Intra- and post-operative acute hemorrhagic complications of Onyx embolization of brain arteriovenous malformations: A single-center experience

Abstract

BackgroundThe intra- and post-operative acute (within 72 h) hemorrhagic complications of endovascular treatment (EVT) for a brain arteriovenous malformation (BAVM) are disastrous. Thus, further experiential summaries are required to fully understand them.Materials and methodsThis was a retrospective study of 25 patients with consecutive BAVM who were treated via EVT with Onyx embolization and suffered intra- and post-operative acute hemorrhage. The clinical and imaging data of the patients were recorded, analyzed, and discussed.ResultTwenty-five patients were aged 11–70 years (mean, 37.2 ± 16.1 years), of whom 12 were female (48%, 12/25). Of the 25 hemorrhagic complications, 17 (68%, 17/25) were intraoperative, and 8 (32%, 8/25) were post-operative and occurred between 1 and 12 h after EVT. Of 17 intraoperative hemorrhages, 13 (76.5%, 13/17) were due to high-pressure Onyx casting. Of eight post-operative hemorrhages, six (75%, 6/8) were attributed to normal perfusion pressure breakthrough. The degree of nidus Onyx embolization was more than 2/3 or complete in seven (87.5%, 7/8) BAVMs. Draining vein occlusion was observed in eight (32%, 8/25) of 25 BAVMs. After hemorrhage, conservative treatment was administered in 12 (48%, 12/25) cases, and surgical management was performed in other cases. There were eight cases of mortality; the remaining 17 patients had follow-up data. Among them, 15 patients had good outcomes, with Glasgow Outcome Scale scores of 5 and 4, accounting for 60% (15/25).ConclusionIn EVT for BAVMs, intra- and post-operative acute hemorrhagic complications are disastrous; only 60% of patients have a good outcome. Therefore, high-pressure Onyx casting or casting too much Onyx at one time to pursue a high degree of nidus embolization should be performed cautiously, and primary draining vein occlusion should be avoided. In short, EVT needs to be performed carefully.

Brain arteriovenous malformations of the middle cerebral artery region: image characteristics and endovascular treatment based on a new classification system

“…When performing EVT for BAVMs, the goal should not be an embolization degree, as the role of curative embolization is uncertain [40,41]. In addition, in large BAVMs, the embolization of too large a volume in one stage may result in normal perfusion pressure breakthrough or occlusion of the draining vein, resulting in hemorrhagic complications [16,17]. Therefore, in our study, the percentage of MCA-BAVMs with an embolization degree of > 2/3 nidus was only 36.3%.…”

“…In addition, during casting Onyx, it is important to preserve the primary draining vein to prevent intraoperative or acute postoperative hemorrhagic complications due to venous hypertension (Fig. 5 ) [ 16 , 17 ].

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