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Borges de Almeida G, Pamplona J, Baptista M, Carvalho R, Conceição C, Lopes da Silva R, Sagarribay A, Reis J, Fragata I. Endovascular Treatment of Brain Arteriovenous Malformations in Pediatric Patients: A Single Center Experience and Review of the Literature. J Neurol Surg A Cent Eur Neurosurg 2024; 85:361-370. [PMID: 37494960 DOI: 10.1055/s-0043-1770356] [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: 07/28/2023]
Abstract
BACKGROUND Brain arteriovenous malformations (bAVMs) are abnormal vascular connections with direct arteriovenous shunts, generally symptomatic in the adult life. However, a small number of bAVMs may manifest in pediatric patients, with higher bleeding risk and mortality rates when compared to adults. The purpose of this study is to review our experience with endovascular treatment of bAVMs in pediatric patients. METHODS This is a retrospective analysis of all bAVMs in pediatric patients (0-18 years) who underwent diagnostic digital subtraction angiography (DSA) at our institution from January 2010 to June 2021. RESULTS Twenty-six patients met the inclusion criteria, of which 12 underwent endovascular treatment. Treated patients had a mean age of 10.25 years and 58% were females. Complete angiographic exclusion was achieved in five (42%) patients with endovascular treatment. Five patients with residual bAVM after embolization needed adjuvant therapy with surgery (n = 3) or stereotactic radiosurgery (SRS; n = 2). Two patients are still undergoing embolization sessions. Procedure-related complications occurred in two patients (17%) and included small vessel perforation and an occipital ischemic stroke. Two patients showed bAVM recurrence on follow-up (17%) and subsequently underwent SRS (n = 1) or surgery (n = 1), both resulting in complete bAVM exclusion. All patients had a modified Rankin scale (mRS) score of 0 to 2 on follow-up. CONCLUSION Our experience supports the effectiveness and safety of endovascular treatment of bAVM in selected pediatric patients. A multidisciplinary approach combining surgery and SRS is warranted to achieve higher complete bAVM obliteration rates. Long-term follow-up is important as these lesions may show recurrence over time, especially in the pediatric population.
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Affiliation(s)
| | - Jaime Pamplona
- Department of Neuroradiology, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Portugal
| | - Mariana Baptista
- Department of Neuroradiology, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Portugal
| | - Rui Carvalho
- Department of Neuroradiology, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Portugal
| | - Carla Conceição
- Department of Neuroradiology, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
| | - Rita Lopes da Silva
- Department of Pediatric Neurology, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
| | - Amets Sagarribay
- Department of Neurosurgery, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
| | - João Reis
- Department of Neuroradiology, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar e Universitário de Lisboa Central, Lisboa, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Portugal
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Batista S, Fim Andreão F, Sousa MP, Oliveira LDB, Palavani LB, Melo Silva G, de Abreu LV, Bertani R, Gomes Quadros D. Spinal tumor embolization with Onyx: A systematic review and meta-analysis. Interv Neuroradiol 2024:15910199241227990. [PMID: 38646670 DOI: 10.1177/15910199241227990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024] Open
Abstract
INTRODUCTION Onyx embolization has emerged as a promising technique for spinal tumor embolization due to its high devascularization rate and low incidence of complications. OBJECTIVE Evaluate the safety and efficacy of Onyx embolization in spinal tumor procedures. METHODS Following the PRISMA guidelines, we conducted a systematic review and meta-analysis. To be included, the articles had to report specific outcomes of Onyx embolization for spinal tumors (complications, mortality, blood loss, tumor devascularization, or reduction in tumor blush). RESULTS We selected 11 out of 2941 articles, encompassing 127 patients. Among them, no major complications or persistent neurological deficits were reported, and no deaths occurred as a result of the embolization procedure. Of the 63 patients with available data, two complications were observed: one infarct leading to transient neurological deficit and one clinically silent vessel perforation related to the microcatheter. Thus, the complication rate was 1% (95% confidence interval (CI): 0% to 6%). Blood loss during surgery ranged from 100 to 1500 mL (four studies). Complete tumor blush reduction was achieved in 52% of the cases (95% CI: 16% to 88%) across 32 patients. Three studies reported a median percentage of tumor devascularization of 91% (86.1% to 97.5%). CONCLUSION Onyx embolization for spinal tumor procedures appears to be a safe technique, as evidenced by the absence of major complications or deaths. However, the determination of its efficacy remains challenging due to limited data availability and substantial heterogeneity across studies. These findings highlight the need for future research to address this knowledge gap and further validate our results.
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Affiliation(s)
- Savio Batista
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | - Filipi Fim Andreão
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | - Marcelo Porto Sousa
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | | | | | - Guilherme Melo Silva
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | - Livia V de Abreu
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio De Janeiro, Brazil
| | - Raphael Bertani
- Department of Neurosurgery, University of Sao Paulo, Sao Paulo, Brazil
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Wier GP, Larochelle RD, Seinfeld J, Hink EM. Orbital Venous Malformation Excision after Transcaruncular Embolization with Onyx. Case Rep Ophthalmol 2023; 14:121-126. [PMID: 37007838 PMCID: PMC10051039 DOI: 10.1159/000526830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 08/04/2022] [Indexed: 04/04/2023] Open
Abstract
Orbital venous malformations are low-flow lesions resulting from vascular dysgenesis during development. Patients may present with vision loss, proptosis accentuated by Valsalva, and/or painful spontaneous thrombosis. The preferred treatment for symptomatic lesions is embolization combined with excision. A 34-year-old male presented to our institution from an outside emergency department with a diagnosis of presumed idiopathic orbital inflammation. For the prior month, he had been experiencing left orbital pressure, subjective eye bulging, and both diplopia and blurry vision when in peripheral gaze or when bending over. Despite initial improvement with steroids, his symptoms recurred with tapering. Visual acuity was reduced to 20/25, but pupils and motility remained normal. Biopsy demonstrated a vascular lesion characterized by fibroadipose tissue with histologically unremarkable blood vessels, and cerebral arteriography showed no high-flow components. A diagnosis of orbital venous malformation was made. He then underwent intraoperative angiography and Onyx embolization followed by excision via a transcaruncular approach. Two prior reports have described the use of Onyx in venolymphatic malformations. This report highlights a detailed approach to defining flow characteristics pre- and intraoperatively and expands upon our understanding of the use of Onyx for such cases.
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Affiliation(s)
| | | | - Joshua Seinfeld
- Department of Neurosurgery, University of Colorado, Aurora, CO, USA
| | - Eric M. Hink
- Department of Ophthalmology, University of Colorado, Aurora, CO, USA
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4
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Jha VC, Alam MS, Sinha VS. Comparative outcome of endovascular embolization with microsurgery in managing acute spontaneous cerebral hemorrhage in pediatric patients, an institutional experience. Childs Nerv Syst 2022; 39:963-974. [PMID: 36571597 DOI: 10.1007/s00381-022-05785-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/06/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVES A few previous studies have reported the role of embolization with curative intent in the treatment of the early phase of a spontaneous cerebral hemorrhage in pediatric patients, and its efficacy needs to be compared with surgery at the same time risk factors for hemorrhage following early embolization in such patients need to be evaluated. METHODS From a pool of 80 pediatric (< 18 years) who had undergone treatment for ruptured AVM with hemorrhage at our center between July 2018 and July 2022, we identified 36 patients with spontaneous bleeding due to AVM. Out of which, 20 were treated solely by embolization (group 1), while the remaining patients were treated surgically (with and without adjuvant embolization) (group 2). RESULT Spetzler-Martin's grading of the lesion suggested seven lesions < 3 and 13 lesions ≥ 3 in the embolization group. Similarly, seven lesions were < 3 and nine ≥ 3 Spetzler-Martin grade in the surgery group. Incomplete embolization was associated with hemorrhage in two patients treated with curative intent and four patients treated with embolization as adjuvant in the surgery group (p = 0.01). On follow-up, 18 patients in the embolization group and 12 in the surgery group had Glasgow outcome scores ≥ 4 (p = 0.273). CONCLUSION In the pediatric age group, incomplete embolization is the significant risk factor for hemorrhage in AVMs treated after a hemorrhagic stroke. Embolization with curative intent is as effective as surgery in treating such lesions as adjuvant embolization with careful patient selection.
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Affiliation(s)
- Vikas Chandra Jha
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India.
| | | | - Vivek Sharan Sinha
- Department of Neurosurgery, All India Institute of Medical Sciences, Patna, Bihar, India
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Marra P, Di Fazio B, Dulcetta L, Carbone FS, Muglia R, Bonaffini PA, Valle C, Corvino F, Giurazza F, Muscogiuri G, Venturini M, Sironi S. Embolization in Pediatric Patients: A Comprehensive Review of Indications, Procedures, and Clinical Outcomes. J Clin Med 2022; 11:jcm11226626. [PMID: 36431102 PMCID: PMC9696500 DOI: 10.3390/jcm11226626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/30/2022] [Accepted: 11/02/2022] [Indexed: 11/10/2022] Open
Abstract
Embolization in pediatric patients encompasses a large spectrum of indications, ranging from the elective treatment of congenital diseases of the cardiovascular system to the urgent management of acute hemorrhagic conditions. In particular, the endovascular treatment of central and peripheral vascular malformations and hypervascular tumors represents a wide chapter for both congenital and acquired situations. Thanks to the progressive availability of low-profile endovascular devices and new embolic materials, the mini-invasive approach has gradually overtaken surgery. In this review, the main embolization procedures will be illustrated and discussed, with a focus on clinical indications and expected outcomes. The most recent mini-invasive techniques will be described, with hints on the cutting-edge devices and embolic materials.
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Affiliation(s)
- Paolo Marra
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Barbaro Di Fazio
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
- Correspondence: ; Tel.: +39-347-516-5851 or +39-035-267-4359
| | - Ludovico Dulcetta
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Francesco Saverio Carbone
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Riccardo Muglia
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Pietro Andrea Bonaffini
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Clarissa Valle
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Fabio Corvino
- Department of Vascular and Interventional Radiology, Cardarelli Hospital, 80131 Naples, Italy
| | - Francesco Giurazza
- Department of Vascular and Interventional Radiology, Cardarelli Hospital, 80131 Naples, Italy
| | - Giuseppe Muscogiuri
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
- Department of Radiology, IRCCS Istituto Auxologico Italiano, San Luca Hospital, 20149 Milan, Italy
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Department, Circolo Hospital, ASST Sette Laghi, Insubria University, 21100 Varese, Italy
| | - Sandro Sironi
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
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Savage C, Hale AT, Parr MS, Hedaya A, Saccomano BW, Tsemo GB, Hafeez MU, Tanweer O, Kan P, Solomon LJ, Meila D, Dirks PB, Blount JP, Johnston JM, Rocque BG, Rozzelle CJ, Bhatia K, Muthusami P, Krings T, Jones J. Outcomes of endovascular embolization for Vein of Galen malformations: An individual participant data meta-analysis. Front Pediatr 2022; 10:976060. [PMID: 36245731 PMCID: PMC9561813 DOI: 10.3389/fped.2022.976060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/15/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Understanding outcomes after Vein of Galen malformation (VOGM) embolization has been limited by small sample size in reported series and predominantly single center studies. To address these limitations, we perform an individual-participant meta-analysis (IPMA) to identify risk factors associated with all-cause mortality and clinical outcome after VOGM endovascular embolization. Methods We performed a systematic review and IPMA of VOGM endovascular outcomes according to PRISMA guidelines. Individual patient characteristics including demographic, intra/post-operative adverse events, treatment efficacy (partial or complete occlusion), and clinical outcome were collected. Mixed-effects logistic regression with random effects modeling and Bonferroni correction was used (p ≤ 0.003 threshold for statistical significance). The primary and secondary outcomes were all-cause mortality and poor clinical outcome (moderate/severe developmental delay or permanent disabling injury), respectively. Data are expressed as (mean ± standard deviation (SD)) or (odds ratio (OR), 95% confidence interval (CI), I 2, p-value). Results Thirty-five studies totaling 307 participants quantifying outcomes after endovascular embolization for VOGM were included. Follow up time was 42 (±57) months. Our analysis contained 42% neonates (<1 month) at first embolization, 45% infants (1 month ≤2 years), and 13% children (>2 years). Complete occlusion was reported in 48% of participants. Overall all-cause mortality was 16%. Overall, good clinical outcome was achieved in 68% of participants. First embolization as a neonate [OR = 6.93; 95% CI (1.99-24.08); I 2 < 0.01; p < 0.001] and incomplete embolization [OR = 10.87; 95% CI (1.86-63.55); I 2 < 0.01; p < 0.001] were associated with mortality. First embolization as a neonate [OR = 3.24; 95% CI (1.47-7.15); I 2 < 0.01; p < 0.001], incomplete embolization [OR = 5.26; 95% CI (2.06-13.43); I 2 < 0.01; p < 0.001], and heart failure at presentation [OR = 3.10; 95% CI (1.03-9.33); I 2 < 0.01; p = 0.002] were associated with poor clinical outcomes. Sex, angioarchitecture of lesion, embolization approach (transvenous vs. transarterial), and single or multistage embolization were not associated with mortality or clinical outcome. Conclusions We identify incomplete VOGM embolization independently associated with mortality and poor clinical outcome. While this study provides the highest level of evidence for VOGM embolization to date, prospective multicenter studies are needed to understand the optimal treatment strategies, outcomes, and natural history after VOGM embolization.
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Affiliation(s)
- Cody Savage
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Andrew T. Hale
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Matthew S. Parr
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Alexander Hedaya
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Benjamin W. Saccomano
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Georges Bouobda Tsemo
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Muhammad U. Hafeez
- Department of Neurology, Baylor College of Medicine, Houston, TX, United States
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston TX, United States
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Laurent J. Solomon
- Department of Obstetrics and Fetal Medicine, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants, Paris, France
| | - Dan Meila
- Department of Interventional Radiology, Helois Klinikum Krefeld, Johanna-Etienne Hospital Neuss, Neuss, Germany
| | - Peter B. Dirks
- Division of Pediatric Neurosurgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jeffrey P. Blount
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - James M. Johnston
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Brandon G. Rocque
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Curtis J. Rozzelle
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kartik Bhatia
- Department of Medical Imaging, Sydney Children’s Hospital Network, Westmead, NSW, Australia
| | - Prakash Muthusami
- Division of Interventional Radiology, University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Timo Krings
- Division of Interventional Radiology, University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Jesse Jones
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
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7
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Schmidt VF, Olivieri M, Häberle B, Masthoff M, Deniz S, Sporns PB, Wohlgemuth WA, Wildgruber M. Interventional Treatment Options in Children with Extracranial Vascular Malformations. Hamostaseologie 2022; 42:131-141. [PMID: 35263769 DOI: 10.1055/a-1728-5686] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Extracranial vascular malformations vary greatly and belong to the complex field of orphan diseases and can involve all segments of the vascular tree: arteries, capillaries, and veins, and similarly the lymphatic system. The classification according to the International Society for the Study of Vascular Anomalies (ISSVA) represents an important guidance for selecting appropriate therapy. Although many of the principles of endovascular treatment, including image-guided sclerotherapy and embolization, are similar in adult and pediatric practice, there are some distinct differences regarding the treatment of vascular malformations of children. Thus, it is crucial to involve longer-term plan about managing these chronic diseases and their impact on a growing child. This review provides a detailed overview over the clinical presentation of venous, lymphatic, and arteriovenous malformations in children and emphasizes the specifics of their interventional treatment options, including distinct pediatric dose limitations and procedure-related side effects.
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Affiliation(s)
- Vanessa F Schmidt
- Department of Radiology, Ludwig Maximilian University Hospital, Munich, München, Germany
| | - Martin Olivieri
- Paediatric Thrombosis and Haemostasis Unit, Dr. von Hauner Children's Hospital Munich, Ludwig Maximilian University, Munich, Germany
| | - Beate Häberle
- Department for Pediatric Surgery, Ludwig Maximilian University Hospital, Munich, München, Germany
| | - Max Masthoff
- Clinic of Radiology, University Hospital Muenster, Muenster, Germany
| | - Sinan Deniz
- Department of Radiology, Ludwig Maximilian University Hospital, Munich, München, Germany
| | - Peter B Sporns
- Department of Neuroradiology, Clinic for Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg - Eppendorf, Hamburg, Germany
| | - Walter A Wohlgemuth
- Clinic and Policlinic of Diagnostic Radiology, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Moritz Wildgruber
- Department of Radiology, Ludwig Maximilian University Hospital, Munich, München, Germany
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8
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Rodriguez-Calienes A, Bustamante-Paytan D, Camacho-Caballero K, Mayoria-Vargas A, Rodríguez-Varela R, Saal-Zapata G. Single-center experience with endovascular treatment of cerebral arteriovenous malformations with intent to cure in pediatric patients. Childs Nerv Syst 2022; 38:343-351. [PMID: 34605999 DOI: 10.1007/s00381-021-05376-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/01/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE This study aimed to report the incidence of technical complications and immediate complete angiographic occlusion, identify associated factors with failure of complete occlusion and identify predictors of technical complications in a single-center experience of pediatric arteriovenous malformations (AVM) treated with endovascular treatment with intent to cure. METHODS Patients between 1 and 18 years of age undergoing endovascular embolization between 2011 and 2020 were included. RESULTS A total of 120 embolizations were performed in 69 patients. The most frequent clinical presentation was intracerebral hemorrhage (76.8%). Immediate obliteration of the malformations was achieved in 40 (58%) cases. The technical complication rate was 15%. AVM nidus size between 3 and 6 cm (OR: 3.91; 95% CI 1.1-13.85; p = 0.035) and the presence of multiple feeders (OR: 5.08; 95% CI 1.41-18.28; p = 0.074) were predictive of failure of immediate complete occlusion. The location of the temporal lobe (OR: 7.83; p = 0.048), deep venous drainage (OR: 4.67; p = 0.112), and the presence of an intranidal aneurysm (OR: 3.58; p = 0.134) were predictors of technical complications. CONCLUSIONS Embolization of pediatric AVMs with intent to cure shows a high rate of technical complications and acceptable immediate occlusion rates. Nidus size and the presence of multiple feeders were predictive of failure of complete occlusion, while temporal lobe location, deep venous drainage, and the presence of an intranidal aneurysm were predictors of technical complications. Further studies are needed to determine the best therapeutic approach in the pediatric population.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Alameda del Corregidor 1531, La Molina 15024, Lima, Peru
| | - Diego Bustamante-Paytan
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru. .,Facultad de Medicina Humana, Universidad de San Martín de Porres, Alameda del Corregidor 1531, La Molina 15024, Lima, Peru.
| | - Kiara Camacho-Caballero
- Facultad de Medicina Humana, Universidad Científica del Sur, Lima, Peru.,CHANGE, Research Working Group, Carrera de Medicina Humana, Universidad Cientifica del Sur, Lima, Peru
| | - Angie Mayoria-Vargas
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Alameda del Corregidor 1531, La Molina 15024, Lima, Peru
| | - Rodolfo Rodríguez-Varela
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Giancarlo Saal-Zapata
- Department of Neurosurgery, Endovascular Neurosurgery Service, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
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Chen K, Dawkins D, Orbach DB, Aagaard-Kienitz B. Low profile sheaths in pediatric neurointervention: a multicenter experience. J Neurointerv Surg 2021; 14:1135-1138. [PMID: 34625510 DOI: 10.1136/neurintsurg-2021-017936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/03/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pediatric neurointervention is challenged by the appropriateness of adult catheters and devices. This multicenter report on the smallest groin access sheaths offers technical notes and clinical outcomes in the pediatric neurointerventional population. METHODS All pediatric neurointerventional cases from 2019 to 2021 were reviewed for use of a 3.3F Pediavascular or a 4F Merit Prelude Ideal low profile sheath. Hospital records were reviewed for complications and technical notes and compared with arterial groin access with the 4F Terumo Pinnacle in infants less than 1 year old, before the low profile sheaths at one author's institution were introduced. RESULTS From January 1, 2019 to March 31, 2021 there were 347 procedures performed at Boston Children's Hospital and University of Wisconsin. Forty-four procedures in 26 patients were identified in which a 3.3F (38 cases, 20 patients) or 4F (6 cases, 6 patients) sheath was used. The average age was 2.2 years (1.5 days to 18 years). Retinoblastoma intra-arterial chemotherapy infusion (18 of 44) was the most common indication. The remaining procedures comprised vein of Galen embolization (12), diagnostic cerebral angiography (13), and one preoperative tumor embolization. Morbidity included a groin hematoma and decreased pulses (4.5%). No major groin complications occurred. There was no statistically significant difference compared with the historical cohort (132 procedures), which had seven instances of decreased pulses (5.3%, p>0.05). CONCLUSION The 3.3F Pediavascular and 4F Merit Prelude Ideal sheaths are easily incorporated into the pediatric neurointerventionalist's armamentarium for infants and readily accommodate various microcatheters for distal embolization and catheterization.
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Affiliation(s)
- Karen Chen
- Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Demi Dawkins
- Neurosurgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Darren B Orbach
- Neurointerventional Radiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Beverly Aagaard-Kienitz
- Radiology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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10
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Dmytriw AA, Ha W, Bickford S, Bhatia K, Shroff M, Dirks P, Muthusami P. Long Vascular Sheaths for Transfemoral Neuroendovascular Procedures in Children. Neurointervention 2021; 16:149-157. [PMID: 34078026 PMCID: PMC8261116 DOI: 10.5469/neuroint.2021.00192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/21/2021] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To evaluate the safety and efficacy of long vascular sheaths for transfemoral neuroendovascular procedures in children. MATERIALS AND METHODS A retrospective evaluation of transfemoral neuroendovascular procedures in children <18 years, using long sheaths was undertaken analyzing procedure type, fluoroscopic times, technical success, access site and systemic complications. Twenty-seven consecutive procedures were included over a 2-year period. Mean age was 8.4 years (standard deviation [SD] 6.3) (range 17.0 months-16.3 years). RESULTS Patients were 44% female and mean weight was 35.0 kg (SD 22.8) (range 9.8-72.2 kg). A third of the procedures were performed in ≤15 kg children. The most common procedure was for embolization (n=13, 48.1%) and the most common indication was dual microcatheter technique (52%). The most common device used was the 5 Fr Cook Shuttle sheath. Mean fluoroscopy time was 61.9 minutes (SD 43.1). Of these procedures, 93% were technically successful. Femoral vasospasm, when present, was self-limiting. Complications (3/27, 11.1%) included groin hematoma (n=1), neck vessel spasm that resolved with verapamil (n=1), and intracranial thromboembolism (n=1), with no significant difference between the ≤15 kg and >15 kg subcohorts. There were no aorto-femoro-iliac or limb-ischemic complications. CONCLUSION Long vascular sheaths without short femoral sheaths can be safely used for pediatric neuroendovascular procedures as they effectively increase inner diameter access without increasing the outer sheath diameter. This property increases the range of devices used and intracranial techniques that can be safely performed without arterial compromise, thus increasing the repertoire of the neurointerventionist.
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Affiliation(s)
- Adam A Dmytriw
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Winston Ha
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Suzanne Bickford
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Kartik Bhatia
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Manohar Shroff
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
| | - Peter Dirks
- Department of Neurosurgery, Hospital for Sick Children, Toronto, ON, Canada
| | - Prakash Muthusami
- Neuroradiology and Image Guided Therapy, Hospital for Sick Children, Toronto, ON, Canada
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11
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Baro V, Gabrieli JD, Cester G, D’Errico I, Landi A, Denaro L, Causin F. Preoperative Devascularization of Choroid Plexus Tumors: Specific Issues about Anatomy and Embolization Technique. Brain Sci 2021; 11:brainsci11050540. [PMID: 33922937 PMCID: PMC8146914 DOI: 10.3390/brainsci11050540] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Surgical treatment of choroid plexus tumors is challenging, burdened by a notable risk of bleeding. Neoadjuvant chemotherapy and preoperative embolization have been attempted, with encouraging results; however, the consensus on these procedures is lacking. (2) Methods: We present a case of a 10-month-old girl who underwent preoperative embolization of a hemorrhagic choroid plexus carcinoma of the lateral ventricle via the anterior choroidal artery, followed by total resection. (3) Results: The endovascular procedure was successfully completed, despite the rectification of the anterior choroidal artery associated with the absence of flow proximal to the plexal point. Minimal bleeding was observed during resection and the patient remained neurologically intact. (4) Conclusions: The time from entrance to exit in the anterior choroidal artery should be monitored and regarded as a potential 'occlusion time' in this specific group of patients. Nevertheless, our case supports the feasibility and effectiveness of preoperative embolization of a choroid plexus carcinoma of the lateral ventricle via the anterior choroidal artery, without complications. Furthermore, we suggest the use of a fast-embolic agent, such as N-butyl cyanoacrylate glue, as the preferred agent for this specific pathology and patient population.
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Affiliation(s)
- Valentina Baro
- Academic Neurosurgery, Department of Neuroscience, University of Padova, 35100 Padova, Italy; (A.L.); (L.D.)
- Correspondence:
| | - Joseph Domenico Gabrieli
- Neuroradiology Unit, University of Padova, 35100 Padova, Italy; (J.D.G.); (G.C.); (I.D.); (F.C.)
| | - Giacomo Cester
- Neuroradiology Unit, University of Padova, 35100 Padova, Italy; (J.D.G.); (G.C.); (I.D.); (F.C.)
| | - Ignazio D’Errico
- Neuroradiology Unit, University of Padova, 35100 Padova, Italy; (J.D.G.); (G.C.); (I.D.); (F.C.)
| | - Andrea Landi
- Academic Neurosurgery, Department of Neuroscience, University of Padova, 35100 Padova, Italy; (A.L.); (L.D.)
| | - Luca Denaro
- Academic Neurosurgery, Department of Neuroscience, University of Padova, 35100 Padova, Italy; (A.L.); (L.D.)
| | - Francesco Causin
- Neuroradiology Unit, University of Padova, 35100 Padova, Italy; (J.D.G.); (G.C.); (I.D.); (F.C.)
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12
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Ha W, Dmytriw AA, Bickford S, Amirabadi A, Rea V, Muthusami P. Use of radial access sheaths for transfemoral neuroendovascular procedures in children. Neuroradiology 2021; 63:633-635. [PMID: 33559702 DOI: 10.1007/s00234-021-02664-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/01/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Pediatric neuroendovascular procedures require special considerations. Given small vessel sizes, risk for arterial injury must be weighed against use of larger devices, with the diameter of the sheath being a known association with arterial complications. We recently transitioned to using thin-walled radial sheaths for transfemoral angiography in children, given their lower profile. Here, we report on these sheaths' technical success and complications, comparing against a historical cohort where regular vascular sheaths were employed. METHODS We retrospectively recorded patient and procedural data from 168 consecutive procedures from September 2017 to January 2019 when radial-specific sheaths were exclusively used at our tertiary pediatric hospital. These results were compared to data from September 2015 to January 2017, when regular vascular sheaths were exclusively used in 152 consecutive procedures. Statistical analysis was performed using unpaired t test or chi-square test, with p < 0.05 considered statistically significant. RESULTS Patient characteristics (age, sex, weight) were not statistically different between the case and control group. No significant differences were found in the procedural data with the exception of heparin use which was higher in the radial-sheath cohort. There was a decrease in the rate of complications in the case group (1.2%) versus control group (2.6%), though not statistically different. CONCLUSION Radial-specific sheaths have numerous beneficial characteristics that make them well-suited to the pediatric population. In our study, we show that radial sheaths are equally effective and safe perioperatively. Follow-up research may show if radial sheaths used transfemorally decrease long-term complications such as limb-length discrepancy and mortality.
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Affiliation(s)
- Winston Ha
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Adam A Dmytriw
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada.
| | - Suzanne Bickford
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Afsaneh Amirabadi
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Vanessa Rea
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
| | - Prakash Muthusami
- Divisions of Neuroradiology and Image Guided Therapy, Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, M5G 1X8, Canada
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13
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Embolization of congenital hemangioma with severe hemorrhage. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2020.101772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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14
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Rodriguez-Calienes A, Bustamante-Paytan D, Camacho K, Mayoria-Vargas A, Saal-Zapata G, Rodriguez-Varela R. Early Outcomes and Complications of Endovascular Treatment of Cerebral Arteriovenous Malformations in Pediatric Patients. Pediatr Neurosurg 2021; 56:116-124. [PMID: 33601400 DOI: 10.1159/000513577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 12/03/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Arteriovenous malformations (AVMs) are the commonest cause of hemorrhagic stroke in children. Endovascular embolization is a feasible treatment modality, but cure rates are heterogenous from one series to another. We aimed to describe the immediate obliteration rates and periprocedural complications of embolization of pediatric AVMs. METHODS Between 2011 and 2019, participants below 18 years of age with AVMs treated by the same neurosurgeon at a single center were included. The clinical features, immediate angiographic results, and periprocedural complications were retrospectively collected from the clinical records. RESULTS Thirty-four embolization sessions were performed on 20 children (12 females with a mean age of 13). Intracranial hemorrhage was the most common presentation (75%), and the majority were frontal (30%) and basal ganglia (30%) lesions. An immediate complete angiographic obliteration was achieved in 9 patients (45%) with low-grade lesions (Spetzler-Martin grade I and II). NBCA was the most common embolic agent used (52.9%). Complications were reported in 3 (8.8%) out of 34 sessions. Two of them were intraoperative perforations with clinical consequences. A slight cortical hemorrhage during the procedure was observed in 1 patient without clinical repercussions. DISCUSSION This single-surgeon single-center experience suggests that endovascular treatment is a safe and efficient treatment for pediatric AVMs. Pediatric prognostic scores for a suitable selection of candidates are needed. Further studies are required to validate these results.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru, .,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru,
| | - Diego Bustamante-Paytan
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru
| | - Kiara Camacho
- Facultad de Medicina Humana, Universidad Científica del Sur, Lima, Peru
| | - Angie Mayoria-Vargas
- Grupo Estudiantil de Investigación en Neurociencias, Sociedad de Estudiantes de Medicina de la Universidad de San Martín de Porres, Lima, Peru.,Facultad de Medicina Humana, Universidad de San Martín de Porres, Lima, Peru
| | - Giancarlo Saal-Zapata
- Departamento de Neurocirugía, Servicio de Neurocirugía Endovascular, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Rodolfo Rodriguez-Varela
- Departamento de Neurocirugía, Servicio de Neurocirugía Endovascular, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
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15
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Treatment options and long-term outcomes in pediatric spinal cord vascular malformations: a case report and review of the literature. Childs Nerv Syst 2020; 36:3147-3152. [PMID: 32377828 DOI: 10.1007/s00381-020-04624-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 04/15/2020] [Indexed: 12/14/2022]
Abstract
A 16-month-old female was admitted for prolonged fever, gait ataxia, and neurogenic bowel and bladder. Neurological exam was significant for decreased sensory and motor functions in bilateral lower extremities. Initial MRI showed a thoracic spine hematoma and diagnostic angiogram revealed a large AVM and aneurysm. The patient underwent surgical resection of the hematoma and AVM, as well as clipping and later endovascular coiling of the aneurysm. Due to significant hemorrhage perioperatively, she developed spastic paraplegia improved by baclofen and onabotulinumtoxin A injections. The aims of this paper were to conduct a systematic review of the literature on pediatric spinal cord vascular malformations and analyze trends in treatment options and long-term neurological outcomes. PubMed searches were conducted using keywords "pediatric spinal vascular malformation" and "pediatric spinal AVM", yielding 34 results after abstract screening and cross-reference. Endovascular embolization was determined to have better long-term outcomes, with 10/19 (52.6%) patients with postoperative complications associated with open vascular surgeries. Open versus endovascular surgical decisions can be difficult with unique spinal AVM pathologies in pediatric patients. Important considerations such as size, location, neurological deficits, and risk of rupture are important factors to consider in treating these patients. We recommend endovascular treatment as a first-line approach due to lower risk of hemorrhage and postoperative deficits.
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16
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Gibson CR, Barnacle AM. Vascular anomalies: special considerations in children. CVIR Endovasc 2020; 3:60. [PMID: 32886264 PMCID: PMC7474047 DOI: 10.1186/s42155-020-00153-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 08/14/2020] [Indexed: 12/13/2022] Open
Abstract
The diagnosis and treatment of vascular anomalies are a large part of the caseload for paediatric interventional radiologists. Although many of the principles of sclerotherapy and embolisation are the same in adult and paediatric practice, there are some key differences in the approach for children, including some longer term thinking about managing these chronic diseases and their impact on a growing child. Vascular tumours are not often seen in adult IR practice and the rarest can be life threatening; knowledge of the commonest types and the role IR can play in their management can be instrumental in ensuring that children get appropriate treatment in a timely manner. Vascular anomalies also encompass some conditions associated with complex overgrowth, a subject that often causes confusion and uncertainty for interventional radiologists. This paper presents a simplified and practical approach to this spectrum of disease.
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Affiliation(s)
- Craig R Gibson
- Department of Medical Imaging, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Alex M Barnacle
- Department of Radiology, Great Ormond Street Hospital for Children, London, WC1N 3JH, UK.
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17
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Maharaj MM, Biju R, Khashram M, Hussain Z. Delayed Fragmentation and Distal Embolization of Retained Microcatheter Causing Lower Limb Ischemia: Case Report and Review of the Literature. World Neurosurg 2020; 140:369-373. [PMID: 32294566 DOI: 10.1016/j.wneu.2020.03.197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/26/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Endovascular microcatheter adherence and retention is an uncommon complication during brain arteriovenous malformation (AVM) embolization with glue or ethylene-vinyl alcohol copolymer that has previously reported, although there are sparse reports of symptomatic complications thereafter. CASE DESCRIPTION We present a unique complication 6 years after initial embolization of a cerebral AVM. The patient presented with acute lower limb insufficiency with computed tomography angiogram revealing fragmentation of the microcatheter and associated popliteal aneurysm. The patient underwent an emergency grafting and removal of the retained fragment and recovered without deficit postoperatively. CONCLUSIONS Fragmentation over retained microcatheters remains a concern that may be worth monitoring in the long term, although there are no recommendations for timing.
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Affiliation(s)
- Monish M Maharaj
- Department of Neurosurgery, Waikato Hospital, Hamilton, New Zealand; Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand; Faculty of Medicine, The University of Auckland, Auckland, New Zealand.
| | - Rakesh Biju
- Department of Neurosurgery, Waikato Hospital, Hamilton, New Zealand
| | - Manar Khashram
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand; Faculty of Medicine, The University of Auckland, Auckland, New Zealand
| | - Zakier Hussain
- Department of Neurosurgery, Waikato Hospital, Hamilton, New Zealand
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18
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Lv X, Jiang C, Wang J. Pediatric intracranial arteriovenous shunts: Advances in diagnosis and treatment. Eur J Paediatr Neurol 2020; 25:29-39. [PMID: 31996298 DOI: 10.1016/j.ejpn.2019.12.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/24/2019] [Accepted: 12/29/2019] [Indexed: 02/07/2023]
Abstract
Pediatric intracranial arteriovenous shunts (IAVSs) comprise a wide range of lesions, including pial arteriovenous malformation (AVM) and arteriovenous fistula (AVF), dural arteriovenous fistula (DAVF) and vein of Galen aneurysmal malformation (VGAM). We provide an overview of pediatric IAVSs, encompassing both diagnosis and endovascular treatment. We include references from pertinent literature and representative cases from our hospital. Pediatric IAVS are frequently associated two broader conditions, such as capillary malformation-arteriovenous malformation (CM-AVM) and hereditary hemorrhagic telangiectasia (HHT). These conditions and the associated genetic mutations have only recently been described. Their impact on the brain will be different in the prenatal period, in neonates, in infants, and in children, with variable symptoms according to each age group and the current strategies of endovascular treatment in the management of these vascular lesions will be discussed. This review could improve the understanding of pediatric IAVSs and their diagnosis and treatment.
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Affiliation(s)
- Xianli Lv
- Neurosurgery Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
| | - Chuhan Jiang
- Neurosurgery Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - James Wang
- Neurosurgery Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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19
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Alias Q, Boulouis G, Blauwblomme T, Benichi S, Beccaria K, Gariel F, Garzelli L, Meyer P, Kossorotoff M, Boddaert N, Brunelle F, Naggara O. First Line Onyx Embolization in Ruptured Pediatric Arteriovenous Malformations : Safety and Efficacy. Clin Neuroradiol 2019; 31:155-163. [PMID: 31802150 DOI: 10.1007/s00062-019-00861-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/18/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Brain arteriovenous malformations (bAVM) are the main cause of pediatric intracerebral hemorrhage (pICH). Embolization with Onyx (ev3, Irvine, CA, USA) in children with ruptured bAVM has been infrequently reported. The aim of this study was to assess the safety and efficacy profile of Onyx embolization as first line endovascular treatment of ruptured pediatric bAVMs. METHODS Children with non-traumatic pICH due to bAVM rupture at a pediatric quaternary care center were prospectively enrolled in a registry and retrospectively analyzed between 2013 and 2018. Clinical and demographic data, treatment modalities and clinical imaging follow-up were retrieved, and detailed procedural data were retrospectively assessed by two investigators. The safety (procedural morbidity and mortality) and efficacy (obliteration and interval rebleeding) were evaluated. RESULTS In this study 29 children treated for a bAVM by Onyx embolization were included (14 girls, 48%; median age 11.1 years, interquartile range, IQR 8.1-12.7 years) with a total of 72 endovascular sessions (median of 2 sessions per patient IQR 1-3). The AVMs were deeply located in 23 patients (79%). No systemic complications occurred, and no child experienced embolization-related persistent neurological deficits. Non-clinically relevant complications were observed during five procedures, unrelated to Onyx. After a mean follow-up of 31 months from rupture complete obliteration rates were 100%, 89%, 29%, 14% in bAVM Spetzler Martin grades I, II, III and IV-V, respectively. CONCLUSION It was found that Onyx embolization is safe and represents a good option for an initial treatment approach, in a sequential treatment strategy for pediatric ruptured brain AVMs. Younger age may not be an argument to deny Onyx embolization.
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Affiliation(s)
- Quentin Alias
- Pediatric Radiology, Necker Children Hospital, Paris, France
| | - Grégoire Boulouis
- Pediatric Radiology, Necker Children Hospital, Paris, France.,INSERM UMR 1266 IMA-BRAIN, Department of Neuroradiology, CHSA, Université de Paris, Paris, France
| | - Thomas Blauwblomme
- Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France
| | - Sandro Benichi
- Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France
| | - Kevin Beccaria
- Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France
| | - Florent Gariel
- Pediatric Radiology, Necker Children Hospital, Paris, France.,INSERM UMR 1266 IMA-BRAIN, Department of Neuroradiology, CHSA, Université de Paris, Paris, France.,Pediatric Neurosurgery Department, Necker Children Hospital, APHP, Paris, France.,Institut Imagine, INSERM UMR 1163, Université De Paris, Paris, France.,Department of Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | | | - Philippe Meyer
- Pediatric Neuro ICU, Necker Children Hospital, APHP, Paris, France
| | - Manoelle Kossorotoff
- Department of Pediatric Neurology, French Centre for Pediatric Stroke, APHP University Necker Children Hospital, Paris, France
| | | | | | - Olivier Naggara
- Pediatric Radiology, Necker Children Hospital, Paris, France. .,INSERM UMR 1266 IMA-BRAIN, Department of Neuroradiology, CHSA, Université de Paris, Paris, France.
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20
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Zaki Ghali MG, Kan P, Britz GW. Curative Embolization of Arteriovenous Malformations. World Neurosurg 2019; 129:467-486. [DOI: 10.1016/j.wneu.2019.01.166] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
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21
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Al-Smadi AS, Ansari SA, Shokuhfar T, Malani A, Sattar S, Hurley MC, Potts MB, Jahromi BS, Alden TD, Dipatri AJ, Shaibani A. Safety and outcome of combined endovascular and surgical management of low grade cerebral arteriovenous malformations in children compared to surgery alone. Eur J Radiol 2019; 116:8-13. [PMID: 31153578 DOI: 10.1016/j.ejrad.2019.02.016] [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: 10/19/2018] [Revised: 01/17/2019] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To evaluate the outcomes of combined preoperative embolization and microsurgical resection in comparison with microsurgical resection alone as the current standard of care for low-grade cerebral arteriovenous malformations (AVM) in the pediatric population. MATERIALS & METHODS We performed a single-center retrospective study of pediatric patients presenting with Spetzler-Martin (SM) grade I and II cerebral AVMs at a high-volume tertiary pediatric hospital between January 2005 and September 2016. Low grade AVM patients were divided into two groups: pre-operative embolization with subsequent microsurgical resection or microsurgical resection alone. Patient demographics, clinical and imaging presentations, AVM morphological characteristics, post-operative complications, and mid to long-term clinical outcomes were studied. Post-embolization and post-surgical outcomes were assessed prior to and after treatment, at 3 months and at final follow-up using the modified Rankin Scale (mRS) to compare both final independent (mRS 0-2) and favorable (no change or improved mRS) clinical outcomes for comparison between study groups. Statistical associations of patient demographics, AVM characteristics/SM grading, and treatment modality group with post-operative complications were performed using univariate logistic regression analysis. RESULTS Thirty-four patients with low grade cerebral AVMs met the study inclusion criteria (mean age 10.6 ± 3.4 years; range 3-16 years, 22M:12 F). Twenty patients (59%) presented with ruptured AVMs. Twenty-five patients (73.5%) underwent combined treatment with embolization and microsurgical resection, while 9/34 (26.5%) underwent microsurgical resection alone. A total of 35 embolization procedures performed in 25 patients (Mode, 1; Range, 1-7) were associated with two minor post-embolization and 7 subsequent post-surgical (28%) complications, resulting in clinical deterioration in a single patient. Microsurgical resection alone was associated with 3 post-surgical complications (33%), resulting in permanent neurological disability in a single patient. There was no significance association of post-operative complications with either treatment modality group, combined treatment versus surgical resection alone [OR:1.13; 95% CI:0.23-5.62; p-value 0.88]. SM Grade II and eloquent locations were found to be significantly associated with post-surgical complications of low grade pediatric cerebral AVMs [OR 13.2 and OR 8 respectively, p-value 0.004 and 0.005). On mean follow-up time of 35.7 months, final clinical outcome was favorable in the majority of both treatment arms with no dependent (mRS>2) patients in the combined endovascular and surgical cohort. Two patients in the surgical cohort failed to achieve independent functional status, primarily due to a pre-operative morbid status (p-value 0.015). However, there was no significant difference in favorable outcomes between the treatment groups [p-value 0.14]. CONCLUSION Our study suggests equivalent safety and favorable clinical outcomes related to combined endovascular embolization and microsurgical resection of low grade pediatric cerebral AVMs in comparison to microsurgical resection alone. On long term clinical follow-up, the vast majority of patients achieved an independent and favorable functional status irrespective of pre-operative embolization.
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Affiliation(s)
- Anas S Al-Smadi
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Sameer A Ansari
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Tahaamin Shokuhfar
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Aresha Malani
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Saadia Sattar
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Michael C Hurley
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Matthew B Potts
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Babak S Jahromi
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Tord D Alden
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Arthur J Dipatri
- Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| | - Ali Shaibani
- Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States; Department of Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States.
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Primary Intracranial Rhabdomyosarcoma in the Cerebellopontine Angle Resected After Preoperative Embolization. World Neurosurg 2018; 116:110-115. [DOI: 10.1016/j.wneu.2018.05.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/06/2018] [Accepted: 05/08/2018] [Indexed: 11/22/2022]
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23
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Shokuhfar T, Hurley MC, Al-Smadi A, Ansari SA, Potts MB, Jahromi BS, Alden TD, Shaibani A. MynxGrip vascular closure device use in pediatric neurointerventional procedures. J Neurosurg Pediatr 2018; 21:466-470. [PMID: 29498605 DOI: 10.3171/2017.11.peds17481] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The aim of this paper was assess the efficacy and safety of using the MynxGrip arterial closure device in pediatric neuroendovascular procedures where the use of closure devices remains off-label despite their validation and widespread use in adults. METHODS A retrospective review of all pediatric patients who underwent diagnostic or interventional neuroendovascular procedures at the authors' institution was performed. MynxGrip use was predicated by an adequate depth of subcutaneous tissue and common femoral artery (CFA) diameter. Patients remained on supine bedrest for 2 hours after diagnostic procedures and for 3 hours after therapeutic procedures. Patient demographics, procedural details, hemostasis status, and complications were recorded. RESULTS Over 36 months, 83 MynxGrip devices were deployed in 53 patients (23 male and 30 female patients; mean age 14 years) who underwent neuroendovascular procedures. The right-side CFA was the main point of access for most procedures. The mean CFA diameter was 6.24 mm and ranged from 4 mm to 8.5 mm. Diagnostic angiography comprised 46% of the procedures. A single device failure occurred without any sequelae; the device was extracted, and hemostasis was achieved by manual compression with the placement of a Safeguard compression device. No other immediate or delayed major complications were recorded. CONCLUSIONS MynxGrip can be used safely in the pediatric population for effective hemostasis and has the advantage of earlier mobilization.
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Affiliation(s)
| | - Michael C Hurley
- Departments of1Radiology.,3Neurology, Northwestern University Feinberg School of Medicine, Chicago; and
| | | | - Sameer A Ansari
- Departments of1Radiology.,3Neurology, Northwestern University Feinberg School of Medicine, Chicago; and
| | | | | | - Tord D Alden
- 2Neurological Surgery, and.,Departments of4Neurosurgery and
| | - Ali Shaibani
- Departments of1Radiology.,2Neurological Surgery, and.,5Medical Imaging, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
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Kieran I, Zakaria Z, Kaliaperumal C, O'Rourke D, O'Hare A, Laffan E, Caird J, King MD, Murray DJ. Possible toxicity following embolization of congenital giant vertex hemangioma: case report. J Neurosurg Pediatr 2017; 19:296-299. [PMID: 27935467 DOI: 10.3171/2016.5.peds13345] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe the case of a 3-year-old boy with a giant congenital vertex hemangioma who underwent presurgical embolization with Onyx (ethylene-vinyl alcohol copolymer dissolved in dimethyl sulfoxide) and Glubran ( N-butyl-2-cyanoacrylate). This vascular tumor had no intracranial vascular communication as assessed by pre-embolization MRI and catheter angiography. All embolizations were performed by direct percutaneous injection. One week following the last embolization procedure the child presented with a 24-hour history of ataxia and extrapyramidal tremor. He was diagnosed with a possible immune-mediated reaction to Onyx or Glubran, which was treated with an urgent surgical excision of the hemangioma followed by intravenous administration of immunoglobulin and steroids. To the authors' knowledge, this is the first case of possible immune-mediated toxicity secondary to either Onyx or Glubran administration. This case highlights the need for awareness of potential toxic reactions to these embolic agents in the treatment of hemangiomas in the pediatric patient.
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Affiliation(s)
| | | | | | | | - Alan O'Hare
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Eoghan Laffan
- Radiology, Temple Street Children's University Hospital; and
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Incidental occlusion of anterior spinal artery due to Onyx reflux in embolization of spinal type II arteriovenous malformation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:75-79. [DOI: 10.1007/s00586-016-4767-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 09/01/2016] [Indexed: 10/20/2022]
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26
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Safety and outcomes of preoperative embolization of intracranial hemangioblastomas: A systematic review. Clin Neurol Neurosurg 2016; 150:143-151. [PMID: 27668858 DOI: 10.1016/j.clineuro.2016.09.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/05/2016] [Accepted: 09/18/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION While preoperative embolization is often reserved for large and highly vascular tumors in order to minimize blood loss, its safety and efficacy in the treatment of hemangioblastomas (HB) is unclear. We present the largest systematic review focusing on the safety and outcome of preoperative embolization of intracranial HB. MATERIALS AND METHODS To identify all cases of preoperative embolization for HB, a literature search was conducted via Medline (OVID and PubMed), Scopus, Embase, and Web of Science. Studies that were in English, included intracranial hemangioblastomas treated with preoperative embolization and provided sufficient disaggregated clinical data for each patient were included. Historical control patients with non-embolized intracranial HB undergoing resection were similarly identified. RESULTS A total of 111 patients that underwent preoperative embolization of HB prior to planned resection were identified. Patient age ranged from 12 to 72 years, with a cohort of 63% males and 36% females. Nine studies comprising 392 non-embolized patients were included as controls. Gross total resection was achieved in 83.7% of embolized and 95.6% of non-embolized patients. Intraoperative blood transfusion was required in 15.3% of embolized and 0.51% of non-embolized controls, while rates of post-operative hemorrhage were 8.4% and 1.6%, respectively. Complication rates from embolization were 11.7% and following consequent surgery were 20.7%. DISCUSSION Embolization did not increase rates of gross total resection, decrease estimated blood loss, or decrease incidence of complications. Not only does embolization fail to mitigate surgical risks, the embolization procedure itself carries significant risk for complications. Embolization should not be standard of care for intracranial HB.
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27
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Hansen D, Kan PT, Reddy GD, Mohan AC, Jea A, Lam S. Pediatric knowledge update: Approach to the management of vein of Galen aneurysmal malformations in neonates. Surg Neurol Int 2016; 7:S317-21. [PMID: 27274404 PMCID: PMC4879847 DOI: 10.4103/2152-7806.182415] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 03/26/2016] [Indexed: 12/14/2022] Open
Affiliation(s)
- Daniel Hansen
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Peter T Kan
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Gaddum D Reddy
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Arvind Chintagumpala Mohan
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Andrew Jea
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Sandi Lam
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Curative embolization of pediatric intracranial arteriovenous malformations using Onyx: the role of new embolization techniques on patient outcomes. Neuroradiology 2016; 58:585-594. [DOI: 10.1007/s00234-016-1666-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 02/12/2016] [Indexed: 11/26/2022]
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Lin N, Smith ER, Scott RM, Orbach DB. Safety of neuroangiography and embolization in children: complication analysis of 697 consecutive procedures in 394 patients. J Neurosurg Pediatr 2015; 16:432-8. [PMID: 26114994 DOI: 10.3171/2015.2.peds14431] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The safe treatment of children using catheter-based angiography and embolization poses unique challenges because of the technical factors regarding the size and fragility of access and target vessels, as well as unique pediatric cerebrovascular pathologies. The complication rates for neurointerventional procedures in children have not been established. METHODS The records of a consecutive cohort of pediatric patients who underwent neuroangiography and/or embolization between 2007 and 2013 were reviewed retrospectively to identify both intraprocedural and postprocedural complications. Demographic and clinical risk factors were analyzed with a multivariate logistic regression model. RESULTS The 697 consecutive procedures consisted of 429 diagnostic angiograms and 268 embolizations (mean age of patients 11.1 years; range 4 days to 18 years; 217 females). There were 130 intracranial, 122 extracranial, and 16 spinal embolizations. Pathologies included 28 intracranial arteriovenous malformations (AVMs), 12 spinal AVMs, 19 aneurysms, 29 vein of Galen malformations, 29 dural arteriovenous fistulas, 96 extracranial AVMs, 39 tumors, 3 strokes, and 13 others. Overall, 2 intraprocedural and 1 postprocedural complication (0.7%) occurred in the diagnostic group, all of which were nonneurological events. In the embolization group, 7 intraprocedural and 11 postprocedural complications (6.7%) were observed. Of these complications, 15 were nonneurological events (5.6%), 1 was a short-term neurological event (0.4%), and 2 were long-term neurological events (0.7%). CONCLUSIONS Neither the technical challenges posed by children's access and target vessels nor the unique neuro-vascular pathologies seen in children need result in an elevated morbidity rate related to neuroangiography and embolization. At a dedicated high-volume center, the complication rates may be lower than those for comparable procedures performed in adults.
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Affiliation(s)
- Ning Lin
- Department of Neurosurgery, Weill Cornell Medical Center, New York, New York; and.,Department of Neurosurgery and
| | | | | | - Darren B Orbach
- Division of Interventional and Neurointerventional Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Ethylene vinyl alcohol copolymer (Onyx®) in peripheral interventional radiology: indications, advantages and limitations. Diagn Interv Imaging 2015; 96:319-26. [PMID: 25704146 DOI: 10.1016/j.diii.2014.11.030] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 11/21/2014] [Accepted: 11/24/2014] [Indexed: 12/31/2022]
Abstract
Onyx(®) is a remarkable liquid embolizing agent that may allow a well-trained operator to undertake challenging embolization procedures. In multiple interventional radiology indications, the physico-chemical properties of Onyx(®) allow safe embolization. The purpose of this article is to review the advantages and disadvantages of Onyx(®) and identify its main indications.
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Hashemi N, Ling JD, Soparkar C, Sami M, Ellezam B, Klucznik R, Lee AG, Chévez-Barrios P. Transarterial Onyx Embolization of an Orbital Solitary Fibrous Tumor. Ocul Oncol Pathol 2015; 1:98-102. [PMID: 27171911 DOI: 10.1159/000370048] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 11/14/2014] [Indexed: 11/19/2022] Open
Abstract
Solitary fibrous tumor (SFT) is an uncommon mesenchymal neoplasm sometimes found in the orbit. We report a case of an aggressive orbital SFT with enlarged feeding vessels that was successfully resected immediately after transarterial embolization with Onyx (ethylene vinyl alcohol copolymer). To our knowledge, this is the first report showing the histopathology of Onyx embolization material in an orbital SFT.
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Affiliation(s)
- Nafiseh Hashemi
- The University of Texas Health Sciences, University of Texas, Houston Tex., USA
| | - Jeanie D Ling
- Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston Tex., USA
| | - Charles Soparkar
- Department of Plastic Surgery, MD Anderson Cancer Center, University of Texas, Houston Tex., USA; Department of Ophthalmology, MD Anderson Cancer Center, University of Texas, Houston Tex., USA; Department of Ophthalmology, MD Anderson Cancer Center, University of Texas, Houston Tex., USA; Department of Division of Head and Neck Surgery, MD Anderson Cancer Center, University of Texas, Houston Tex., USA; Department of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medical College, New York, N.Y., USA
| | - Mirwat Sami
- Department of Ophthalmology, MD Anderson Cancer Center, University of Texas, Houston Tex., USA
| | - Benjamin Ellezam
- Department of Pathology and Genomic Medicine, MD Anderson Cancer Center, University of Texas, Houston Tex., USA
| | - Richard Klucznik
- Department of Radiology, Houston Methodist Hospital, MD Anderson Cancer Center, University of Texas, Houston Tex., USA
| | - Andrew G Lee
- The University of Texas Health Sciences, University of Texas, Houston Tex., USA; Department of Baylor College of Medicine, MD Anderson Cancer Center, University of Texas, Houston Tex., USA; Department of Ophthalmology, MD Anderson Cancer Center, University of Texas, Houston Tex., USA; Department of Ophthalmology, The University of Texas Medical Branch, Galveston, Tex., USA; Department of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medical College, New York, N.Y., USA; Department of Ophthalmology, The University of Iowa Hospitals and Clinic, Iowa City, Iowa, USA
| | - Patricia Chévez-Barrios
- Department of Baylor College of Medicine, MD Anderson Cancer Center, University of Texas, Houston Tex., USA; Department of Ophthalmology, MD Anderson Cancer Center, University of Texas, Houston Tex., USA; Department of Pathology and Genomic Medicine, MD Anderson Cancer Center, University of Texas, Houston Tex., USA; Department of Pathology and Laboratory Medicine, MD Anderson Cancer Center, University of Texas, Houston Tex., USA; Pathology and Laboratory Medicine and Ophthalmology, Weill Cornell Medical College, New York, N.Y., USA
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Ladner TR, He L, Lakomkin N, Davis BJ, Cheng JS, Devin CJ, Mocco J. Minimizing bleeding complications in spinal tumor surgery with preoperative Onyx embolization via dual-lumen balloon catheter. J Neurointerv Surg 2014; 8:210-5. [DOI: 10.1136/neurintsurg-2014-011505] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 11/24/2014] [Indexed: 11/03/2022]
Abstract
BackgroundIntraoperative bleeding is a significant risk in surgery for highly vascular spinal tumors, but preoperative embolization can safely decrease intraoperative blood loss in extrinsic spine tumors. Onyx, widely used for cerebrovascular embolization, has been increasingly used as an embolic agent for preoperative spinal tumor embolization. The Scepter catheter, a dual-lumen balloon catheter, may improve tumor parenchymal penetration without the danger and limitations of significant embolic reflux. This may reduce bleeding risk during spinal surgery.MethodsEleven consecutive cases of preoperative Onyx embolization of extrinsic spinal tumors were identified, all of whom had subsequent spinal surgery. Demographic data and clinical variables were collected. Patients were divided into Scepter (n=6) and non-Scepter (n=5) groups. The Mann–Whitney U test was used to compare continuous outcome variables and the Fisher exact test was used to compare categorical variables.ResultsEstimated blood loss in the Scepter group was significantly lower than in the non-Scepter group (584±124 vs 2400±738 mL, p=0.004). The volume of intraoperative transfusion was also significantly lower (1.2±0.4 vs 5.8±1.7 units, p=0.004). There was no significant difference in the number of vessels embolized, vials of Onyx used, use of coiling adjunct, contrast load, radiation dose, or fluoroscopy time per pedicle (p>0.05).ConclusionsThe addition of the Scepter catheter to preoperative Onyx embolization is safe and feasible. In this small series, the Scepter catheter was associated with a reduction of intraoperative bleeding by 76% and a 79% lower transfusion volume. This was not accompanied by any unwanted increase in vials of Onyx used, contrast load, radiation dose, or fluoroscopy time.
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Abstract
In this article, the indications for, technical principles of, and complications/outcomes after Onyx cerebral aneurysm embolization are reviewed.
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Proliferative ischemic retinopathy after arteriovenous malformation embolization in a child with hereditary hemorrhagic telangiectasia. Retin Cases Brief Rep 2014; 8:219-22. [PMID: 25372443 DOI: 10.1097/icb.0000000000000047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe a case of hereditary hemorrhagic telangiectasia, presenting with multiple branch retinal artery occlusions, retinal ischemia, neovascularization, and vitreous hemorrhage after cerebral arteriovenous malformation embolization. METHODS The authors report a 7-year-old patient with decreased vision in his left eye after embolization of a pineal arteriovenous malformation secondary to hereditary hemorrhagic telangiectasia. Ophthalmic evaluation, fundus photography, fluorescein angiography, spectral domain optical coherence tomography, electroretinogram, examination under anesthesia, and pars plana vitrectomy (PPV) were performed. RESULTS Fundus examination of the left eye revealed extensive posterior segment ischemia, vascular tortuosity, and vitreous hemorrhage. Fluorescein angiography was remarkable for partial obstruction of retinal arteries, midperipheral nonperfusion, and associated leakage from multiple areas of neovascularization. Spectral domain optical coherence tomography was normal. Electroretinogram demonstrated decreased b-wave amplitude. The patient was subsequently treated with 25-gauge pars plana vitrectomy, panretinal endophotocoagulation, and intravitreal bevacizumab. Five weeks after surgery, best-corrected visual acuity had improved to 20/40, and examination showed resolution of vitreous hemorrhage and neovascularization. CONCLUSION Retinal vascular abnormalities, posterior segment ischemia, and vitreous hemorrhage suggested a combination of retinal involvement of hereditary hemorrhagic telangiectasia complicated by nontarget embolization.
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Abstract
In this article, the authors review general principles and technical details of preoperative embolization of various hypervascular head, neck, and spinal tumors encountered in contemporary neuroendovascular practice. Indications, treatment goals, techniques, outcomes, and complications are discussed, and illustrative case examples are presented.
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Affiliation(s)
- Ramsey Ashour
- Department of Neurological Surgery, Lois Pope LIFE Center, University of Miami Miller School of Medicine, 1095 Northwest 14th Terrace, 2nd Floor, (D4-6), Miami, FL 33136-1060, USA.
| | - Ali Aziz-Sultan
- Department of Neurosurgery, Brigham & Women's Hospital, 75 Francis Street, PBB-311, Boston, MA 02115, USA
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Affiliation(s)
- Giuseppe Lanzino
- 1Departments of Neurologic Surgery and
- 2Radiology, Mayo Clinic, Rochester, Minnesota
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Ghobrial GM, Chalouhi N, Harrop J, Dalyai RT, Tjoumakaris S, Gonzalez LF, Hasan D, Rosenwasser RH, Jabbour P. Preoperative spinal tumor embolization: an institutional experience with Onyx. Clin Neurol Neurosurg 2013; 115:2457-63. [PMID: 24169150 DOI: 10.1016/j.clineuro.2013.09.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 09/05/2013] [Accepted: 09/29/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Preoperative embolization has the potential to decrease intraoperative blood loss and facilitate spinal cord decompression and tumor resection. OBJECTIVE We report our institutional experience with the embolization of hypervascular extradural spinal tumors with Onyx as well as earlier embolic agents in a series of 28 patients. METHODS A retrospective case review was conducted on patients undergoing preoperative transarterial embolization of a spinal tumor between 1995 and 2012 at our institution. RESULTS Twenty-eight patients met the inclusion criteria, with a mean age of 60.6 years. Twenty-eight patients had metastatic tumors. In 14 (50%) patients the metastases were from renal cell carcinomas. Fifty-four vessels were embolized using PVA, NBCA, Onyx, coils, or embospheres. Sixteen patients were treated with Onyx, 6 patients with PVA, 3 patients with embospheres, 2 patients with NBCA, and 3 patients with a combination of embolic agents. The average decrease in tumor blush was 97.8% with Onyx versus 92.7% with the rest of the embolic agents (p=0.08). The estimated blood loss was 1616ml (range 350-5000ml). Blood loss was 750cm(3) on average with Onyx versus 1844 with the rest of the embolic agents (p=0.14). The mean length of stay was 16 days. The mortality rate was zero. Pre- and post-operative modified Rankin Score (mRS) did not differ significantly in the series (3.12 versus 3.10, respectively, p=0.9). CONCLUSION In our experience, the use of transarterial tumor embolization as an adjunct for spinal surgery is a safe and feasible option.
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Affiliation(s)
- George M Ghobrial
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA
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Factors determining the success of endovascular treatments among patients with spinal dural arteriovenous fistulas. Neuroradiology 2013; 55:1389-95. [DOI: 10.1007/s00234-013-1285-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 09/23/2013] [Indexed: 11/26/2022]
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Honarmand AR, Ansari SA, Soltanolkotabi M, Tomita T, Alden TD, Hurley MC, Schoeneman SE, Shaibani A. Use of Onyx for endovascular embolization of pediatric spinal perimedullary (Type IV) fistula: case report. Clin Neurol Neurosurg 2013; 115:2260-3. [PMID: 23932489 DOI: 10.1016/j.clineuro.2013.07.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 07/12/2013] [Accepted: 07/14/2013] [Indexed: 11/16/2022]
Affiliation(s)
- Amir R Honarmand
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Losey AD, Lillaney P, Martin AJ, Halbach VV, Cooke DL, Dowd CF, Higashida RT, Saloner DA, Wilson MW, Saeed M, Hetts SW. Safety of retained microcatheters: an evaluation of radiofrequency heating in endovascular microcatheters with nitinol, tungsten, and polyetheretherketone braiding at 1.5 T and 3 T. J Neurointerv Surg 2013; 6:314-9. [PMID: 23685793 DOI: 10.1136/neurintsurg-2013-010746] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The use of ethylene-vinyl alcohol copolymer for liquid embolization of cranial vascular lesions has resulted in microcatheter fragments entrapped in patients following endovascular procedures. Undergoing subsequent diagnostic MRI examinations poses a safety concern due to the possibility of radiofrequency heating of the metallic braid incorporated into the microcatheter. Heating of nitinol, tungsten, and polyetheretherketone (PEEK) braided microcatheters was assessed and compared using a phantom model. METHODS Microcatheters coupled with fluoroptic temperature probes were embedded in a polyacrylamide gel within a head and torso phantom. Experiments were performed at 1.5 T and 3 T, analyzing the effects of different catheter immersion lengths, specific absorption rate (SAR) levels, short clinical scans, long clinical scans, and microcatheter fragment lengths. RESULTS The maximal increase in temperature for the nitinol braided microcatheter during a 15 min scan was 3.06°C using the T1 fast spin echo sequence at 1.5 T and 0.45°C using the balanced steady state free precession sequence at 3 T. The same scans for fragment lengths of 9, 18, 36, and 72 cm produced maximal temperature rises of 0.68, 0.80, 1.70, and 1.07°C at 1.5 T, respectively. The temperature changes at 3 T for these fragment lengths were 0.66, 0.83, 1.07, and 0.72°C, respectively. The tungsten and PEEK braided microcatheters did not demonstrate heating. CONCLUSIONS Substantial heating of nitinol braided microcatheters occurred and was a function of SAR level and geometric considerations. SAR and time limitations on MR scanning are proposed for patients with this microcatheter entrapped in their vasculature. In contrast, tungsten and PEEK braided microcatheters showed potential safe use in MRI.
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Affiliation(s)
- Aaron D Losey
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
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Pediatric neurosurgery-science, art, and humility: reflection of personal experience. Childs Nerv Syst 2013; 29:1403-14. [PMID: 24013313 PMCID: PMC3766518 DOI: 10.1007/s00381-013-2157-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 05/08/2013] [Indexed: 10/26/2022]
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