Recurrent Arteriovenous Malformations Research Articles

P.125 Cerebral AVM recurrence post gamma knife obliteration: a 20 year single centre retrospective analysis and review of literature

Background: Pediatric arteriovenous malformations (AVMs) are rare, but represent the leading cause of intracranial hemorrhage in children. These are traditionally understood to be congenital lesions, however AVMs recurrence within previously unaffected tissue challenges this understanding. Recurrence after microsurgery and endovascular treatment have been studied in greater detail, but little literature exists surrounding recurrence after Gamma Knife Radiosurgery (GKRS). Methods: We performed a retrospective chart review of all pediatric AVMs treated with GKRS at our centre. Charts were assessed by two reviewers to identify cases of AVM recurrence after angiographically confirmed obliteration. To contextualize our institutional patterns, we also performed a structured literature review of published data reporting pediatric AVM recurrence after GKRS. Results: Our institutional review revealed two cases of AVM recurrence after angiographically proven cure, and our review of literature identified nine retrospective reviews and three case reports, which in total reported 22 individual cases of recurrence. The recurrence rate in the retrospective reviews ranged from 0 to 18%. Conclusions: The current work illustrates that while AVM recurrence is rare, it is a possible complication of GKRS. There was also a qualitative suggestion that embolization prior to CT increased risk of recurrence. Both these facts should be included in decision-making and patient counselling.

Treatment Effectiveness and Recurrence of Extracranial Arteriovenous Malformations Following Surgical Operations: A 15-Year Retrospective Cohort Study.

At present, there is no golden standard for treatment of extracranial arteriovenous malformations (AVMs) and recurrence remains a major challenge with limited available evidence on the associated factors. This study aimed to evaluate the effectiveness of surgical treatment options, in terms of size reduction, symptoms, and early recurrence in patients treated surgically for AVMs. A retrospective cohort study was conducted to evaluate patients with AVMs following surgical treatment in 2 centers from 2005 to 2020. Posttreatment lesion size and symptoms, as well as recurrence, were assessed. Multiple regression analysis was performed to identify factors associated with recurrence. Forty-four surgical treatment cases in 31 patients were assessed with a mean follow-up duration period of 67.9 ± 39.5 months. Treatment included total resection in 26 cases (59.1%) and partial resection 18 (40.9%), with free flap coverage used in 19 cases (43.2%). No acute exacerbation following treatment was observed in our cohort. Total resection significantly reduced posttreatment lesion size ( P < 0.001), symptoms ( P < 0.001), and recurrence (20.0%, P = 0.03). The recurrence rate was significantly higher after partial resection (73.7%, P = 0.03). Total resection was identified as an associated factor for significantly reduced AVM recurrence (odds ratio: 0.12; 95% confidence interval: 0.03, 0.52). However, the use of free flaps did not significantly reduce recurrence, post treatment size or improve AVM symptoms. Total resection is the optimal treatment for AVMs. Free flaps are useful in covering large defects but the regulative effect of free flap remains controversial.

Recurrence of arteriovenous malformation in an adult patient after complete resection: illustrative case.

Complete resection of an arteriovenous malformation (AVM) is considered a curative treatment. In this paper the authors discuss two possibilities in the event of hemorrhage after satisfactory resection of an AVM: recurrence or remnant. A 33-year-old female patient was diagnosed with an incidental right frontal AVM that was microsurgically resected and whose postoperative angiography showed no remnant. Eight years later, she presented with an episode of headache and speech arrest. Magnetic resonance imaging showed bleeding in the previous surgical site, and a new angiography revealed the presence of a vascular blush not seen previously. The patient did not show the most frequently associated factors for recurrence described in the literature, which are hemorrhage on presentation and deep venous drainage. In addition, factors related to undetected vascular remnants, such as preoperative hemorrhage and early postoperative angiography, were absent. Considering the characteristics of the case, we believe that the most likely explanation is the development of a de novo vascular formation secondary to factors not yet elucidated. Preexisting views on AVM formation, the curative value of resection, and long-term follow-up in certain patients should be reevaluated.

Regulating Microvascular Free Flaps Reconstruction in "Schobinger Stage 4" Arteriovenous Malformations of Face.

Objectives Arteriovenous malformations (AVMs) are high-flow, aggressive lesions that cause systemic effects and may pose a risk to life. These lesions are difficult to treat as they have a tendency to recur aggressively after excision or embolization. So, it requires a regulating free flap with robust vascular flow averting the postexcisional ischemia-induced collateralization, parasitization, and recruitment of neovessels from the surrounding mesenchyme-a phenomenon precipitating and perpetuating the recurrence of AVM. Materials and Methods Sixteen patients (12 males and 4 females) with AVMs Schobinger type 4 involving face were treated from March 2015 to March 2021 with various free flaps: three free rectus abdominis flaps, one free radial forearm flap, and twelve free anterolateral thigh flaps were used for reconstruction following the wide local excision of Schobinger type 4 facial AVM. The records of these patients were analyzed retrospectively. The average follow-up period was 18.5 months. The functional and aesthetic outcomes were analyzed with institutional assessment scores. Results The average size of the flap harvested was 113.43 cm 2 . Fourteen patients (87.5%) had good-to-excellent score ( p = 0.035) with institutional aesthetic and functional assessment system. The remaining two patients (12.5%) had only fair results. There was no recurrence (0%) in the free flap group versus 64% recurrence in the pedicled flap and skin grafting groups ( p = 0.035). Conclusion Free flaps with their robust and homogenized blood supply provide a good avenue for void filling and an excellent regulating effect in inhibiting any locoregional recurrences of AVMs.

Missed feeder vessel induced recurrent and refractory arteriovenous vascular malformation in the upper eye lid

ABSTRACT A 25-year-old male presented with recurrent swelling in the left upper eyelid despite multiple surgeries in the past 6 years. He was initially misdiagnosed as capillary hemangioma elsewhere, for which multiple surgical excision procedures were done. In 2020, he presented to us for a second opinion regarding the same painless swelling which recurred at the same site. Clinical examination and Doppler ultrasound shifted the diagnosis in favor of arteriovenous malformation (AVM). Computed tomography of the brain and cerebral angiogram (three-dimensional reconstructed) images confirmed the AVM in the left upper eyelid with an arterial feeder from the left ophthalmic artery branch. The patient had multiple recurrences due to the inadvertent misdiagnosis and missed management of the feeder vessel from the ophthalmic artery. We highlight this case, to bring to light the deceptive diagnosis and management of recurrent and refractory AVM due to a feeder vessel from the ophthalmic artery.

Hemorrhage and Recurrence of Obliterated Brain Arteriovenous Malformations Treated With Stereotactic Radiosurgery.

Although complete nidal obliteration of brain arteriovenous malformations (AVM) is generally presumed to represent durable cure, postobliteration hemorrhage, and AVM recurrence have become increasingly recognized phenomena. The goal of the study was to define hemorrhage and nidal recurrence risks of obliterated AVMs treated with stereotactic radiosurgery (SRS). This is a retrospective cohort study from the International Radiosurgery Research Foundation comprising AVM patients treated between 1987 and 2020. Patients with AVM obliteration on digital subtraction angiography (DSA) were included. Outcomes were (1) hemorrhage and (2) AVM recurrence. Follow-up duration began at the time of AVM obliteration and was censored at subsequent hemorrhage, AVM recurrence, additional AVM treatment, or loss to follow-up. Annualized risk and survival analyses were performed. A sensitivity analysis comprising patients with AVM obliteration on magnetic resonance imaging or DSA was also performed for postobliteration hemorrhage. The study cohort comprised 1632 SRS-treated patients with AVM obliteration on DSA. Pediatric patients comprised 15% of the cohort, and 42% of AVMs were previously ruptured. The mean imaging follow-up after AVM obliteration was 22 months. Among 1607 patients with DSA-confirmed AVM obliteration, 16 hemorrhages (1.0%) occurred over 2223 patient-years of follow-up (0.72%/y). Of the 1543 patients with DSA-confirmed AVM obliteration, 5 AVM recurrences (0.32%) occurred over 2071 patient-years of follow-up (0.24%/y). Of the 16 patients with postobliteration hemorrhage, AVM recurrence was identified in 2 (12.5%). In the sensitivity analysis comprising 1939 patients with post-SRS AVM obliteration on magnetic resonance imaging or DSA, 16 hemorrhages (0.83%) occurred over 2560 patient-years of follow-up (0.63%/y). Intracranial hemorrhage and recurrent arteriovenous shunting after complete nidal obliteration are rare in AVM patients treated with SRS, and each phenomenon harbors an annual risk of <1%. Although routine postobliteration DSA cannot be recommended to SRS-treated AVM patients, long-term neuroimaging may be advisable in these patients.

Successful Treatment of a Recurrent Arteriovenous Malformation of the Toe with Foam Sclerotherapy: A Case Report

Successful Treatment of a Recurrent Arteriovenous Malformation of the Toe with Foam Sclerotherapy: A Case Report

Recurrence after treatment of arteriovenous malformations of the head and neck

&lt;abstract&gt;&lt;sec&gt; &lt;title&gt;Objective&lt;/title&gt; &lt;p&gt;Arteriovenous malformations (AVMs) are aggressive diseases with a high tendency to recur. AVM treatment is complex, especially in the anatomically difficult head and neck region. This study analyzed correlations between extracranial head and neck AVM presentations and the frequency of recurrence.&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Methods&lt;/title&gt; &lt;p&gt;We retrospectively assessed AVM recurrence among 55 patients with head and neck AVMs treated with embolization and resection between January 2008 and December 2015. Recurrence was defined as any evidence of AVM expansion following embolization and resection. Patient variables, including sex, age, AVM size, AVM location, stage, and treatment modalities, were examined for correlations with the recurrence of head and neck AVMs. Statistical analysis was performed using SPSS 20.0.&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Results&lt;/title&gt; &lt;p&gt;A total of 55 patients with at least 6 months of follow-up following AVM treatment with embolization and surgical resection were enrolled in this study. During follow-up, 14 of 55 patients experienced recurrence (the long-term recurrence rate was 25.5%). Sex, stage, AVM size, and treatment modality were identified as independent predictors of recurrence. Recurrence was less likely following the treatment of lower-stage or smaller lesions and did not correlate with age or location.&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Conclusions&lt;/title&gt; &lt;p&gt;AVMs of the head and neck are among the most challenging conditions to manage due to a high risk of recurrence. Early and total AVM resection is the best method for preventing recurrence.&lt;/p&gt; &lt;/sec&gt;&lt;/abstract&gt;

Return of the lesion: a meta-analysis of 1134 angiographically cured pediatric arteriovenous malformations.

Brain arteriovenous malformations (AVMs) carry a risk of rupture and subsequent morbidity or mortality unless fully treated. AVMs in pediatric patients are known to occasionally recur after obliteration. The objective of this study was to characterize the risk of AVM recurrence following angiographically confirmed obliteration in children. Consecutive pediatric AVMs treated at a single center were identified from a prospective database. Patients with angiographically confirmed AVM obliteration following treatment were included in this study. Associations between AVM recurrence and patient or procedural factors were characterized using the two-tailed Fisher exact test or Mann-Whitney U-test. A literature search was conducted using PubMed, Scopus, Embase, and the Clarivate Web of Science with defined search criteria, and eligible studies were included alongside this study cohort in a meta-analysis. Rates of AVM recurrence following obliteration were pooled across studies with a random-effects model and reported with 95% confidence intervals (CIs). Recurrence after angiographic confirmation of AVM obliteration was observed in 10.4% (7/67) of pediatric AVMs treated at the authors' center. Patients with recurrent AVMs were significantly younger than those without recurrence (p = 0.002). In the meta-analysis, which included 1134 patients across 24 studies, the rate of recurrence was 4.8% (95% CI 3.0%-6.7%). The rate of AVM recurrence following radiosurgery was 0.7% (95% CI 0%-1.6%), which was significantly lower than the 8.5% rate (95% CI 5.0%-12.0%) following microsurgery. Recurrence of obliterated brain AVMs is common in children. Recurrence is more common in young children and following microsurgery.

Pediatric brain arteriovenous malformation recurrence: a cohort study, systematic review and meta-analysis

BackgroundRecurrence following obliteration of brain arteriovenous malformations (AVMs) is common in children surgically treated, but recurrences following endovascular (EVT) and radiosurgical approaches are scantily reported.ObjectiveTo analyze the rates and risk...

Microsurgical resection of previously embolized recurrent cerebellopontine angle AVM.

This is the case of a ruptured Spetzler-Martin grade II arteriovenous malformation (AVM) located in the cerebellopontine angle and draining into the transverse sinus. The AVM was initially treated with staged embolization using Onyx (ev3 Neurovascular). However, recurrence was noted and treatment with microsurgical resection was undertaken. The authors present technical nuances of the approach and strategies for microsurgical resection of a previously embolized recurrent AVM with the aid of intraoperative indocyanine green angiography. Follow-up after endovascular treatment is critical, and curative treatment with microsurgical resection can be achieved with low morbidity in such AVMs as demonstrated by this case.The video can be found here: https://youtu.be/LMpz_YTFC0g

Modern approaches to treatment of complex cerebral arteriovenous malformations

Background . Cerebral arteriovenous malformations (AVMs) are not static congenital lesions, but can grow, recur, and appear de novo after complete resection, embolization, or radiosurgery. Understanding the complex molecular biology of AVMs is critical to predicting their behavior during treatment and improving treatment outcomes. Objective . To study the dynamics of angiogenesis factors in the process of cerebral AVM embolization in order to develop a strategy for their personalized treatment. Design and methods . The study included 314 patients with AVM who received surgical treatment at the Department of Brain Vascular Surgery of the Polenov Neurosurgical Institute. Determined the level of vascular endothelial growth factor (VEGF), angiopoietin-2 (ANG-2) and matrix metalloproteinase-9 (MMP-9) in blood serum before and 24 hours after endovascular embolization using enzyme-linked immunosorbent assay (Personal Lab, Adaltis, Italy). Results . Primary patients (48.4 %) with AVM showed an increase in VEGF, MMP-9, ANG-2. A high level of VEGF and MMP-9 demonstrated AVM III grades according to Spetzler-Martin, AVM with a hemorrhagic flow type, with a deep drainage pattern, with afferents from the external carotid artery. The return to control values of all elevated growth factors after total embolization confirms the lack of potency for AVM recurrence. The absence of a decrease in aniogenesis factors after radical, according to angiographic criteria, embolization is a sign of subtotal AVM shutdown. Conclusion . A personalized concept of embolization in patients with a high risk of growth and recurrence has been formulated.

Brain Arteriovenous Malformation Recurrence After Apparent Microsurgical Cure: Increased Risk in Children Who Present With Arteriovenous Malformation Rupture.

Do children have an increased risk for brain arteriovenous malformation (AVM) recurrence compared with adults and does this risk vary depending on initial presentation with AVM rupture? We retrospectively studied 115 patients initially presenting with brain AVM under age 25 years who underwent complete surgical resection of the AVM as documented by digital subtraction angiography (DSA) and had delayed follow-up DSA to evaluate for AVM recurrence after apparent initial cure. The mean time from baseline DSA to follow-up DSA was 2.3 years, ranging from 0 to 15 years. Twelve patients (10.4% of the 115 patient cohort and 16.7% of 72 patients with hemorrhage at initial presentation) demonstrated AVM recurrence on follow-up DSA. All patients with recurrence initially presented with intracranial hemorrhage, and intracranial hemorrhage was a significant predictor of recurrence (log rank P=0.037). Among patients with initial hemorrhage, the 5-year recurrence rate was 17.8% (95% CI, 8.3%-35.7%). All recurrences occurred in patients who were children at the time of their initial presentation; the oldest was 15 years of age at the time of initial AVM surgery. The 5-year recurrence rate for children (0-18 years of age) with an initial presentation of hemorrhage was 21.4% (95% CI, 10.1%-41.9%). Using Cox regression, we found the risk of AVM recurrence decreased by 14% per each year increase in age at the time of initial surgical resection (hazard ratio=0.86 [95% CI, 0.75-0.99]; P=0.031). There is a high rate of recurrence of apparently cured brain AVMs in children who initially present with AVM rupture. Imaging follow-up is warranted to prevent re-rupture.

Ten Years' Follow-Up after Microsurgical Reconstruction of the Lip Using Forearm Flap Combined with Gracilis Muscle Transfer.

Dynamic reconstruction of the face by muscle transplantation using microsurgery may cause problems with muscle atrophy and synkinesia. Therefore, it is necessary to observe the patient on a long-term basis. In 2006, we reported a case of functional reconstruction using a radial forearm flap combined with an innervated gracilis muscle flap for total reconstruction of the lower lip.1 We applied the same method to reconstruct both the upper and lower lips and the commissure.2 The aim of this report is to describe the 10-year postoperative result in the latter case. The details of the case and surgical technique were reported.2 Briefly, the patient underwent a resection of two-fifths of his upper lip and one-third of his lower lip including the left commissure because of arteriovenous malformation. His left forearm flap was transferred and the radial artery and vein were anastomosed to the left facial artery and vein. Then, the gracilis muscle was transferred and the cut ends of the muscle were sutured to the orbicularis oris muscle, after which the motor nerve of the muscle was sutured to the buccal branch of the facial nerve. In addition, skin and mucosal defects were covered by a forearm flap and a sensory nerve of the forearm flap was sutured to the mental nerve. After 5 months, the skin of the forearm flap on the face was resected and replaced using a local flap. After 10 years, there is no recurrence of arteriovenous malformation. The patient has not required any additional treatment in the past 10 years. The lip sphincter function is maintained (Fig. 1). Facial expression and lip movement are achieved independently and no facial synkinesia is recognized. [See Video (online), which displays 10-year follow-up of the case. Oral sphincter function is maintained by the combination of the innervated gracilis muscle and the sensate forearm flap.] The depth of oral vestibule space and the length of lower lip are maintained and no salivation is observed. The patients can eat a normal diet. The result of Semmes-Weinstein monofilament test on the forearm flap in the oral cavity was 2.44. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video.","caption":"This video displays 10-year follow-up of the case. Oral sphincter function is maintained by the combination of the innervated gracilis muscle and the sensate forearm flap.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_1himk65z"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Fig. 1.: (Left) Ten years after the reconstruction. (Right) Oral sphincter function is maintained and no facial synkinesia is recognized.The most important consideration in lip function is maintenance of the sphincter function by the orbicularis oris muscle. Ninkovic et al. reported a similar method using a gracilis muscle free flap.3 The difference from our method is the technique of covering the muscle. A graft or local flap covered the muscle in that report. The forearm flap provides a long pedicle and better sensation. Sensation of the lip and depth of vestibular space are important to reduce the saliva and support speech and eating. To achieve muscle sphincter function, the palmaris longus tendon can be attached to the forearm flap to suspend the lip by suturing it to the orbicularis oris muscle.4 However, postoperative loosening of the tendon and drooping of the flap may occur, and additional surgical treatment may be required.5 Our 10-year follow-up of this patient shows that combining the innervated gracilis muscle, which did not exhibit any dyssynergia and synkinesia, with the sensate forearm flap allows for a successful and sustainable lip reconstruction and contributes to maintenance of the patient’s quality of life, even in the long term. PATIENT CONSENT The patient provided written consent for the use of his images. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Gastrointestinal Bleeding After HeartMate II or HVAD Implantation: Incidence, Location, Etiology, and Effect on Survival.

The number of patients on destination therapy is increasing as long-term survival on continuous-flow left ventricular assist device (CF-LVAD) therapy has improved. Gastrointestinal bleeding (GIB) is a common complication after CF-LVAD implantation, and its risk correlates with longer support time, emphasizing the importance of GIB management. The lower pulsatility of CF-LVADs may promote arteriovenous malformations, which amplify the bleeding risk. Here, we retrospectively analyzed the location, incidence, and survival effect of GIB events in HeartMate II (HM-II) and HeartWare Ventricular Assist Device (HVAD) recipients to provide specific details regarding these complications. From November 2003 to March 2016, 526 patients with chronic heart failure underwent primary implantation of an HM-II (n = 403) or HVAD (n = 123) CF-LVAD at our center. Of the 526 patients, 140 (26.6%) had a GIB event (HM-II: n = 100; HVAD: n = 40), 92 (17.5%) had a single GIB event, and 48 (9.1%) had multiple GIB events (range: 2-9 events). HVAD recipients had a higher incidence of both upper and lower GIB events (p < 0.001 and P = 0.002, respectively) than HM-II recipients. Arteriovenous malformation was the most common etiology for GIB (50 patients/72 events); for this group, the average time-to-event was 300.4 days, the recurrence rate was 34%, and the 90-day and 1-year survival rates were 88.3% and 66.7%, respectively. Age at implantation was the only predictor of GIB. In conclusion, our study provides detailed information about GIB events associated with current CF-LVADs. Additional studies are required to evaluate strategies to reduce the incidence of GIB morbidity.

Pediatric intracranial arteriovenous malformations: a single-center experience

OBJECTIVEIntracranial arteriovenous malformations (AVMs) are a common cause of intracranial hemorrhage in children. Exploring outcomes of treatment and factors that predict recurrence may help guide the management of pediatric AVMs. In this study, the authors review a single-center experience with pediatric AVMs, aiming to identify factors contributing to recurrence and areas for improvement in treatment.METHODSA single-center retrospective review of patients ages 0–18 years with AVMs in the period from 2005 to 2018 was conducted. Demographic, clinical, and radiographic data were collected and examined to compare the clinical and functional outcomes of patients managed with and those managed without open microsurgical resection.RESULTSOne hundred five patients were diagnosed and treated during the study period. Fifty (47.6%) had been treated surgically and 35 (33.3%) nonsurgically, and 20 (19%) had been treated primarily at an outside institution and thus were excluded from further analysis. Of the 50 treated surgically, 92% had complete obliteration on postoperative imaging, with the remaining patients having residual AVM and undergoing re-resection or SRS, ultimately resulting in a 96% radiographic cure rate. The surgically treated patients were followed up for an average of 3.34 years. Eighty-two percent had a modified Rankin Scale (mRS) score of 0–2. There was a recurrence rate of 12%, with the time to recurrence averaging 327.86 days (range 85–596 days). Of the 35 patients managed without open surgery, 77% underwent serial imaging surveillance, 20% underwent endovascular embolization, and 3% underwent stereotactic radiosurgery. Radiographic cure was seen in 6% of those treated nonsurgically, and all had undergone endovascular treatment alone. The nonsurgically treated patients were followed up for an average of 2.14 years. Eighty percent had an mRS score of 0–2.CONCLUSIONSThe data revealed that patients with lower-grade AVMs treated surgically and those with higher-grade AVMs managed without surgery have good functional and clinical outcomes. A high rate of recurrence was noted, and the possible contributing factors were explored. The authors encourage further study into mechanisms to reduce AVM recurrence in pediatric patients and look forward to advances in the medical management of lesions that are considered unresectable.

Molecular mechanisms of growth and recurrence of cerebral arteriovenous malformations: part 2 (our own research)

Cerebral arteriovenous malformations (AVM) are not static congenital formations. These structures can grow, recur, and even appear de novo after a "complete" cure. To analyze the dynamics of angiogenic factors before and after embolization of cerebral AVMs. The study enrolled 314 patients with AVM who underwent endovascular treatment at the Department of Brain Vessels Surgery of the Polenov Russian Research Neurosurgical Institute for the period from 2011 to 2017. The control group included 33 healthy volunteers. Their age was comparable to that in the main group. The levels of serum vascular endothelial growth factor (VEGF), angiopoietin-2 (ANG-2) and matrix metalloproteinase-9 (MMP-9) were measured before and in 24 hours after endovascular embolization using enzyme-linked immunosorbent assay (Personal Lab, «Adaltis», Italy). Increased levels of VEGF, MMP-9 and ANG-2 were observed in 48.4% of primary patients with AVM. No correlation of increased level of these factors with gender, age, co-morbidities, localization and structure of AVM was found. High level of VEGF and MMP-9 was typical for AVM Spetzler-Martin grade III, AVM with hemorrhagic course, drainage into the deep cerebral veins and with afferents from the external carotid artery. Total embolization of AVM led to normalization of all elevated angiogenesis factors. In contrast, partial embolization resulted augmentation of VEGF and MMP-9 levels. Normalization of all elevated growth factors after total embolization confirms the absence of potency for AVM recurrence. Identification of the factors predisposing to possible growth of AVM should be a justification for total resection of AVM. Persistent elevation of serum growth factors after total embolization in accordance with the angiographic criteria may be a sign of subtotal occlusion of AVM.

Oral propranolol as palliative treatment for a recurrent arteriovenous malformation

Dermatologic TherapyVolume 32, Issue 6 e13075 Therapeutic Hotline: Letter Oral propranolol as palliative treatment for a recurrent arteriovenous malformation Pedro Rodríguez-Jiménez, Corresponding Author Pedro Rodríguez-Jiménez pedro.rodriguez.jimenez90@gmail.com orcid.org/0000-0002-7061-3027 Dermatology Unit, Clínica Dermatológica Internacional, Madrid, Spain Correspondence Pedro Rodríguez-Jiménez, Dermatology Unit, Clínica Dermatológica Internacional, Marques de Villamagna 8, 28006 Madrid, Spain. Email: pedro.rodriguez.jimenez90@gmail.comSearch for more papers by this authorMarta Uceda, Marta Uceda Dermatology Unit, Clínica Dermatológica Internacional, Madrid, SpainSearch for more papers by this authorJose Luis Ramirez-Bellver, Jose Luis Ramirez-Bellver orcid.org/0000-0001-7954-9335 Dermatology Unit, Clínica Dermatológica Internacional, Madrid, SpainSearch for more papers by this authorRicardo Ruiz-Rodríguez, Ricardo Ruiz-Rodríguez Dermatology Unit, Clínica Dermatológica Internacional, Madrid, SpainSearch for more papers by this authorIgnacio Sánchez-Carpintero, Ignacio Sánchez-Carpintero Dermatology Unit, Clínica Dermatológica Internacional, Madrid, SpainSearch for more papers by this author Pedro Rodríguez-Jiménez, Corresponding Author Pedro Rodríguez-Jiménez pedro.rodriguez.jimenez90@gmail.com orcid.org/0000-0002-7061-3027 Dermatology Unit, Clínica Dermatológica Internacional, Madrid, Spain Correspondence Pedro Rodríguez-Jiménez, Dermatology Unit, Clínica Dermatológica Internacional, Marques de Villamagna 8, 28006 Madrid, Spain. Email: pedro.rodriguez.jimenez90@gmail.comSearch for more papers by this authorMarta Uceda, Marta Uceda Dermatology Unit, Clínica Dermatológica Internacional, Madrid, SpainSearch for more papers by this authorJose Luis Ramirez-Bellver, Jose Luis Ramirez-Bellver orcid.org/0000-0001-7954-9335 Dermatology Unit, Clínica Dermatológica Internacional, Madrid, SpainSearch for more papers by this authorRicardo Ruiz-Rodríguez, Ricardo Ruiz-Rodríguez Dermatology Unit, Clínica Dermatológica Internacional, Madrid, SpainSearch for more papers by this authorIgnacio Sánchez-Carpintero, Ignacio Sánchez-Carpintero Dermatology Unit, Clínica Dermatológica Internacional, Madrid, SpainSearch for more papers by this author First published: 23 August 2019 https://doi.org/10.1111/dth.13075Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume32, Issue6November/December 2019e13075 RelatedInformation

Ferumoxytol-enhanced MRI for surveillance of pediatric cerebral arteriovenous malformations.

Children with intracranial arteriovenous malformations (AVMs) undergo digital DSA for lesion surveillance following their initial diagnosis. However, DSA carries risks of radiation exposure, particularly for the growing pediatric brain and over lifetime. The authors evaluated whether MRI enhanced with a blood pool ferumoxytol (Fe) contrast agent (Fe-MRI) can be used for surveillance of residual or recurrent AVMs. A retrospective cohort was assembled of children with an established AVM diagnosis who underwent surveillance by both DSA and 3-T Fe-MRI from 2014 to 2016. Two neuroradiologists blinded to the DSA results independently assessed Fe-enhanced T1-weighted spoiled gradient recalled acquisition in steady state (Fe-SPGR) scans and, if available, arterial spin labeling (ASL) perfusion scans for residual or recurrent AVMs. Diagnostic confidence was examined using a Likert scale. Sensitivity, specificity, and intermodality reliability were determined using DSA studies as the gold standard. Radiation exposure related to DSA was calculated as total dose area product (TDAP) and effective dose. Fifteen patients were included in this study (mean age 10 years, range 3-15 years). The mean time between the first surveillance DSA and Fe-MRI studies was 17 days (SD 47). Intermodality agreement was excellent between Fe-SPGR and DSA (κ = 1.00) but poor between ASL and DSA (κ = 0.53; 95% CI 0.18-0.89). The sensitivity and specificity for detecting residual AVMs using Fe-SPGR were 100% and 100%, and using ASL they were 72% and 100%, respectively. Radiologists reported overall high diagnostic confidence using Fe-SPGR. On average, patients received two surveillance DSA studies over the study period, which on average equated to a TDAP of 117.2 Gy×cm2 (95% CI 77.2-157.4 Gy×cm2) and an effective dose of 7.8 mSv (95% CI 4.4-8.8 mSv). Fe-MRI performed similarly to DSA for the surveillance of residual AVMs. Future multicenter studies could further investigate the efficacy of Fe-MRI as a noninvasive alternative to DSA for monitoring AVMs in children.

Resection of an Embolized Cirsoid Aneurysm With Intracranial Venous Drainage: 2-Dimensional Operative Video.

Cirsoid aneurysms, also known as scalp arteriovenous malformations (AVM), are rare congenital extracranial vascular anomalies that often present as an enlarging pulsatile scalp mass. A 14-yr-old male presented with a pulsatile scalp lesion that was first noticed 3 yr prior and had progressively enlarged. No history of trauma was reported. MRI demonstrated a 4 cm wide and 2 cm tall nidus and catheter angiography was performed to further define the vascular supply and drainage. The patient underwent transvenous endovascular embolization followed by surgical excision via a bicoronal incision, as shown in this operative video. Care was taken to identify, cauterize, and transect feeding vessels from the superficial temporal, supratrochlear, and supraorbital arteries circumferentially to completely devascularize and resect the galeal nidus from overlying scalp tissue and underlying pericranium. Previously unreported in the literature, transosseous emissary veins partially draining the lesion were noted on angiography and were waxed thoroughly during surgery. Six-month follow-up examination demonstrated a well-healed incision without evidence of AVM recurrence. The unique venous drainage of this cirsoid aneurysm highlights the value of diagnostic angiography to fully characterize these rare and complex vascular lesions prior to pursuing definitive treatment. IRB approval was obtained from the Ann & Robert H. Lurie Children's Hospital of Chicago Institutional Review Board (IRB #2018-1799). The IRB waives the requirement of obtaining informed consent for this study in accordance with 45 CFR 46.116(d).