DOI: 10.3171/2014.7.focus14211] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Patients with posterior fossa arteriovenous malformations (AVMs) are more likely to present with hemorrhage than those with supratentorial AVMs. Observed patients subject to the AVM natural history should be informed of the individualized effects of AVM characteristics on the clinical course following a new, first-time hemorrhage. The authors hypothesize that the debilitating effects of first-time bleeding from an AVM in a previously intact patient with an unruptured AVM are more pronounced when AVMs are located in the posterior fossa. METHODS The University of California, San Francisco prospective registry of brain AVMs was searched for patients with a ruptured AVM who had a pre-hemorrhage modified Rankin Scale (mRS) score of 0 and a post-hemorrhage mRS score obtained within 2 days of the hemorrhagic event. A total of 154 patients met the inclusion criteria for this study. Immediate post-hemorrhage presentation mRS scores were dichotomized into nonsevere outcome (mRS ≤ 3) and severe outcome (mRS > 3). There were 77 patients in each group. Univariate and multivariate logistic regression analyses using severe outcome as the binary response were run. The authors also performed a logistic regression analysis to measure the effects of hematoma volume and AVM location on severe outcome. RESULTS Posterior fossa location was a significant predictor of severe outcome (OR 2.60, 95% CI 1.20-5.67, p = 0.016) and the results were strengthened in a multivariate model (OR 4.96, 95% CI 1.73-14.17, p = 0.003). Eloquent location (OR 3.47, 95% CI 1.37-8.80, p = 0.009) and associated arterial aneurysms (OR 2.58, 95% CI 1.09, 6.10; p = 0.031) were also significant predictors of poor outcome. Hematoma volume for patients with a posterior fossa AVM was 10.1 ± 10.1 cm(3) compared with 25.6 ±28.0 cm(3) in supratentorial locations (p = 0.003). A logistic analysis (based on imputed hemorrhage volume values) found that posterior fossa location was a significant predictor of severe outcome (OR 8.03, 95% CI 1.20-53.77, p = 0.033) and logarithmic hematoma volume showed a positive, but not statistically significant, association in the model (p = 0.079). CONCLUSIONS Patients with posterior fossa AVMs are more likely to have severe outcomes than those with supratentorial AVMs based on this natural history study. Age, sex, and ethnicity were not associated with an increased risk of severe outcome after AVM rupture, but posterior fossa location, associated aneurysms, and eloquent location were associated with poor post-hemorrhage mRS scores. Posterior fossa hematomas are poorly tolerated, with severe outcomes observed even with smaller hematoma volumes. These findings support an aggressive surgical posture with respect to posterior fossa AVMs, both before and after rupture.
Collapse
Affiliation(s)
- Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, California
| | | | | | | | | | | |
Collapse
|
|
38
|
Han SJ, Englot DJ, Kim H, Lawton MT. Brainstem arteriovenous malformations: anatomical subtypes, assessment of "occlusion in situ" technique, and microsurgical results. J Neurosurg 2015; 122:107-17. [PMID: 25343188 DOI: 10.3171/2014.8.jns1483] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The surgical management of brainstem arteriovenous malformations (AVMs) might benefit from the definition of anatomical subtypes and refinements of resection techniques. Many brainstem AVMs sit extrinsically on pia mater rather than intrinsically in the parenchyma, allowing treatment by occluding feeding arteries circumferentially, interrupting draining veins after arteriovenous shunting is eliminated, and leaving the obliterated nidus behind. The authors report here the largest series of brainstem AVMs to define 6 subtypes, assess this "occlusion in situ" technique, and analyze the microsurgical results. METHODS Brainstem AVMs were categorized as 1 of 6 types: anterior midbrain, posterior midbrain, anterior pontine, lateral pontine, anterior medullary, and lateral medullary AVMs. Data from a prospectively maintained AVM registry were reviewed to evaluate multidisciplinary treatment results. RESULTS During a 15-year period, the authors treated 29 patients with brainstem AVMs located in the midbrain (1 anterior and 6 posterior), pons (6 anterior and 7 lateral), and medulla (1 anterior and 8 lateral). The nidus was pial in 26 cases and parenchymal in 3 cases. Twenty-three patients (79%) presented with hemorrhage. Brainstem AVMs were either resected (18 patients, 62%) or occluded in situ (11 patients, 38%). All lateral pontine AVMs were resected, and the occlusion in situ rate was highest with anterior pontine AVMs (83%). Angiography confirmed complete obliteration in 26 patients (89.6%). The surgical mortality rate was 6.9%, and the rate of permanent neurological deterioration was 13.8%. At follow-up (mean 1.3 years), good outcomes (modified Rankin Scale [mRS] score ≤ 2) were observed in 18 patients (66.7%) and poor outcomes (mRS score of 3-5) were observed in 9 patients (33.3%). The mRS scores in 21 patients (77.8%) were unchanged or improved. The best outcomes were observed with lateral pontine (100%) and lateral medullary (75%) AVMs, and the rate of worsening/death was greatest with posterior midbrain and anterior pontine AVMs (50% each). CONCLUSIONS Brainstem AVMs can be differentiated by their location in the brainstem (midbrain, pons, or medulla) and the surface on which they are based (anterior, posterior, or lateral). Anatomical subtypes can help the neurosurgeon determine how to advise patients, with lateral subtypes being a favorable surgical indication along with extrinsic pial location and hemorrhagic presentation. Most AVMs are dissected with the intention to resect them, and occlusion in situ is reserved for those AVMs that do not separate cleanly from the brainstem, that penetrate into the parenchyma, or are more anterior in location, where it is difficult to visualize and preserve perforating arteries (anterior pontine and lateral medullary AVMs). Although surgical morbidity is considerable, surgery results in a better obliteration rate than nonoperative management and is indicated in highly selected patients with high rerupture risks.
Collapse
|
|
39
|
Almeida JP, Medina R, Tamargo RJ. Management of posterior fossa arteriovenous malformations. Surg Neurol Int 2015; 6:31. [PMID: 25745586 PMCID: PMC4348799 DOI: 10.4103/2152-7806.152140] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 11/20/2014] [Indexed: 11/28/2022] Open
Abstract
Background: Posterior fossa arteriovenous malformations (AVMs) are rare vascular lesions, representing 7–15% of all intracranial AVMs. Although less frequent than supratentorial AVMs, they present higher rupture, morbidity, and mortality rates. Microsurgery, radiosurgery, and endovascular neurosurgery are treatment options for obliteration of those lesions. In this paper, we present a critical review of the literature about the management of posterior fossa AVM. Methods: A MEDLINE-based search of articles published between January 1960 and January 2014 was performed. The search terms: “Posterior fossa arteriovenous malformation,” “microsurgery,” “radiosurgery,” and “endovascular” were used to identify the articles. Results: Current data supports the role of microsurgery as the gold standard treatment for cerebellar AVMs. Brainstem AVMs are usually managed with radiotherapy and endovascular therapy; microsurgery is considered in cases of pial brainstem AVMs. Conclusions: Succsseful treatment of posterior fossa AVMs depend on an integrated work of neurosurgeons, radiosurgeons, and endovascular neurosurgery. Although the development of radiosurgery and endovascular techniques is remarkable, microsurgery remains as the gold standard treatment for most of those lesions.
Collapse
Affiliation(s)
- Joao Paulo Almeida
- Department of Neurosurgery, Division of Cerebrovascular Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Roberto Medina
- Department of Neurosurgery, Division of Cerebrovascular Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Division of Cerebrovascular Neurosurgery, The Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
|
40
|
Yang W, Wang JY, Caplan JM, Braileanu M, Shang H, Upadhyay U, Zenonos GA, Rigamonti D, Colby GP, Coon AL, Tamargo RJ, Huang J. Predictors of functional outcome following treatment of posterior fossa arteriovenous malformations. J Clin Neurosci 2015; 22:357-62. [DOI: 10.1016/j.jocn.2014.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 08/22/2014] [Indexed: 11/15/2022]
|
|
41
|
Stein KP, Wanke I, Forsting M, Zhu Y, Moldovan AS, Dammann P, Sandalcioglu IE, Sure U. Associated Aneurysms in Supratentorial Arteriovenous Malformations: Impact of Aneurysm Size on Haemorrhage. Cerebrovasc Dis 2015; 39:122-9. [DOI: 10.1159/000369958] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 11/17/2014] [Indexed: 11/19/2022] Open
Abstract
Background: Associated aneurysms (AAs) are presumed to represent an additional risk factor for intracranial haemorrhage from cerebral arterio-venous malformations (AVMs). To date, efforts to capture their natural history, as well as to identify aneurysms with the potential capability of regression after AVM treatment remain incomprehensive. As the aneurysm size represents an important aspect for the treatment indication of incidental saccular aneurysms, this factor has rarely been encountered for the treatment of AAs so far. The present study aims to determine the angiographic and clinical characteristics of AAs with special focus on aneurysm size and their consequences for treatment. Methods: Patients with cerebral AVMs, treated in our department between 1990 and 2013, were analyzed retrospectively. Only patients with supratentorial AVMs and flow-related AAs of the feeding arteries were evaluated. Thus, patients harboring AVMs of the cerebellum and the brain stem and patients with intranidal, venous or remote aneurysms were excluded. Treatment strategies were assessed with special attention on bleeding source and on AA size. Results: In 59 of 409 patients (14%) with supratentorial AVMs, a total of 85 AAs of the feeding arteries were identified. 14 of 59 individuals (24%) presented with multiple AAs. Of 85 AA, 58 aneurysms (68%) were classified as proximal and 27 aneurysms (32%) as distal. The most common location of AAs was the middle cerebral artery (MCA, 39%), followed by the internal carotid artery (ICA, 27%) and the anterior cerebral artery (ACA, 21%). The mean AA size was 4.4 mm ± 3.4 mm. Intracranial haemorrhage was found in 21 of 59 patients (36%) with coexisting AAs. Among these, 10 individuals (17%) suffered from rupture of an AA, accounting for nearly half of all bleedings in this subgroup. Among those patients bearing a single AA, the size of ruptured aneurysms differed significantly from those unruptured (6.6 mm vs. 4.4 mm, p = 0.0046). Nineteen patients (32%) received treatment of 22 AAs, whereas sole AVM treatment was adopted in 26 patients (44%) and conservative management in 14 patients (24%). The main reasons to leave AAs untreated were the small AA size (<5 mm), poor clinical state or treatment denial by the patients. Conclusions: The aneurysm size of AAs in AVM influences the risk of haemorrhage. Therefore, the treatment of larger (diameter ≥5 mm) AAs should be considered, even if a treatment indication of the associated AVM is not given.
Collapse
|
|
42
|
Magro E, Chainey J, Chaalala C, Jehani HA, Fournier JY, Bojanowski MW. Management of ruptured posterior fossa arteriovenous malformations. Clin Neurol Neurosurg 2015; 128:78-83. [DOI: 10.1016/j.clineuro.2014.11.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/16/2014] [Accepted: 11/09/2014] [Indexed: 10/24/2022]
|
|
43
|
Platz J, Berkefeld J, Singer OC, Wolff R, Seifert V, Konczalla J, Güresir E. Frequency, risk of hemorrhage and treatment considerations for cerebral arteriovenous malformations with associated aneurysms. Acta Neurochir (Wien) 2014; 156:2025-34. [PMID: 25246143 DOI: 10.1007/s00701-014-2225-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 09/01/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Data on arteriovenous malformations (AVMs) of the brain with AVM-associated aneurysms (AAA) are scarce. This study addresses the incidence, rate of hemorrhage, treatment strategies and stability during follow-up in a neurovascular center. METHODS We retrospectively reviewed patients harboring an AVM with at least one AAA treated at our neurovascular center between 2002 and 2013. RESULTS Of 216 patients, 59 (27.3%) had at least one AAA (n = 92 aneurysms total). Compared to patients without AAA, hemorrhagic presentation occurred more frequently (61.0% versus 43.9%, p = 0.025), and the rate of infratentorial AVMs was higher (37.3% versus 16.6%, p = 0.001). The aneurysm was the origin of the bleeding in most cases, most often categorized as a feeding artery aneurysm. Overall, the first and recurrent hemorrhage were associated with a high mortality and morbidity (15.3% and 39%, respectively). Aneurysms were treated by coiling (n = 21), surgery (n = 18), or embolizaton with liquid embolization agents (n = 11). All aneurysms treated by embolization and surgery remained occluded during follow-up (mean follow-up 39.0 ± 45.0 months). However, in incomplete AVM obliteration, significant recurrence of the treated aneurysm was noted after endovascular coiling (37.5%), which may be related to the persistence of pathological blood flow. CONCLUSION In our series, AAA was a significant risk factor for hemorrhage and was associated with a poor outcome. It seems worthwhile to consider whether the aneurysm itself is a risk factor or only an epiphenomenon of severely altered hemodynamics induced by these special AVMs and therefore only the most common site of rupture. As the complication rate was low for aneurysm occlusion, we recommend treating these aneurysms whenever possible. Furthermore, obliteration of the AVM should be strived for as this subtype may be associated with an increased risk of hemorrhage.
Collapse
|
|
44
|
Flores BC, Klinger DR, Rickert KL, Barnett SL, Welch BG, White JA, Batjer HH, Samson DS. Management of intracranial aneurysms associated with arteriovenous malformations. Neurosurg Focus 2014; 37:E11. [DOI: 10.3171/2014.6.focus14165] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial or brain arteriovenous malformations (BAVMs) are some of the most interesting and challenging lesions treated by the cerebrovascular neurosurgeon. It is generally believed that the combination of BAVMs and intracranial aneurysms (IAs) is associated with higher hemorrhage rates at presentation and higher rehemorrhage rates and thus with a more aggressive course and natural history. There is wide variation in the literature on the prevalence of BAVM-associated aneurysms (range 2.7%–58%), with 10%–20% being most often cited in the largest case series. The risk of intracranial hemorrhage in patients with unruptured BAVMs and coexisting IAs has been reported to be 7% annually, compared with 2%–4% annually for those with BAVM alone. Several different classification systems have been applied in an attempt to better understand the natural history of this combination of lesions and implications for treatment. Independent of the classification used, it is clear that a few subtypes of aneurysms have a direct hemodynamic correlation with the BAVM itself. This is exemplified by the fact that the presence of a distal flow-related or an intranidal aneurysm appears to be associated with an increased hemorrhage risk, when compared with an aneurysm located on a vessel with no direct supply to the BAVM nidus. Debate still exists regarding the etiology of the association between those two vascular lesions, the subsequent implications for patients’ risk of hemorrhagic stroke, and finally the determination of which patients warrant treatment and when. The ultimate goals of the treatment of a BAVM associated with an IA are to prevent hemorrhage, avoid stepwise neurological deterioration, and eliminate the mortality risk associated with recurrent hemorrhagic events. The treatment is only justifiable if the risks associated with an intervention are lower than or equivalent to the long-term risks of disability or mortality caused by the lesion itself. When faced with this difficult decision, a few questions need to be answered by the treating neu-rosurgeon: What is the mode of presentation? What is the symptomatic lesion? Which one of the lesions bled? What is the relationship between the BAVM and IA? Is it possible to safely treat both BAVM and IA? The objective of this review is to discuss the demographics, natural history, classification, and strategies for management of BAVMs associated with IAs.
Collapse
Affiliation(s)
- Bruno C. Flores
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Daniel R. Klinger
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kim l. Rickert
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
- 2 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samuel l. Barnett
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Babu G. Welch
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
- 2 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jonathan A. White
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
- 2 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - H. Hunt Batjer
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Duke S. Samson
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
|
45
|
Posterior fossa arterio-venous malformations: current multimodal treatment strategies and results. Neurosurg Rev 2014; 37:619-28. [DOI: 10.1007/s10143-014-0551-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 01/08/2014] [Accepted: 03/23/2014] [Indexed: 10/25/2022]
|
|
46
|
Bowden G, Kano H, Tonetti D, Niranjan A, Flickinger J, Lunsford LD. Stereotactic radiosurgery for arteriovenous malformations of the cerebellum. J Neurosurg 2014; 120:583-90. [DOI: 10.3171/2013.9.jns131022] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Arteriovenous malformations (AVMs) of the posterior fossa have an aggressive natural history and propensity for hemorrhage. Although the cerebellum accounts for the majority of the posterior fossa volume, there is a paucity of stereotactic radiosurgery (SRS) outcome data for AVMs of this region. The authors sought to evaluate the long-term outcomes and risks of cerebellar AVM radiosurgery.
Methods
This single-institution retrospective analysis reviewed the authors' experience with Gamma Knife surgery during the period 1987–2007. During this time 64 patients (median age 47 years, range 8–75 years) underwent SRS for a cerebellar AVM. Forty-seven patients (73%) presented with an intracranial hemorrhage. The median target volume was 3.85 cm3 (range 0.2–12.5 cm3), and the median marginal dose was 21 Gy (range 15–25 Gy).
Results
Arteriovenous malformation obliteration was confirmed by MRI or angiography in 40 patients at a median follow-up of 73 months (range 4–255 months). The actuarial rates of total obliteration were 53% at 3 years, 69% at 4 years, and 76% at 5 and 10 years. Elevated obliteration rates were statistically higher in patients who underwent AVM SRS without prior embolization (p = 0.005). A smaller AVM volume was also associated with a higher rate of obliteration (p = 0.03). Four patients (6%) sustained a hemorrhage during the latency period and 3 died. The cumulative rates of AVM hemorrhage after SRS were 6% at 1, 5, and 10 years. This correlated with an overall annual hemorrhage rate of 2.0% during the latency interval. One patient experienced a hemorrhage 9 years after confirmed MRI and angiographic obliteration. A permanent neurological deficit due to adverse radiation effects developed in 1 patient (1.6%) and temporary complications were seen in 2 additional patients (3.1%).
Conclusions
Stereotactic radiosurgery proved to be most effective for patients with smaller and previously nonembolized cerebellar malformations. Hemorrhage during the latency period occurred at a rate of 2.0% per year until obliteration occurred.
Collapse
Affiliation(s)
- Greg Bowden
- 1Departments of Neurological Surgery and
- 3the Center for Image-Guided Neurosurgery,
- 5Departnemt of Neurological Surgery, University of Western Ontario, London, Ontario, Canada
| | - Hideyuki Kano
- 1Departments of Neurological Surgery and
- 3the Center for Image-Guided Neurosurgery,
| | - Daniel Tonetti
- 4University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Ajay Niranjan
- 1Departments of Neurological Surgery and
- 3the Center for Image-Guided Neurosurgery,
| | - John Flickinger
- 2Radiation Oncology and
- 3the Center for Image-Guided Neurosurgery,
| | - L. Dade Lunsford
- 1Departments of Neurological Surgery and
- 3the Center for Image-Guided Neurosurgery,
| |
Collapse
|
|
47
|
Al-Jehani H, Tampieri D, Cortes M, Melançon D. Re-growth of a posterior inferior cerebellar artery aneurysm after resection of the associated posterior fossa arteriovenous malformation. Interv Neuroradiol 2014; 20:61-6. [PMID: 24556301 DOI: 10.15274/inr-2014-10008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 08/25/2013] [Indexed: 11/12/2022] Open
Abstract
Arteriovenous malformation (AVM)-related aneurysms have been described in the literature. Their behavior varies based on their location in relation to and the activity of the shunting through the index AVM. The intuitive expectation supported by numerous reports is that these aneurysms should regress if the AVM is excluded from the circulation. We describe a case of 46-year-old man who presented with a posterior fossa AVM with an aneurysm on the posterior inferior cerebellar artery feeding the AVM. The nidus of the AVM was successfully excluded by glue embolization, with initial regression of the PICA aneurysm on serial imaging. Five years after the endovascular treatment, the aneurysm showed significant re-growth necessitating endovascular coiling. This case presents the re-growth of an AVM-related aneurysm and emphasizes the importance of long-term follow-up of such aneurysms even if the AVM is completely excluded.
Collapse
Affiliation(s)
- Hosam Al-Jehani
- Department of Neuroradiology, Montreal Neurological Institute and Hospital, McGill University; Montreal, Quebec, Canada - Department of Neurosurgery, King Fahad University Hospital, Dammam University; Al-Khobar, Saudi Arabia-
| | - Donatella Tampieri
- Department of Neuroradiology, Montreal Neurological Institute and Hospital, McGill University; Montreal, Quebec, Canada
| | - Maria Cortes
- Department of Neuroradiology, Montreal Neurological Institute and Hospital, McGill University; Montreal, Quebec, Canada
| | - Denis Melançon
- Department of Neuroradiology, Montreal Neurological Institute and Hospital, McGill University; Montreal, Quebec, Canada
| |
Collapse
|
|
48
|
Sumioka S, Kondo A, Tanabe H, Yasuda S. Intrinsic arteriovenous malformation embedded in the trigeminal nerve of a patient with trigeminal neuralgia. Neurol Med Chir (Tokyo) 2013; 51:639-41. [PMID: 21946727 DOI: 10.2176/nmc.51.639] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
A 66-year-old man presented with typical right trigeminal neuralgia. Neuroimaging showed a small arteriovenous malformation (AVM) in the right cerebellopontine angle. Suboccipital craniotomy verified that the AVM was almost completely embedded in the root entry zone of the trigeminal nerve and the nerve axis was tilted infero-posteriorly. The patient obtained complete pain relief without sequelae after surgery by transposition of the superior cerebellar artery and correction of the tilted nerve axis. The nidus of the unresected AVM was obliterated by gamma knife radiosurgery.
Collapse
Affiliation(s)
- Shinya Sumioka
- Department of Neurosurgery, Brain, Spine and Neurology Center, Shiroyama Hospital, Habikino, Osaka, Japan.
| | | | | | | |
Collapse
|
|
49
|
Mortazavi MM, Patel D, Griessenauer CJ, Tubbs RS, Fisher WS. Long-term control of large pontine arteriovenous malformation using gamma knife therapy: a review with illustrative case. Brain Behav 2013; 3:329-34. [PMID: 24381806 PMCID: PMC3869676 DOI: 10.1002/brb3.149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Revised: 05/04/2013] [Accepted: 05/06/2013] [Indexed: 11/12/2022] Open
Abstract
Brain stem arteriovenous malformations (AVMs) are rare and their clinical management is controversial. A location in highly eloquent areas and a greater risk of radionecrosis are both serious issues for radiosurgery of this entity. We report a case of a pontine AVM treated successfully with gamma knife therapy. At 3 years angiographic follow-up, imaging demonstrated complete thrombosis and there were no new neurological deficits, and at 7 years clinical follow-up, the patient continued to be neurologically stable. Although all treatments carry risk of neurological compromise, gamma knife therapy may offer the best treatment option for brain stem AVMs as seen in the case presented herein. This case illustrates a rare case of holo-pontine AVM tolerating gamma radiation with complete angiographical response and minimal neurological sequalae.
Collapse
Affiliation(s)
- Martin M Mortazavi
- Division of Neurosurgery, Department of Surgery, University of Alabama at Birmingham Birmingham, Alabama
| | - Daxa Patel
- Division of Neurosurgery, Department of Surgery, University of Alabama at Birmingham Birmingham, Alabama
| | - Christoph J Griessenauer
- Division of Neurosurgery, Department of Surgery, University of Alabama at Birmingham Birmingham, Alabama
| | - R Shane Tubbs
- Pediatric Neurosurgery, Children's Hospital Birmingham, Alabama
| | - Winfield S Fisher
- Division of Neurosurgery, Department of Surgery, University of Alabama at Birmingham Birmingham, Alabama
| |
Collapse
|
|
50
|
Rodríguez-Hernández A, Kim H, Pourmohamad T, Young WL, Lawton MT. Cerebellar arteriovenous malformations: anatomic subtypes, surgical results, and increased predictive accuracy of the supplementary grading system. Neurosurgery 2013; 71:1111-24. [PMID: 22986595 DOI: 10.1227/neu.0b013e318271c081] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Anatomic diversity among cerebellar arteriovenous malformations (AVMs) calls for a classification that is intuitive and surgically informative. Selection tools like the Spetzler-Martin grading system are designed to work best with cerebral AVMs but have shortcomings with cerebellar AVMs. OBJECTIVE To define subtypes of cerebellar AVMs that clarify anatomy and surgical management, to determine results according to subtypes, and to compare predictive accuracies of the Spetzler-Martin and supplementary systems. METHODS From a consecutive surgical series of 500 patients, 60 had cerebellar AVMs, 39 had brainstem AVMs and were excluded, and 401 had cerebral AVMs. RESULTS Cerebellar AVM subtypes were as follows: 18 vermian, 13 suboccipital, 12 tentorial, 12 petrosal, and 5 tonsillar. Patients with tonsillar and tentorial AVMs fared best. Cerebellar AVMs presented with hemorrhage more than cerebral AVMs (P < .001). Cerebellar AVMs were more likely to drain deep (P = .04) and less likely to be eloquent (P < .001). The predictive accuracy of the supplementary grade was better than that of the Spetzler-Martin grade with cerebellar AVMs (areas under the receiver-operating characteristic curve, 0.74 and 0.59, respectively). The predictive accuracy of the supplementary system was consistent for cerebral and cerebellar AVMs, whereas that of the Spetzler-Martin system was greater with cerebral AVMs. CONCLUSION Patients with cerebellar AVMs present with hemorrhage more often than patients with cerebral AVMs, justifying an aggressive treatment posture. The supplementary system is better than the Spetzler-Martin system at predicting outcomes after cerebellar AVM resection. Key components of the Spetzler-Martin system such as venous drainage and eloquence are distorted by cerebellar anatomy in ways that components of the supplementary system are not.
Collapse
Affiliation(s)
- Ana Rodríguez-Hernández
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California 94143-0112, USA
| | | | | | | | | | | |
Collapse
|