Targeting Cerebral Arteriovenous Malformations for Minimally Invasive Therapy

Abstract

The further evaluation and understanding of the vascular biology of AVM vessels and the endothelium cell wall biology will help us devise more bioactive material solutions to AVM nidus obliteration. Targeting specific receptors in AVMs with the embolic material delivered may additionally enhance the effects of radiosurgery in these patients.

Curative Embolization of Brain Arteriovenous Malformations with Onyx: Patient Selection, Embolization Technique, and Results

“…[1][2][3][4][5][6][7][8] In AVMs presenting with intracranial hemorrhage, better recognition of certain angioarchitectural features of the AVM as likely weak spots prone to recurrent hemorrhage, such as intranidal-and flow-related aneurysms and venous stenoses, has prompted many operators to perform a partial targeted embolization treatment when complete AVM obliteration is unlikely or impossible. [9][10][11][12][13][14] The growing experience with the use of Onyx in our department together with advancement in imaging possibilities and the adjustment of the technique of curative embolization have gradually resulted in the adaptation of the treatment paradigm of patients with AVMs in our hospital. Embolization is no longer basically restricted to partial nidus obliteration of large AVMs to facilitate subsequent surgery or radiosurgery.…”

Embolization of Intracranial Arteriovenous Malformations Using Onyx in 53 Patients

“…Onyx was first described by Yamashita et al (6) and Terada et al (7) in the 1990s. It is a polymerizing agent consisting of ethylene-vinyl alcohol dissolved in dimethyl sulfoxide and mixed with micronized tantalum powder for radiopaque visualization (8). The polymer solidifies slowly from outside to inside as it comes in contact with the blood, with limited influence by the AVM flow, allowing better control of penetration behavior and achieving more solid nidus cast compared with n-butyl cyanoacrylate (n-BCA).…”

Endovascular Treatment of Ruptured Brain AVMs in the Acute Phase of Hemorrhage

“…[16][17][18][19] Better recognition of certain angioarchitectural features of the AVM as likely weak spots prone to recurrent hemorrhage, such as intranidal-and flow-related aneurysms and venous stenoses, have prompted many operators to perform a partial targeted embolization treatment when complete AVM obliteration is unlikely or impossible. 7,[11][12][13][14][15] Intranidal-and flow-related aneurysms can be excluded from the circulation with Onyx, acrylic glue, or coils, and venous outflow restrictions can be exonerated by occlusion of high-flow intranidal fistula with Onyx under flow arrest with a microballoon. 21 These new developments in the treatment of brain AVMs, in combination with the concurrent and similar advancement of endovascular treatment with Onyx of dural arteriovenous fistulas with drainage to the cortical veins, 22,23 have led our hospital to an adaptation of the diagnosis and treatment strategy in patients with hemorrhagic stroke.…”

“…Specific elimination of these weak spots or reduction of flow through the AVM by endovascular or surgical therapy is thought to decrease the rate of repeated hemorrhage and to improve prognosis, even when the AVM is only partially obliterated. [11][12][13][14][15][16] With modern endovascular techniques, targeted treatment of AVM-associated aneurysms, partial nidus obliteration with flow reduction, or complete obliteration is possible in most patients with AVMs. [16][17][18][19] In this article, we evaluate the results of a treatment strategy for brain AVMs that present with hemorrhage that includes early angiographic diagnosis and endovascular treatment in the acute phase.…”