Embolization of feeding arteries and symptom alleviation of mixed dural-pial arteriovenous malformations

Abstract

Background: To examine whether embolization of dural or pial blood supply branch is more efficient for symptom alleviation for unruptured mixed dural-pial arteriovenous malformations (DPAVMs). Methods: We retrospectively reviewed 30 DPAVM patients from a database of 425 consecutive cerebral arteriovenous malformation (CAVM) patients who underwent endovascular embolization between January 2010 and December 2015 at our institution. Demographics, angioarchitectural characteristics, endovascular embolization details and patients clinical outcomes were recorded. The modified Rankin Scale (mRS), Engel's classification and Visual Analogue pain scale (VAS) were used to assess clinical outcomes. Results: The single center cohort data shows that the incidence of DPAVM is 7.1%. Among the 30 DPAVM patients, 9 (30.0%) are ruptured and 21 (70.0%) are unruptured. Four (19.0%) of the 21 unruptured DPAVM patients are failed to follow-up, leaving 17 to analysis the clinical outcomes. Clinical presentations of the 17 unruptured DPAVM patients are epilepsy (n = 10), headache (n = 5) and focal neurological dysfunction (n = 2). Six patients have DPAVMs occluded via pial blood supply branches, 4 via dural branches and 7 via both pial and dural branches. Unruptured DPAVM patients with nidus occluded via dural blood supply branches, or both pial and dural branches have higher symptom alleviation rate than patients with nidus occluded via pial branches (100%/85.7% vs 66.7%). Conclusions: For DPAVM patients presented with epilepsy, headache and FND, embolization via dural blood supply branches may be more efficient for symptom alleviation. Large cohort study is needed to confirm the generalizability.

Brain arteriovenous malformation with transdural blood supply: Current status (Review)

“…The most important clinical manifestation of BAVM with TBS is intracranial hemorrhage, which is life-threatening in severe cases (35). For instance, nine of the 30 cases of BAVM with TBS reported by Jin et al (36) were caused by intracranial hemorrhage (incidence, 30.0%). Intracranial hemorrhage may occur at the BAVM nidus or from aneurysmal dilated drained veins, with the latter being more common than the former, and is characterized by intracranial hematoma and subarachnoid hemorrhage (37).…”

“…The advantage of EVT is its low procedural invasiveness and preservation of brain functionality (52). Performing EVT in BAVM with TBS mainly involves transarterial embolization, which is performed via either a dural blood supply approach or a pial blood supply approach (non-dural blood supply approach) (36).…”

“…Among these, the pial blood supply approach in EVT may effectively embolize the BAVM and prevent rebleeding (57). However, the dural blood supply approach is safer; furthermore, by reducing the blood flow of the brain surface, certain clinical symptoms may be improved, including epilepsy and headache from dural feeding pulsation, particularly in unruptured BAVM with TBS (36). During the dural blood supply approach, the use of a dual-lumen balloon catheter is helpful to inject the liquid embolic material into the BAVM to prevent reflux (58,59).…”