Acute embolization of ruptured brain arteriovenous malformations

Stemer, Andrew; Bank, William O.; Armonda, Rocco A.; Liu, Ai‐Hsi; Herzig, David W; Bell, Randy S.

doi:10.1136/neurintsurg-2011-010214

Cited by 32 publications

(16 citation statements)

References 33 publications

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“…Even in the cases of ruptured BAVMs, recent reports have suggested that early embolization may be safe, particularly if the goal of embolization is to eliminate high-risk features that may increase the rehemorrhage rates. 73 Curative BAVM embolization often requires aggressive nidal embolization and may be associated with prohibitive complication rates, largely related to unintended early occlusion of draining veins. BAVMs that are most likely to be cured using endovascular treatment have a small nidus and limited number of feeders (particular ly those of Spetzler-Martin Grades I-III), characteristics that also make those lesions perfect microsurgical candidates, with associated low morbidity and mortality rates.…”

Section: Endovascular Treatmentmentioning

confidence: 99%

Management of intracranial aneurysms associated with arteriovenous malformations

Flores

Klinger

Rickert

et al. 2014

FOC

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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.

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Section: Endovascular Treatmentmentioning

confidence: 99%

Management of intracranial aneurysms associated with arteriovenous malformations

Flores

Klinger

Rickert

et al. 2014

FOC

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“…51 Complete occlusion was achieved in 52% of the patients. However, 29% and 5% of the ruptured AVMs were subsequently treated with resection and radiosurgery, respectively, and the intraprocedural complication and posttreatment mortality rates were each 10%.…”

Section: Stemer Et Al Reported On 21 Patients With Rupturedmentioning

confidence: 99%

Radiosurgery for ruptured intracranial arteriovenous malformations

Ding¹,

Yen²,

Starke³

et al. 2014

JNS

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Object Ruptured intracranial arteriovenous malformations (AVMs) are at a significantly greater risk for future hemorrhage than unruptured lesions, thereby necessitating treatment in the majority of cases. In a retrospective, single-center study, the authors describe the outcomes after radiosurgery in a large cohort of patients with ruptured AVMs. Methods From an institutional review board–approved, prospectively collected AVM radiosurgery database, the authors identified all patients with a history of AVM rupture. They analyzed obliteration rates in all patients in whom radiological follow-up data were available (n = 639). However, to account for the latency period associated with radiosurgery, only those patients with more than 2 years of radiological follow-up and those with earlier AMV obliteration were included in the analysis of prognostic factors related to obliteration and complications. This resulted in a cohort of 565 patients with ruptured AVMs for whom data were analyzed; these patients had a median radiological follow-up of 57 months and a median age of 29 years. Twenty-one percent of the patients underwent preradiosurgery embolization. The median volume and prescription dose were 2.1 cm3 and 22 Gy, respectively. The Spetzler-Martin grade was III or higher in 56% of patients, the median radiosurgery-based AVM score was 1.08, and the Virginia Radiosurgery AVM Scale (RAS) score was 3 to 4 points in 44%. Survival and regression analyses were performed to determine obliteration rates over time and predictors of obliteration and complications. Results In the overall population of 639 patients with ruptured AVMs, the obliteration rate was 11.1% based on MRI only (71 of 639 patients), 56.0% based on angiography (358 of 639), and 67.1% based on combined modalities (429 of 639 patients). In the cohort of patients with 2 years of follow-up or an earlier AVM obliteration, the cumulative obliteration rate was 76% and the actuarial obliteration rates were 41% and 64% at 3 and 5 years, respectively. Multivariate analysis identified the absence of preradiosurgery embolization (p < 0.001), increased prescription dose (p = 0.001), the presence of a single draining vein (p = 0.046), no postradiosurgery-related hemorrhage (p = 0.007), and lower Virginia RAS score (p = 0.020) as independent predictors of obliteration. The annual risk of a hemorrhage occurring during the latency period was 2.0% and the rate of hemorrhage-related morbidity and mortality was 1.6%. Multivariate analysis showed that decreased prescription dose (p < 0.001) and multiple draining veins (p = 0.003) were independent predictors of postradiosurgery hemorrhage. The rates of symptomatic and permanent radiation-induced changes were 8% and 2.7%, respectively. In the multivariate analysis, a single draining vein (p < 0.001) and higher Virginia RAS score (p = 0.005) were independent predictors of radiation-induced changes following radiosurgery. Conclusions Radiosurgery effectively treats ruptured AVMs with an acceptably low risk-to-benefit ratio. For patients with ruptured AVMs, favorable outcomes are more likely when preradiosurgical embolization is avoided and a higher prescription dose can be delivered.

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“…Embolization with liquid occlusive agents will occasionally penetrate the AVM nidus from treatable feeders and occlude compartments supplied by inaccessible sources (specifically, branches that are too small and/or too tortuous to adequately catheterize or branches distal to the AVM nidus that are supplied by leptomeningeal networks through normal brain tissue) 4 5. The frequency with which supply from these compartments persists after endovascular treatment, however, has necessitated the frequent combination of endovascular treatment with gamma knife irradiation, resection and/or intraoperative embolization of feeding arteries distal to the AVM nidus 6…”

Section: Discussionmentioning

confidence: 99%

Intermittent balloon occlusion to favor nidal penetration during embolization of arteriovenous malformations: a technique modification

Bank

Stemer

Armonda

et al. 2013

J NeuroIntervent Surg

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SUMMARYEndovascular embolization of brain arteriovenous malformations (AVMs) has improved with liquid occlusive agents, but flow-related and anatomic restrictions limit endovascular capabilities. AVM compartments supplied by leptomeningeal networks and feeding arteries too small and/or tortuous for safe catheterization are rarely penetrated by liquid occlusive agents. A case with both impediments prompted a novel solution. A balloon was inflated across the supply to a lenticulostriate feeder, thereby favoring penetration of the liquid occlusive agent, injected from a different feeding territory, back into the AVM compartment supplied by the temporarily occluded feeder. This technique may reduce the number of embolization stages in large high-flow AVMs and increase the likelihood of achieving complete occlusion. This technique is highly complex and requires meticulous monitoring of multiple events. BACKGROUND

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Acute embolization of ruptured brain arteriovenous malformations

Abstract: Treatment of ruptured bAVMs is often delayed but our experience with Onyx suggests that acute embolization is safe and feasible.

Cited by 32 publications

References 33 publications

Management of intracranial aneurysms associated with arteriovenous malformations

Management of intracranial aneurysms associated with arteriovenous malformations

Radiosurgery for ruptured intracranial arteriovenous malformations

Intermittent balloon occlusion to favor nidal penetration during embolization of arteriovenous malformations: a technique modification

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