A joint protocol for the neurosurgical and neuroradiologic treatment of cerebral arteriovenous malformations: Indications, technique, and results in 76 cases

doi:10.1016/0090-3019(93)90050-B

Surgical Neurology

Volume 40, Issue 6, December 1993, Pages 476-484

https://doi.org/10.1016/0090-3019(93)90050-B Get rights and content

Abstract

We report on a group of 76 patients who had been treated during a period in which preoperative embolization using interventional neuroradiologic technique was standard procedure. During this time, 20 consecutive patients were operated on without embolization, eight patients were treated with embolization only, and 48 patients were operated on after embolization. In 35 cases surgery immediately followed the last embolization procedure. All arteriovenous malformations (AVMs) were classified and the outcome analyzed according to Spetzler [J Neurosurg 1986;65:476-83]. Those lesions treated with a combination of embolization and surgery had higher Spetzler grading than those that had been operated without previous embolization. The overall recovery rate was 82.9%. In 7.9% of the cases the AVMs were not totally extirpated. The overall complication rate was 9.2%. It is concluded that preoperative embolization facilitates surgery and reduces the risk of severe morbidity and mortality, especially in high-grade lesions. In addition to the clinical results, the application and usefulness of Ethibloc® as an embolizing agent is reported.

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Cited by (33)

Angioarchitectural Risk Factors for Hemorrhage and Clinical Long-Term Outcome in Pediatric Patients with Cerebral Arteriovenous Malformations
2016, World Neurosurgery
Citation Excerpt :
We were able to confirm small AVM size (P < 0.01; OR, 0.12; 95% CI, 0.02–0.59) and exclusive venous drainage (deep vs. superficial; P < 0.01; OR, 29.74; 95% CI, 2.45–4445.34) as independent risk factors for hemorrhage in children with AVMs via multivariate analysis (Figure 6). Twenty pediatric patients (43.5%) were treated by surgery alone; 15 (32.6%) were embolized before surgery, which followed the same day in the same anesthesia as the single-staged procedure, which was established as standard in our department a long time ago15; 1 patient (2.2%) with a left-sided SM grade III AVM involving the corpus callosum was embolized curatively, and 3 children (6.5%) were embolized with a palliative intention to reduce arterial shunting and minimize the risk for recurrent hemorrhage. These were all children who presented with deep-seated, high-grade AVMs (involving internal capsule, thalamus, or wide parts of 1 hemisphere), in whom a microsurgical approach was not possible.
Intracranial arteriovenous malformation (AVM) in children is a rare diagnosis. Little is known about factors determining AVM rupture and appropriate treatment strategies to prevent hemorrhage and associated disability. Available data suggest that children are subject to an increased risk for AVM rupture compared with adults.
In 46 pediatric patients with AVM, demographic factors, clinical presentation, angioarchitectural features, and treatment regimens as well as clinical and radiologic outcomes were retrospectively analyzed. First-line treatment option was microsurgical resection of the disease, with or without preoperative embolization.
Twenty-four boys (52.2%) and 22 girls (47.8%) with a mean age on admission of 12.4 years (4–18 years) were included. Mean follow-up was 4 years (median, 1.5; range, 0.1–16.4). Thirty-one children presented with intracerebral hemorrhage (67.4%). Small AVMs (<3 cm) ruptured in 83.3% (n = 25) and were shown to be more prone to hemorrhage than larger ones (P < 0.01). Small AVM size (P < 0.01; odds ratio [OR], 0.12; 95% confidence interval [CI] 0.02–0.59) and exclusive deep venous drainage (P < 0.01; OR, 29.74; 95% CI, 2.45–4445.34) were independent risk factors for hemorrhage in the presented cohort. Good long-term outcome was associated with a high score on the Glasgow Coma Scale on admittance (P < 0.05; OR, 0.148; 95% CI, 0.03–0.73).
Two-thirds of children with AVM are admitted with intracerebral hemorrhage. Microsurgical resection was successful as confirmed by radiologic studies in 95%, and 79.5% of patients presented in a good clinical condition on follow-up (modified Rankin Scale 0 or 1). Microsurgical treatment is recommended if the lesion is accessible and angioarchitectural risk factors favor definitive treatment.
Endovascular treatment of cerebral arteriovenous malformations: Indications, techniques, outcome, and complications
2005, Neurosurgery Clinics of North America
Citation Excerpt :
Embolization shortened operative time and reduced blood loss. Similar findings have been reported by other practitioners [47–54]. The degree of volume reduction necessary before surgery to effect a difference in surgical resection is debatable.
Selection of treatment modalities for cerebral arteriovenous malformations: A retrospective analysis of 348 consecutive cases
2000, Journal of Clinical Neuroscience
The objective was to establish the selection criteria for the optimal management modalities for cerebral arteriovenous malformations. We analysed the complications and late outcomes in 348 consecutive cases (132 microsurgical resections, 202 stereotactic radiosurgeries, 8 embolisations only, 6 combined treatments) managed at Yonsei University Hospital from 1988 to 1997. Files for all patients were analysed. The outcome was classified into good for the patients who returned to their previous job with or without neurological deficits, fair for the patients who were unable to return to work but performed daily activities independently with minor deficits, and poor for the patients who were performing dependent daily activities with major deficits. The outcome of microsurgery was considered good in 108 patients (81.8%), fair in 18 (13.6%), poor in 4 (3.1%), and 2 (1.5%) patients died. Initial insults and haemodynamic complications were the major cause of an unfavourable outcome. The cumulative occlusion rate of the nidus after radiosurgery was 10.2% within 12 months, 75.3% within 24 months, and 89.8% within 36 months. Perilesional imaging changes with neurological deficits (4 permanent and 6 transient, 4.8%) and haemorrhage (16 patients, 7.7%) during the latent interval were the major cause of an unfavourable outcome (1 poor, 4 dead after radiosurgery). Postradiosurgery bleeding occurred frequently within 6 months (6 patients), and between 13 and 24 months (8 patients). In conclusion, selection of treatment modality for cerebral AVMs depends on the preoperative evaluation of the risk/benefit ratio in each case. Microsurgical removal, which eliminates the risk of bleeding immediately, is preferred for lesions in non-eloquent areas. Radiosurgery is an effective treatment modality for small lesions in eloquent areas, but has a substantial risk of haemorrhage during the latency period. Results of this study suggest that microsurgical removal should be considered for lesions in eloquent areas with high haemorrhage risk, such as prior haemorrhage, medium to large size lesion, and single deep venous drainage.
Two-step presurgical endovascular treatment of five arteriovenous malformations partially fed by single vessels en passage
1999, Surgical Neurology
PURPOSE
To describe a method for the preoperative embolization of arteriovenous malformations (AVM) containing vessels en passage (VeP). First, before embolization of the primary AVM, the distal portion of the VeP beyond the AVM ,which supplies the parenchymal compartment, is blocked through placement of an endovascular ligature (fibered coils). This protects the post lesional parenchymal tissue and isolates malformational compartments before embolization. Thus the proximal AVM-supplying segment of the VeP can be safely embolized.
Patients and Methods
Five of 204 AVM patients admitted for preoperative embolization between 1989 and 1997 fulfilled the following treatment criteria for the placement of an endovascular ligature in a VeP before embolization: 1. The diameter of the distal portion of the VeP behind the AVM was large whereas the parenchymal blush was poor; 2. The VeP fed a large portion of the AVM; 3.The VeP was judged to be accessible only late in the surgical procedure; 4. The VeP and its off branches were an integral part of the AVM periphery and thus not suitable for microdissection.
Results
In all five cases the leptomeningeal collateral perfusion (the arterial supply to parenchymal brain areas) served to supply brain areas distal to the AVM after primary blockage of a VeP by endovascular ligature with fibered coils. Embolization and complete surgical dissection of the AVM was then achieved in all cases. No neurological deficits occurred.
Conclusion
Experience with our five cases indicates that a preparatory endovascular ligature of a VeP between parenchyma and the malformational compartment followed by embolization of the AVM can serve as an alternative to open surgical dissection of a vessel en passage and that it safely allows effective preoperative embolization.
Reflections on the management of cerebral arteriovenous malformations
1998, Surgical Neurology
BACKGROUND The authors report their personal experience in the management of cerebral arteriovenous malformations (AVMs), using the three techniques now available: surgical resection, endovascular embolization, and radiosurgery. They review the recent literature on this topic and present their current management algorithm based on this experience.
METHODS A series of 90 patients treated for cerebral AVMs is reported (68% Grade I-III and 32% Grade IV-V, Spetzler scale). The three methods of treatment were used, either individually or in combination, based on the size and the location of the malformation. The first intervention was surgical resection in 26% of cases, endovascular embolization in 57%, and radiosurgery in 17%. Surgery and embolization were followed by another technique in some cases and eventually single modality treatment was used in 58% of cases (surgical resection 21%, endovascular embolization 20%, radiosurgery 17%) and multimodality treatment in 42% (embolization + resection, 21%; embolization + radiosurgery, 17%; resection + radiosurgery, 4%). Embolization was used as reductive therapy in 38% of the overall series (65% of all embolized patients), and was followed by surgery in 56% of cases or by radiosurgery in 44%. Angiography was used to assess the cure rates.
RESULTS The following cure rates were obtained, when each technique was used as a first treatment: surgical resection, 82%; embolization, 6%; and radiosurgery, 83% (2-year angiographic follow-up). After combined treatment, embolization and resection resulted in a 100% cure rate, embolization and radiosurgery produced a 90% cure rate. The clinical outcome was evaluated in terms of deterioration attributable to treatment. Seventy-one percent of patients had no complication, minor complications were observed in 18%, and severe complications in 11%. Treatment mortality was 3%. All deaths were attributable to hemorrhage during the embolization procedure.
CONCLUSIONS In this management algorithm, AVMs submitted directly to surgery or to radiosurgery were considered “good risk” malformations, and the outcome for these cases was good in terms of clinical result and cure rate. AVMs submitted first to endovascular embolization were considered “poor risk” malformations, including a majority of Spetzler Grade IV-V lesions. Not surprisingly, the majority of severe complications occured in this group during embolization. Thus, the major risk of the treatment of AVMs has now shifted from surgery to endovascular techniques. Endovascular embolization as sole treatment gave a low rate of complete occlusion, but proved to be very useful as a reductive therapy, in preparation for further surgery or radiosurgery. Partial embolization permitted high rates of complete cure in difficult AVMs. Embolization should be used to the maximum extent possible as a reductive technique, despite the risks of the procedure. Because of its risks however, this technique of reductive embolization should be used only if absolutely necessary to allow the complete cure of the malformation. Thus, the use of embolization should be considered very cautiously in small malformations as well as in very large and complex AVMs in which partial embolization will not be sufficient to allow complete cure with either endovascular or surgical techniques.
Improved technique for liquid embolization of cerebral arteriovenous malformation: Catheter-tip position and flow control
1998, Journal of Clinical Neuroscience
This paper outlines the problems currently limiting the success and safety of embolization of cerebral arteriovenous malformations (AVMs) based upon the experiences of 110 cases. In cases where liquid embolic material was deposited mainly in arterial feeders, there was a reconstitution of the nidus through residual primary feeders and recruitment of blood flow via collateral tracts. A recent improvement of flexible microcatheters with minimal friction has made it possible to place the tip of a microcatheter into the nidus with greater success and safety. In order to obtain better filling of the AVM nidus and slower penetration to the draining veins, it is important to perform a temporary balloon occlusion of another main feeding pedicle to reverse the dynamic balance in favor of the pedicle being injected. In order to successfully occlude arteriovenous shunts in the nidus, appropriate flow control and optimal setting time of n-butyl-2 cyanoacrylate have prime importance.

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A joint protocol for the neurosurgical and neuroradiologic treatment of cerebral arteriovenous malformations: Indications, technique, and results in 76 cases

Abstract

Surg Neurol

Cerebral arteriovenuous malformations

J Neurosurg

Surgical treatment of cerebral arteriovenous malformations

Die Stellung der endovaskulären Therapie bei einem interdisziplinären Behandlungsansatz

Cerebral arteriovenous malformations: modern aspects of investigations and treatment

Prog Neurol Surg

Treatment of arteriovenous malformations of the brain with combined embolization and stereotactic radiosurgery

AJNR

Cerebral arteriovenous malformations: considerations for and experience with surgical treatment in 166 cases

Clin Neurosurg

Endovascular treatment of intracerebral arteriovenous malformations: experience in 49 cases

J Neurosurg

Arteriovenous malformations of the brain: recent results of endovascular therapy

Radiology

The use of the “cross over technique” in the management of a traumatic vertebro-vertebral fistula

Neuroradiology

Intracranial dural fistulae

Cerebrovasc Dis

Natural history of arteriovenous malformations of the brain: a clinical study

Neurosurgery

Combined neurosurgical-neuroradiological therapy for cerebral arteriovenous malformations—the Walter Reed protocol

Histopathological follow-up study of 66 cerebral arteriovenous malformations after therapeutic embolization with polyvinyl alcohol

J Neurosurg

Surgical problems in partially embolized angiomas

Intracranial arteriovenous malformations

Stereotaxic angiography in gamma knife radiosurgery of intracranial arteriovenous malformations

AJNR

Unruptured arteriovenous malformations: a dilemma in surgical decision making

Clin Neurosurg

Embolization with “Ethibloc” of vascular tumors and arteriovenous malformations in the head and neck

Neuroradiology

Endovascular treatment of cerebral lesions

Cerebral arteriovenous malformations: indications for and results of surgery, and the role of intravascular techniques

J Neurosurg

Stereotactic radiosurgery of arteriovenous malformations of the brain

J Neurosurg