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Rasyid A, Widjaya N, Harris S, Kurniawan M, Mesiano T, Hidayat R, Harsono AR, Nugroho SW, Yunus RE, Wiyarta E. Endovascular embolization of Spetzler-Martin Grade I brain arteriovenous malformations: A case report on patient-centered neurointervention. Radiol Case Rep 2024; 19:2905-2910. [PMID: 38737177 PMCID: PMC11087695 DOI: 10.1016/j.radcr.2024.03.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 05/14/2024] Open
Abstract
Brain arteriovenous malformations (AVM) present complex treatment decisions, particularly for low-grade AVM where surgical resection is often considered the standard. This case report emphasizes the importance of patient preferences and cultural considerations in selecting endovascular embolization over traditional surgical approaches for Spetzler-Martin Grade I AVM management, highlighting the evolving practice of patient-centered care in neurointervention. A 30-year-old male presented with recurrent seizures, characterized by a sudden onset of headache followed by speech arrest, without any preceding medical history of neurological deficits. Initial physical examination revealed no focal neurological deficits. Non-contrast computed tomography, magnetic resonance imaging, and magnetic resonance angiography suggested an AVM involving the cortical-subcortical regions of the left frontal lobe, measuring approximately 1.7 × 2.6 × 1.5 cm, fed by the left middle cerebral artery M3 segment, and draining into the superior sagittal sinus. Spetzler-Martin Grade I classification was confirmed via digital subtraction angiography. Given the patient's strong preference against invasive procedures, driven by personal and cultural beliefs, endovascular embolization was selected as the treatment strategy. Post-embolization, the patient showed marked symptomatic improvement with no evidence of residual AVM on follow-up imaging, and no postprocedure complications were reported. This case highlights the importance of considering patient preferences in AVM treatment planning, illustrating that endovascular embolization can be an effective and less invasive alternative to surgery in selected patients, reinforcing the need for personalized, patient-centered approaches in neurointerventional care.
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Affiliation(s)
- Al Rasyid
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-RSUPN Cipto Mangunkusumo, 10430, Jakarta, Indonesia
| | - Nita Widjaya
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-RSUPN Cipto Mangunkusumo, 10430, Jakarta, Indonesia
| | - Salim Harris
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-RSUPN Cipto Mangunkusumo, 10430, Jakarta, Indonesia
| | - Mohammad Kurniawan
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-RSUPN Cipto Mangunkusumo, 10430, Jakarta, Indonesia
| | - Taufik Mesiano
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-RSUPN Cipto Mangunkusumo, 10430, Jakarta, Indonesia
| | - Rakhmad Hidayat
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-RSUPN Cipto Mangunkusumo, 10430, Jakarta, Indonesia
| | - Adrian Ridski Harsono
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-RSUPN Cipto Mangunkusumo, 10430, Jakarta, Indonesia
| | - Setyo Widi Nugroho
- Department of Neurosurgery, Faculty of Medicine, Universitas Indonesia-RSUPN Cipto Mangunkusumo, 10430, Jakarta, Indonesia
| | - Reyhan Eddy Yunus
- Department of Radiology, Faculty of Medicine, Universitas Indonesia-RSUPN Cipto Mangunkusumo, 10430, Jakarta, Indonesia
| | - Elvan Wiyarta
- Department of Neurology, Faculty of Medicine, Universitas Indonesia-RSUPN Cipto Mangunkusumo, 10430, Jakarta, Indonesia
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Puthuran M, Gravino G, Babatola F, Pullicino R, Masri S, Biswas S, Chapot R, Chandran A. Primary endovascular embolisation of intracranial arteriovenous malformations (AVM)-UK single centre experience. Neuroradiology 2024; 66:227-236. [PMID: 37999787 DOI: 10.1007/s00234-023-03258-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/19/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE Intracranial arteriovenous malformations (AVMs) treated at our institution with modern techniques of endovascular intervention were analysed for the rate of complete occlusion, associated morbidity, and mortality. To our knowledge, this is the first series from the UK evaluating the effectiveness of endovascular embolisation as a primary treatment for selected cases. METHODS All newly referred AVMs between January 2017 and June 2022 were reviewed and those treated with primary endovascular intervention were identified. Details of the endovascular procedures were retrospectively reviewed. RESULTS In 5½ years, 41.1% of AVMs referred to our institution have been triaged for primary endovascular intervention. Sixty-eight AVMs were embolised and followed-up: 44 ruptured and 24 unruptured. Spetzler-Martin grading varied from I to III, and a single AVM was grade IV. The approach was arterial in 73.5%, solely venous in 7.4%, and combined in 19.1%. The mean follow-up was 18 months for imaging and 26 months for clinical assessment. Complete obliteration was achieved in 95.6%. Ruptured AVM cohort: The rate of functional deterioration was 13.6%. Unruptured AVM cohort: The rate of functional deterioration secondary to complications from embolisation was 4.2%. CONCLUSIONS Endovascular embolisation may be a favourable option for primary AVM treatment in carefully selected patients. However, selection criteria need to be better delineated for more specialists to consider this as a primary therapy.
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Affiliation(s)
- Mani Puthuran
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Gilbert Gravino
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK.
| | - Feyi Babatola
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | | | - Souhyb Masri
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | | | | | - Arun Chandran
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
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Tang W, Chen Y, Ma L, Chen Y, Yang B, Li R, Li Z, Wu Y, Wang X, Guo X, Zhang W, Chen X, Lv M, Zhao Y, Guo G. Current perspectives and trends in the treatment of brain arteriovenous malformations: a review and bibliometric analysis. Front Neurol 2024; 14:1327915. [PMID: 38274874 PMCID: PMC10808838 DOI: 10.3389/fneur.2023.1327915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/19/2023] [Indexed: 01/27/2024] Open
Abstract
Background Currently, there is a lack of intuitive analysis regarding the development trend, main authors, and research hotspots in the field of cerebral arteriovenous malformation treatment, as well as a detailed elaboration of possible research hotspots. Methods A bibliometric analysis was conducted on data retrieved from the Web of Science core collection database between 2000 and 2022. The analysis was performed using R, VOSviewer, CiteSpace software, and an online bibliometric platform. Results A total of 1,356 articles were collected, and the number of publications has increased over time. The United States and the University of Pittsburgh are the most prolific countries and institutions in the field. The top three cited authors are Kondziolka D, Sheehan JP, and Lunsford LD. The Journal of Neurosurgery and Neurosurgery are two of the most influential journals in the field of brain arteriovenous malformation treatment research, with higher H-index, total citations, and number of publications. Furthermore, the analysis of keywords indicates that "aruba trial," "randomised trial," "microsurgery," "onyx embolization," and "Spetzler-Martin grade" may become research focal points. Additionally, this paper discusses the current research status, existing issues, and potential future research directions for the treatment of brain arteriovenous malformations. Conclusion This bibliometric study comprehensively analyses the publication trend of cerebral arteriovenous malformation treatment in the past 20 years. It covers the trend of international cooperation, publications, and research hotspots. This information provides an important reference for scholars to further study cerebral arteriovenous malformation.
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Affiliation(s)
- Weixia Tang
- School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yang Chen
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, Taiyuan, Shanxi, China
| | - Li Ma
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Biao Yang
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, Taiyuan, Shanxi, China
| | - Ren Li
- School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Ziao Li
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, Taiyuan, Shanxi, China
| | - Yongqiang Wu
- Shanxi Provincial Clinical Research Center for Interventional Medicine, Taiyuan, Shanxi, China
- Department of Emergency, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xiaogang Wang
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, Taiyuan, Shanxi, China
| | - Xiaolong Guo
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, Taiyuan, Shanxi, China
| | - Wenju Zhang
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
- Shanxi Provincial Clinical Research Center for Interventional Medicine, Taiyuan, Shanxi, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ming Lv
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Geng Guo
- Shanxi Provincial Clinical Research Center for Interventional Medicine, Taiyuan, Shanxi, China
- Department of Emergency, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
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De Lucia F, Bonnet T, Elens S. Endovascular NBCA treatment of a ruptured arteriovenous malformation with venous pseudoaneurysm in a young child. Radiol Case Rep 2023; 18:3795-3797. [PMID: 37663568 PMCID: PMC10474349 DOI: 10.1016/j.radcr.2023.08.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 09/05/2023] Open
Abstract
We reported imaging findings of arterio-venous malformation complicated by hemorrhage and venous pseudoaneurysm in a young child consulting for headache and emesis: to our knowledge venous pseudoaneurysm in association with ruptured arteriovenous malformation is a rare complication reported in the literature. We present the indications for endovascular treatment, especially with NBCA (N-butyl cyanoacrylate).
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Affiliation(s)
| | - Thomas Bonnet
- Department of Radiology, Hôpital Erasme, Brussels, Belgium
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Brunozzi D, Stone McGuire L, Hossa J, Atwal G, Charbel FT, Alaraj A. Preoperative embolization of brain arteriovenous malformation and efficacy in intraoperative blood loss reduction: a quantitative study. J Neurointerv Surg 2023:jnis-2023-020142. [PMID: 37402571 DOI: 10.1136/jnis-2023-020142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/13/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Embolization of brain arteriovenous malformations (bAVMs) is often used as adjuvant therapy to microsurgical resection to reduce the high-risk features of bAVMs such as large size and high flow. However, the effect of preoperative embolization on surgical performance and patient outcome has shown mixed results. Heterogeneity in treatment goals, selection criteria, and unpredictable changes in bAVM hemodynamics after partial embolization may account for these uncertain findings. In this study we use an objective quantitative technique to assess the impact of preoperative embolization on intraoperative blood loss (IBL). METHODS Patients with bAVM treated with microsurgical resection only or in combination with preoperative embolization from 2012 to 2022 were retrospectively reviewed. Patients were included if quantitative magnetic resonance angiography was performed prior to any treatment. Correlation of baseline bAVM flow, volume, and IBL was evaluated between the two groups. Additionally, bAVM flow prior to and after embolization was compared. RESULTS Forty-three patients were included, 31 of whom required preoperative embolization (20 had more than one session). Mean bAVM initial flow (362.3 mL/min vs 89.6 mL/min, p=0.001) and volume (9.6 mL vs 2.8 mL, p=0.001) were significantly higher in the preoperative embolization group; flow decreased significantly after embolization (408.0 mL/min vs 139.5 mL/min, p<0.001). IBL was comparable between the two groups (258.6 mL vs 141.3 mL, p=0.17). Linear regression continued to show a significant difference in initial bAVM flow (p=0.03) but no significant difference in IBL (p=0.53). CONCLUSION Patients with larger bAVMs who underwent preoperative embolization had comparable IBL to those with smaller bAVMs undergoing only surgical treatment. Preoperative embolization of high-flow bAVMs facilitates surgical resection, reducing the risk of IBL.
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Affiliation(s)
- Denise Brunozzi
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Laura Stone McGuire
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jessica Hossa
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Gursant Atwal
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Fady T Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Muacevic A, Adler JR. Management of Brain Arteriovenous Malformations: A Review. Cureus 2023; 15:e34053. [PMID: 36824547 PMCID: PMC9942537 DOI: 10.7759/cureus.34053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 01/23/2023] Open
Abstract
Brain arteriovenous malformations (bAVM) are vascular malformations of the brain affecting all ages. The optimum management strategy is essentially devoid of high-quality evidence and is highly nuanced and embedded in local customs. This study summarizes the frequently employed management strategies, drawing conclusions on the utility of each method of treatment and delving into controversies surrounding them. A literature search on PubMed and Medline was done on January 3rd, 2022. 11,767 articles were found, and abstracts were reviewed. Full-text review of 153 articles led to chapters from three books and 71 articles incorporated into a summative discussion. Spetzler-Ponce (S-P) Class A patients may be offered surgery if they are good surgical candidates and have a good number of high-quality years of life left. The exception is diffuse Spetzler-Martin (S-M) grade 2 in a patient older than 40 years: radiosurgery for unruptured and embolization for ruptured. S-P Class B may be offered surgery if a compact nidus or if younger than 40 years. If diffuse or age greater than 40, radiosurgery may be preferred if the Pollock-Flickinger score is less than 2.5. For the remainder of S-P Class B, conservative management may be preferred. S-P Class C is generally not treated unless young or those patients with poorly controlled seizures affecting their quality of life are willing to risk permanent neurological deficits. While the quality of studies is generally high, the level of evidence is concerning with only one randomized controlled trial (RCT). Most research output hails from high-income countries, i.e., perhaps not universally applicable to all settings owing to possible genetic, environmental, and resource differences. More research is needed: large volume studies in the pregnant population, validation of scoring systems in pediatric age groups, clinical trials focused on combination multi-staged treatment modalities, and studies originating from the developing world.
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Pinkiewicz M, Pinkiewicz M, Walecki J, Zawadzki M. State of the Art in the Role of Endovascular Embolization in the Management of Brain Arteriovenous Malformations-A Systematic Review. J Clin Med 2022; 11. [PMID: 36498782 DOI: 10.3390/jcm11237208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
As a significant cause of intracerebral hemorrhages, seizures, and neurological decline, brain arteriovenous malformations (bAVMs) are a rare group of complex vascular lesions with devastating implications for patients' quality of life. Although the concerted effort of the scientific community has improved our understanding of bAVM biology, the exact mechanism continues to be elucidated. Furthermore, to this day, due to the high heterogeneity of bAVMs as well as the lack of objective data brought by the lack of evaluative and comparative studies, there is no clear consensus on the treatment of this life-threatening and dynamic disease. As a consequence, patients often fall short of obtaining the optimal treatment. Endovascular embolization is an inherent part of multidisciplinary bAVM management that can be used in various clinical scenarios, each with different objectives. Well-trained neuro-interventional centers are proficient at curing bAVMs that are smaller than 3 cm; are located superficially in noneloquent areas; and have fewer, larger, and less tortuous feeding arteries. The transvenous approach is an emerging effective and safe technique that potentially offers a chance to cure previously untreatable bAVMs. This review provides the state of the art in all aspects of endovascular embolization in the management of bAVMs.
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Morel BC, Wittenberg B, Hoffman JE, Case DE, Folzenlogen Z, Roark C, Seinfeld J. Untangling the Modern Treatment Paradigm for Unruptured Brain Arteriovenous Malformations. J Pers Med 2022; 12:jpm12060904. [PMID: 35743688 PMCID: PMC9224812 DOI: 10.3390/jpm12060904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/26/2022] [Accepted: 05/28/2022] [Indexed: 02/04/2023] Open
Abstract
Brain arteriovenous malformations (AVMs) often present treatment challenges. Patients with unruptured AVMs must consider not only whether they want to be treated, but what treatment modality they would prefer. Vascular neurosurgeons, neurointerventional surgeons, and stereotactic radiosurgeons must in turn guide their patients through the most appropriate treatment course considering the risk of AVM rupture, an individual AVM’s characteristics, and patient preferences. In this review we will look at how the clinical trial “A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA)” has influenced the approach to unruptured brain AVMs and the treatment modalities available to clinicians to deal with these formidable lesions.
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Talaat M, Premat K, Lenck S, Shotar E, Boch AL, Bessar A, Taema M, Hassan F, Elserafy TS, Degos V, Sourour N, Clarençon F. Exclusion treatment of ruptured and unruptured low-grade brain arteriovenous malformations: a systematic review. Neuroradiology 2021; 64:5-14. [PMID: 34562139 DOI: 10.1007/s00234-021-02714-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 04/06/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To assess the obliteration rate, functional outcome, hemorrhagic complication, and mortality rates of exclusion treatment of low-grade brain arteriovenous malformations (BAVMs) (Spetzler and Martin grades (SMGs) 1 and 2), either ruptured or unruptured. METHODS Electronic databases-Ovid MEDLINE and PubMed-were searched for studies in which there was evidence of exclusion treatment of low-grade BAVMs treated either by endovascular, surgical, radiosurgical, or multimodality treatment. The primary outcome of interest was angiographic obliteration post-treatment and at follow-up. The secondary outcomes of interest were functional outcome (mRS), mortality rate, and hemorrhagic complication. Descriptive statistics were used to calculate rates and means. RESULTS Eleven studies involving 1809 patients with low-grade BAVMs were included. Among these, 1790 patients treated by either endovascular, surgical, radiosurgical, or multimodality treatment were included in this analysis. Seventy-two percent of BAVMs were Spetzler-Martin grade II. The overall (i.e., including all exclusion treatment modalities) complete obliteration rate ranged from 36.5 to 100%. The overall symptomatic hemorrhagic complication rate ranged from 0 to 7.3%; procedure-related mortality ranged from 0 to 4.7%. CONCLUSION Our systematic review of the literature reveals a high overall obliteration rate for low-grade BAVMs, either ruptured or unruptured, with low mortality rate and an acceptable post-treatment hemorrhagic complication rate. These results suggest that exclusion treatment of low-grade BAVMs may be safe and effective, regardless of the treatment modality chosen.
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Affiliation(s)
- Maichael Talaat
- Department of Interventional Neuroradiology, GRC BioFast, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, 75013, Paris, France.,Department of Radiodiagnosis, Faculty of Medicine, Zagazig University E44519, Zagazig, Egypt
| | - Kévin Premat
- Department of Interventional Neuroradiology, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, 47-83 Boulevard de l'Hôpital 75013, Paris, France
| | - Stéphanie Lenck
- Department of Interventional Neuroradiology, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, 47-83 Boulevard de l'Hôpital 75013, Paris, France
| | - Eimad Shotar
- Department of Interventional Neuroradiology, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, 47-83 Boulevard de l'Hôpital 75013, Paris, France
| | - Anne-Laure Boch
- Department of Neurosurgery, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, 75013, Paris, France
| | - Awad Bessar
- Department of Radiodiagnosis, Faculty of Medicine, Zagazig University E44519, Zagazig, Egypt
| | - Mohammed Taema
- Department of Radiodiagnosis, Faculty of Medicine, Zagazig University E44519, Zagazig, Egypt
| | - Farouk Hassan
- Department of Radiodiagnosis, Faculty of Medicine, Cairo University, Cairo, C12613, Egypt
| | - Tamer S Elserafy
- Department of Neurology, Faculty of Medicine, Zagazig University, Zagazig, E44519, Egypt
| | - Vincent Degos
- Department of Anesthesiology and Critical Care, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, 75013, Paris, France
| | - Nader Sourour
- Department of Interventional Neuroradiology, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, 47-83 Boulevard de l'Hôpital 75013, Paris, France
| | - Frédéric Clarençon
- Department of Interventional Neuroradiology, GRC BioFast, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, 75013, Paris, France. .,Department of Interventional Neuroradiology, Sorbonne University, AP-HP, Pitié Salpêtrière - Charles Foix Hospital, 47-83 Boulevard de l'Hôpital 75013, Paris, France.
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Wahood W, Alexander AY, Doherty RJ, Bhandarkar A, Lanzino G, Bydon M, Brinjikji W. Elective intervention for unruptured cranial arteriovenous malformations in relation to ARUBA trial: a National Inpatient Sample study. Acta Neurochir (Wien) 2021; 163:2489-95. [PMID: 34287695 DOI: 10.1007/s00701-021-04936-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND In 2014, A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) concluded that medical management alone for cranial arteriovenous malformations (AVMs) had better clinical outcomes than interventional treatment. The impact of the ARUBA study on changes in the rates of intervention and outcomes is unknown. Thus, we investigated whether the conclusions from ARUBA may have influenced treatment modalities and outcomes of unruptured AVMs. METHODS The National Inpatient Sample (NIS) was queried between 2006 and 2018, for adult patients with an AVM who were admitted on an elective basis. Interventions included open, endovascular, and stereotactic surgeries. Join-point regression was used to assess differences in slopes of treatment rate for each modality before and after the time-point. Logistic regression was used to assess the odds of non-routine discharge and hemorrhage between the two time-points for each treatment modality. Linear regression was used to assess the mean length of stay (LOS) for each treatment modality between the two time-points. RESULTS A total of 40,285 elective admissions for AVMs were identified between 2006 and 2018. The rate of intervention was higher pre-ARUBA (n = 15,848; 63.8%) compared to post-ARUBA (n = 6985; 45.2%; difference in slope - 8.24%, p < 0.001). The rate of open surgery decreased, while endovascular and stereotactic surgeries remained the same, after the ARUBA trial time-point (difference in slopes - 8.24%, p < 0.001; - 1.74%, p = 0.055; 0.20%, p = 0.22, respectively). For admissions involving interventions, the odds of non-routine discharge were higher post-ARUBA (OR 1.24; p = 0.043); the odds of hemorrhage were lower post-ARUBA (OR 0.69; p = 0.025). There was no statistical difference in length of stay between the two time-points (p = 0.22). CONCLUSION The rate of intervention decreased, the rate of non-routine discharge increased, and rate of hemorrhage decreased post-ARUBA, suggesting that it may have influenced treatment practices for unruptured AVMs.
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Liu R, Zhan Y, Piao J, Yang Z, Wei Y, Liu P, Chen X, Jiang Y. Treatments of unruptured brain arteriovenous malformations: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e26352. [PMID: 34160402 PMCID: PMC8238300 DOI: 10.1097/md.0000000000026352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/10/2021] [Accepted: 05/28/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The best therapeutic option for unruptured brain arteriovenous malformations (bAVMs) patients is disputed. OBJECTIVE To assess the occurrence of obliteration and complications of patients with unruptured bAVMs after various treatments. METHODS A systematic literature search was performed in PubMed, EMBASE, Web of Science, and so on to identify studies fulfilling predefined inclusion criteria. Baseline, treatment, and outcomes data were extracted for statistical analysis. RESULTS We identified 28 eligible studies totaling 5852 patients. The obliteration rates were 98% in microsurgery group (95% confidence interval (CI): 96%-99%, I2 = 74.5%), 97% in surgery group (95%CI: 95%-99%, I2 = 18.3%), 87% in endovascular treatment group (95%CI: 80%-93%, I2 = 0.0%), and 68% in radiosurgery group (95%CI: 66%-69%, I2 = 92.0%). The stroke or death rates were 1% in microsurgery group (95%CI: 0%-2%, I2 = 0.0%), 0% in surgery group (95%CI: 0%-1%, I2 = 0.0%), 4% in endovascular treatment group (95%CI: 0%-8%, I2 = 85.8%), and 3% in radiosurgery group (95%CI: 3%-4%, I2 = 82.9%). In addition, the proportions of hemorrhage were 2% in microsurgery group (95%CI: 1%-4%, I2 = 0.0%), 23% in endovascular treatment group (95%CI: 7%-39%), and 12% in radiosurgery group (95%CI: 12%-13%, I2 = 99.2%). As to neurological deficit, the occurrence was 9% in microsurgery group (95%CI: 6%-11%, I2 = 94.1%), 20% in surgery group (95%CI: 13%-27%, I2 = 0.0%), 14% in endovascular treatment group (95%CI: 10%-18%, I2 = 64.0%), and 8% in radiosurgery group (95%CI: 7%-9%, I2 = 66.6%). CONCLUSIONS We found that microsurgery might provide lasting clinical benefits in some unruptured bAVMs patients for its high obliteration rates and low hemorrhage. These findings are helpful to provide a reference basis for neurosurgeons to choose the treatment of patients with unruptured bAVMs.
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Affiliation(s)
- Renjie Liu
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Yongle Zhan
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jianmin Piao
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Zhongxi Yang
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Yun Wei
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Pengcheng Liu
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Xuan Chen
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Yu Jiang
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Spiotta AM, Park MS, Bellon RJ, Bohnstedt BN, Yoo AJ, Schirmer CM, DeLeacy RA, Fiorella DJ, Woodward BK, Hawk HE, Nanda A, Zaidat OO, Sunenshine PJ, Liu KC, Kabbani MR, Snyder KV, Sivapatham T, Dumont TM, Reeves AR, Starke RM. The SMART Registry: Long-Term Results on the Utility of the Penumbra SMART COIL System for Treatment of Intracranial Aneurysms and Other Malformations. Front Neurol 2021; 12:637551. [PMID: 33927680 PMCID: PMC8076606 DOI: 10.3389/fneur.2021.637551] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/12/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction: Penumbra SMART COIL® (SMART) System is a novel generation embolic coil with varying stiffness. The study purpose was to report real-world usage of the SMART System in patients with intracranial aneurysms (ICA) and non-aneurysm vascular lesions. Materials and Methods: The SMART Registry is a post-market, prospective, multicenter registry requiring ≥75% Penumbra Coils, including SMART, PC400, and/or POD coils. The primary efficacy endpoint was retreatment rate at 1-year and the primary safety endpoint was the procedural device-related serious adverse event rate. Results: Between June 2016 and August 2018, 995 patients (mean age 59.6 years, 72.1% female) were enrolled at 68 sites in the U.S. and Canada. Target lesions were intracranial aneurysms in 91.0% of patients; 63.5% were wide-neck and 31.8% were ruptured. Adjunctive devices were used in 55.2% of patients. Mean packing density was 32.3%. Procedural device-related serious adverse events occurred in 2.6% of patients. The rate of immediate post-procedure adequate occlusion was 97.1% in aneurysms and the rate of complete occlusion was 85.2% in non-aneurysms. At 1-year, the retreatment rate was 6.8%, Raymond Roy Occlusion Classification (RROC) I or II was 90.0% for aneurysms, and Modified Rankin Scale (mRS) 0-2 was achieved in 83.1% of all patients. Predictors of 1-year for RROC III or retreatment (incomplete occlusion) were rupture status (P < 0.0001), balloon-assisted coiling (P = 0.0354), aneurysm size (P = 0.0071), and RROC III immediate post-procedure (P = 0.0086) in a model that also included bifurcation aneurysm (P = 0.7788). Predictors of aneurysm retreatment at 1-year was rupture status (P < 0.0001). Conclusions: Lesions treated with SMART System coils achieved low long-term retreatment rates. Clinical Trial Registration:https://www.clinicaltrials.gov/, identifier NCT02729740.
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Affiliation(s)
- Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, United States
| | - Richard J Bellon
- Department of Interventional Neuro Radiology, Swedish Medical Center, Denver, CO, United States
| | | | - Albert J Yoo
- Department of Interventional Neuroradiology, Texas Stroke Institute, Dallas, TX, United States
| | | | | | - David J Fiorella
- Stony Brook University Medical Center, Cerebrovascular Center, New York, NY, United States
| | | | - Harris E Hawk
- Erlanger Health System, Chattanooga, TN, United States
| | - Ashish Nanda
- SSM Health Medical Group, Fenton, MO, United States
| | - Osama O Zaidat
- St Vincent Mercy Health Medical Center, Toledo, OH, United States
| | | | - Kenneth C Liu
- Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | | | - Kenneth V Snyder
- Department of Neurosurgery, University of Buffalo, Buffalo, NY, United States
| | | | - Travis M Dumont
- Department of Surgery, University of Arizona, Tucson, AZ, United States
| | - Alan R Reeves
- Department of Radiology, University of Kansas, Kansas City, KS, United States
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Hospital, Miami, FL, United States
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13
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Lantz KE, Armstrong SQ, Butt F, Wang ML, Hardman R, Czum JM. Arteriovenous Malformations in the Setting of Osler-Weber-Rendu: What the Radiologist Needs to Know. Curr Probl Diagn Radiol 2021; 51:375-391. [PMID: 33827770 DOI: 10.1067/j.cpradiol.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 02/15/2021] [Accepted: 03/04/2021] [Indexed: 11/22/2022]
Abstract
Osler-Weber-Rendu, also known as Hereditary Hemorrhagic Telangiectasia, is an autosomal dominant disease with phenotypic manifestations that include pulmonary, cerebrospinal, hepatic, and other visceral arteriovenous malformations (AVMs). Pulmonary AVMs can result in hypoxemia, hemoptysis, or stroke due to paradoxical embolism. The mainstay of treatment is transcatheter embolization. Central nervous system and abdominal visceral AVMs contribute to morbidity of the disease. Radiologists should be familiar with the imaging manifestations and treatment algorithm of AVMs in Osler-Weber-Rendu to effectively guide patient care.
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Affiliation(s)
- Katherine E Lantz
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| | - Samuel Q Armstrong
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Frederick Butt
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Michelle L Wang
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Julianna M Czum
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Abstract
OBJECTIVE The conventional arteriovenous malformation (AVM) Onyx embolization technique is the extrusion Onyx injection technique, with blood-flow control after a certain distance casting through the head end of the microcatheter. This method has elevated periprocedural AVM bleeding complications. In this study, the authors reported safety and efficacy of an updated ante-grade drifting Onyx injection for plexiform AVM embolization. METHODS Between January 2016 and December 2018, 101 consecutive patients with plexiform AVMs were treated with ante-grade drifting Onyx injection. The patients' clinical status was classified using the modified Rankin Scale (mRS). To measure associations, logistic univariate or multivariate regression analyses were used. RESULTS Complete AVM obliteration was achieved in 51.2% (52/101) of patients. Two (2/101, 2.0%) arterial perforations occurred without causing neurological deficits. In univariate and multivariate logistic regression analyses, younger patient age (odds ratio (OR) = 1.06, 95% confidence interval (CI) 1.01-1.12, p = 0.014), haemorrhagic presentation at admission (OR = 7.14, 95% CI 1.52-33.33, p = 0.013) and low Spetzler-Martin grade (OR = 10.00, 95% CI 3.45-25.00, p < 0.001) were significantly correlated with complete obliteration. Pretreatment mRS was correlated with perforation complication (OR = 3.44, 95% CI 1.05-11.29, p = 0.041) in univariate logistic regression analysis but not in multivariate logistic regression analysis (OR = 2.956, 95%CI 0.745, 11.731, p = 0.123). Patients' clinical status was significantly improved after endovascular AVM embolization. CONCLUSIONS With ante-grade drifting Onyx injection, it was possible to prevent serious bleeding complications and elevated complete embolization rate in plexiform AVMs. Younger patient age, haemorrhagic presentation at admission and low AVM Spetzler-Martin grade were significantly correlated with complete obliteration. Although there is not enough statistical power to show that the pretreatment mRS and the arterial perforation complication have a significant correlation, but its OR value is large, and there may be more data in the future to obtain further conclusion.
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Affiliation(s)
- Xianli Lv
- Xianli Lv, Neurosurgery Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Litang Road168, Changping, Beijing, 102218, PR China.
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15
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Baharvahdat H, Blanc R, Fahed R, Pooyan A, Mowla A, Escalard S, Delvoye F, Desilles JP, Redjem H, Ciccio G, Smajda S, Hamdani M, Mazighi M, Piotin M. Endovascular treatment as the main approach for Spetzler-Martin grade III brain arteriovenous malformations. J Neurointerv Surg 2020; 13:241-246. [PMID: 32989031 DOI: 10.1136/neurintsurg-2020-016450] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/02/2020] [Accepted: 09/10/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Because Spetzler-Martin (SM) grade III brain arteriovenous malformations (bAVMs) constitute a heterogeneous group of lesions with various combination of sizes, eloquence, and venous drainage patterns, their management is usually challenging. The aim of this study is to evaluate the clinical/imaging outcomes and the procedural safety of endovascular approach as the main treatment for the cure of SM grade III bAVMs. METHODS In this retrospective study, prospectively collected data of SM grade III bAVMs treated by endovascular techniques between 2010 and 2018 at our hospital were reviewed. Patients older than 16 years with angiographic follow-up of at least 6 months after endovascular treatment were entered in the study. The patients had a mean follow-up of 12 months. The data were assessed for clinical outcome (modified Rankin Scale), permanent neurological deficit, post-operative complications, and optimal imaging outcome, defined by complete exclusion of AVM. The independent predictive variables of poor outcome or hemorrhagic complication were assessed using binary logistic regression. RESULTS Sixty-five patients with 65 AVMs were included in the study. Mean age of the patients was 40.0±14.4. Most common presentation was hemorrhage (61.5%). The patients underwent one to eight endovascular procedures (median=2). Mean nidus diameter was 30.2±13.0. A complete obliteration of AVM was achieved in 57 patients (87.7%). Post-procedure significant hemorrhagic and ischemic complications were seen in 13 (20%) and five (7.7%) patients respectively, leading to five (7.7%) transient and four (6.2%) permanent neurological deficits. Eight patients (12.3%) experienced worsening of mRS after embolization. Ten patients (15.4%) had poor outcome (mRS 3-5) at follow-up and two (3%) died. CONCLUSIONS Endovascular treatment can achieve a high rate of complete exclusion of grade III AVM but may be associated (as in other treatment modalities) with significant important complications. CLINICAL TRIAL REGISTRATION NUMBER NCT02879071.
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Affiliation(s)
- Humain Baharvahdat
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France.,Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran (the Islamic Republic of)
| | - Raphaël Blanc
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | - Robert Fahed
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France.,Medicine - Neurology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ashkan Pooyan
- Neurosurgery, Mashhad University of Medical Sciences, Mashhad, Iran (the Islamic Republic of)
| | - Ashkan Mowla
- Neurosurgery, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Simon Escalard
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | - François Delvoye
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | | | - Hocine Redjem
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | - Gabriele Ciccio
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | - Stanislas Smajda
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | - Mylène Hamdani
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Fondation de Rothschild, Paris, France
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16
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Brisman JL. Curing Low-Grade Brain AVMs with Embolization? AJNR Am J Neuroradiol 2019; 40:673-674. [PMID: 30894359 DOI: 10.3174/ajnr.a6017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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