Cases Of Cerebral Arteriovenous Malformations Research Articles

A Success Story of Cerebral Arteriovenous Malformation (AVM) Treated with Stereotactic Radiosurgery (SRS) in Bangladesh

Purpose: To share a case of cerebral Arteriovenous Malformation (AVM) patient, treated with Stereotactic Radiosurgery (SRS) at Evercare Hospital Dhaka, treatment process and successful outcome. Background: Arteriovenous malformation is an anomaly, mostly congenital due to a misfit in vasculogenic, where arteries and veins come to a direct connection. Treatment options include observation, embolization, microsurgery, Stereotactic Radiosurgery (SRS) either alone or in combination. This report describes our experience in treating a patient of AVM by SRS. Stereotactic Radiosurgery is an established modality to achieve desired nidus obliteration, excellent compliance being noninvasive, and reduced treatment-related morbidity. This case report also reviewed the literature in detail. After a thorough literature search, to the best of our knowledge, this shall be the first published case report of AVM successfully treated with SRS in Bangladesh. Case Presentation: In March 2019, 25-years old male presented in Radiation Oncology OPD as a diagnosed case of AVM, having complaints of headache for two years. Headache was occasional and often associated with vertigo and dizziness. He had no neurologic deficit. A radiological assessment revealed a large (4.6x4.4cm) AVM in the left parieto-occipital lobe showing serpiginous enhancement with IV contrast. After routine workup, he underwent stereotactic Radiosurgery in March’2019. A dose of 23Gy was delivered to the malformation, including all nidus. Acute radiation toxicity was noted as transient hair loss only over the irradiated area and no other side effect. Radiological Assessment was done at six months, 1year, and 2.5 years. After having a stable size at six months, complete nidus obliteration was achieved at one year. His last visit to our OPD was in July 2021, with radiologically complete nidus obliteration without any significant clinical symptoms. Conclusions: Linear Accelerator-based SRS is an excellent treatment option for AVM, encouraging clinical outcomes for carefully selected patients. Bang. J Neurosurgery 2022; 12(1): 53-64

Trends in Incidence of Intracranial and Spinal Arteriovenous Shunts: Hospital-Based Surveillance in Okayama, Japan.

To date, the incidence of intracranial and spinal arteriovenous shunts has not been thoroughly investigated. We aimed to clarify recent trends in the rates of intracranial and spinal arteriovenous shunts in Japan. We conducted multicenter hospital-based surveillance at 8 core hospitals in Okayama Prefecture between April 1, 2009 and March 31, 2019. Patients who lived in Okayama and were diagnosed with cerebral arteriovenous malformations, dural arteriovenous fistulas (DAVFs), or spinal arteriovenous shunts (SAVSs) were enrolled. The incidence and temporal trends of each disease were calculated. Among a total of 393 cranial and spinal arteriovenous shunts, 201 (51.1%) cases of DAVF, 155 (39.4%) cases of cerebral arteriovenous malformation, and 34 (8.7%) cases of SAVS were identified. The crude incidence rates between 2009 and 2019 were 2.040 per 100 000 person-years for all arteriovenous shunts, 0.805 for cerebral arteriovenous malformation, 1.044 for DAVF, and 0.177 for SAVS. The incidence of all types tended to increase over the decade, with a notable increase in incidence starting in 2012. Even after adjusting for population aging, the incidence of nonaggressive DAVF increased 6.0-fold while that of SAVS increased 4.4-fold from 2010 to 2018. In contrast to previous studies, we found that the incidence of DAVF is higher than that of cerebral arteriovenous malformation. Even after adjusting for population aging, all of the disease types tended to increase in incidence over the last decade, with an especially prominent increase in SAVSs and nonaggressive DAVFs. Various factors including population aging may affect an increase in DAVF and SAVS.

Novel Approach of Linear Accelerator-Based Stereotactic Radiosurgery in an Adult Patient With Brain Arteriovenous Malformation: A Case Report and Clinical Outcome

Stereotactic radiosurgery (SRS) is a proven strategy for treating the central nervous system arteriovenous malformation (AVM). We intend to present a case of cerebral AVM in an adult patient, successfully treated with a linear accelerator (LINAC) based SRS using simplified setup techniques and an advanced planning system. In the current scenario, frame-based SRS is the standard of care with LINAC. Recently, it has proven that even frameless SRS has similar results. In our case, we used a frameless SRS technique with similar results. While calculating the dose in radiotherapy planning, we used the Acuros™ algorithm, which has proven dosimetric advantages compared to the traditional AAA™ algorithm.

Evaluation of the dose distribution of tomotherapy using polymer gel dosimeters and optical computed tomography with ring artifact correction

Helical tomotherapy (HT) can provide highly conformal dose distribution through multiple-beam irradiation. Evaluation of such dose distribution is essential to ensure the quality of radiotherapy. In this study, we evaluated the performance of measuring the 3D dose distribution delivered by the HT using an N-Isopropylacrylamide (NIPAM) polymer gel dosimeter (PGD) and optical computed tomography (CT) with ring artifact correction. The 3D dose distribution of a real clinical case of cerebral arteriovenous malformation was measured using the NIPAM PGD. The irradiated PGD was scanned using an optical CT scanner 24-hr after dose delivery. The ring artifact correction was performed by median filtering of the acquired optical CT images in polar coordinates. The optical CT images without and with ring artifact correction were compared. The converted dose distributions from the optical CT images were compared with those generated from a treatment planning system using a gamma evaluation. Results show that the NIPAM PGD could accurately record the dose distribution delivered by the tomography. Also, ring artifact correction with proper filter length could effectively reduce the artifacts and improve the uniformity of the measured dose distribution. The pass rate of the measured dose distribution calculated using a three-dimensional gamma evaluation with 3%/3 mm criteria from 89.2% to 99.7% after ring artifact correction. We concluded that the NIPAM PGD and optical CT with ring artifact correction could be useful for pre-treatment verification of the HT.

Surgical treatment of ruptured cerebellar arteriovenous malformations

To analyze the clinical characteristics and surgical outcomes of ruptured cerebellar arteriovenous malformations (AVM). The clinical data were retrospectively analyzed for 676 brain AVM patients. Among them, 616 cases were treated at Beijing Tiantan Hospital from January 2003 to December 2009 and 32 cases of them were of cerebellar AVM. Another 60 cases of intracranial AVM were managed at Beijing Chaoyang Hospital from January 2003 to December 2011 and there were 8 cases of cerebellar AVM. Microsurgery was performed to remove hematoma and excise AVM. And the postoperative outcomes were evaluated. Statistics analysis of activities of daily living (ADL) scores for 636 cases of cerebral AVM and 40 cases of cerebellar AVM showed no significant difference. Among 40 cases of cerebellar AVM, hemorrhage occurred first in 35 (87.5%) patients. Postoperative re-examinations of computed tomography revealed the resolution of hematoma and the absence of re-hemorrhage. Digital subtraction angiography (DSA) examinations were performed in 39 cases and no residual nidus was observed. Tonsillar herniation occurred preoperatively in 1 case and DSA was not re-examined. There were balance dysfunction (n = 3), dysarthria (n = 2) and dystaxia and dysphasia (n = 1). The postoperative ADL degrees were I(n = 26), II(n = 10), III(n = 3) and IV(n = 1). During a follow-up period of 6 months, no re-hemorrhage occurred and there was no worsening function of central nerve system. Emergency microsurgery is effective in the treatment of ruptured cerebellar AVM.

Imaging Features of Cerebral Vascular Malformations

Computed tomography (CT) and magnetic resonance images (MRI) play an important role in the diagnosis of various types of cerebral vascular malformations. To evaluate the imaging features of some of these lesions and compare the results with other studies reported in literature, eight patients (including four cases of cerebral arteriovenous malformation, one case of pial arteriovenous [AV] fistula, two cases of cerebral cavernous malformation [CVM], and one case of developmental venous anomaly [DVA]), with the age range of 28 to 74 years and symptoms ranging from asymptomatic to massive intracranial haemorrhage and coma, were examined by CT, MRI, conventional angiography, or a combination of these. A survey of 11 studies on CVMs, reported from 1981 to 2008, was also done and results were summarized in brief to compare with our study. Noncontrast CT was unable to detect DVA or characterize the lesion in cases of pial AV fistula and cavernous malformations, but MRI was quite successful in detecting cavernous malformations. Computed tomographic angiography (CTA) was highly successful in detecting and characterizing the imaging features of DVA, pial AV fistula, and AVMs. Angiography showed an additional feeding artery in one case of AVM, which CTA failed to show, and endovascular therapy at the time of angiography was also successful to embolize the large intranidal aneurism, providing significant improvement in the patient's condition.

Analysis of relevant factors of cerebral arteriovenous malformation with hemorrhage

To explore the influencing factors of bleeding in the patients with cerebral arteriovenous malformation (AVM) through observing its angioarchitecture with cerebral digital subtraction angiography (DSA) so as to decipher its hemorrhagic risks. A total of 87 cases of cerebral AVM during the period of 2004-2010 underwent cerebral angiography by digital subtraction angiography. The relationships between bleeding and such factors as the site and size of masses of AVM, the type and site of supplying arteries, the number and pathway of venous drainage, the relationships between AVM and aneurysm in terms of location and venous tumor were determined by univariate analyses and binary Logistic regression with SPSS 18.0. Univariate analysis indicated that such factors as the site and size of masses, the type and site of supplying arteries, the number venous drainage, the relationships between AVM and aneurysm were positively correlated with hemorrhagic presentation. When stepwise multiple Logistic regression analysis was employed, only the size of AVM, the number of venous drainage and aneurysm were the independent predictors of hemorrhagic presentation. The size of masses of AVM, the number of venous drainage and aneurysm are the strong risk predictors for AVM hemorrhage.

Progression of Stenosis Into Occlusion of the Distal Posterior Cerebral Artery Supplying an Occipital Arteriovenous Malformation Manifesting as Multiple Ischemic Attacks

A 31-year-old healthy male presented with a rare case of cerebral arteriovenous malformation (AVM) manifesting as repeated ischemic attacks and cerebral infarction causing left sensori-motor disturbance. Neuroimaging revealed cerebral infarction in the right thalamus as well as right occipital AVM without bleeding. The AVM was mainly fed by the right angular artery, and the right posterior cerebral artery (PCA) showed mild stenosis and segmental dilation at the P(2)-P(3) portion. After referral to our hospital, transient ischemic attacks causing left homonymous hemianopsia, and left arm and leg numbness were frequently recognized. Additional imaging revealed a new ischemic lesion in the occipital lobe, and repeated cerebral angiography showed right PCA occlusion at the P(2)-P(3) segment. Cerebral AVM presenting with cerebral infarction due to occlusion of feeding arteries is rare. In our case, intimal injury due to increased blood flow or spontaneous dissection of the artery were possible causes. We should monitor any changes in the architecture and rheology of the feeding vessels during the clinical course to prevent ischemic complications.

The application of intraoperative near-infrared indocyanine green videoangiography and analysis of fluorescence intensity in cerebrovascular surgery

Objective:To evaluate the usefulness and limitations of the intraoperative near-infrared (NIR) indocyanine green videoangiography (ICG-VA) and analysis of fluorescence intensity in cerebrovascular surgery.Methods:Forty-eight patients received ICG-VA during various surgical procedures from May 2010 to August 2010. Included among them were 45 cases of cerebral aneurysms and 3 cases of cerebral arteriovenous malformations (AVMs). The infrared fluorescence module integrated into the surgical microscope was used to visualize fluorescent areas in the surgical field. An integrated analytical visualization tool constantly analyzed the fluorescence video sequence and generated it in the form of an intensity diagram for objective interpretation.Results:Overall, the procedure of ICG VA was done 158 times in 48 patients. There was no adverse effect of ICG dye. In cerebral aneurysm cases, the images obtained were of high resolution. In 4 cases, incomplete clipping was detected by ICG-VA and allowed suitable adjustment to completely obliterate the aneurysm. In 3 aneurysm cases, the intensity diagram of ICG VA provided valuable information. ICG-VA identified the feeding arteries, the draining veins, and nidus in all 3 AVM cases, which was confirmed by an immediate analysis of fluorescence intensity.Conclusions:ICG-VA provides high resolution images allowing real-time assessment of the blood flow in surgical field. The intensity analysis function, in addition, is a useful adjunct to improve the accuracy of the clipping and decrease the complication rates in cerebral aneurysm cases. In cerebral AVM cases, with the help of color map and intensity diagram function, the superficial feeders, drainers, and nidus can be identified easily.

Retrospective Analysis on 76 Cases of Cerebral Arteriovenous Malformations Treated by Gamma Knife Radiosurgery

Outcome of gamma knife radiosurgery (GKS) in the consecutive 100 cases with cerebral arteriovenous malformations (AVMs) was analyzed. Data from initial 100 patients treated with GKS in the authors' institute were reviewed retrospectively. Spetzler-Martin grade at diagnosis were I in 18 patients, II in 27, III in 36, IV in 11, and V in 8. Thirty-five patients had experienced previous bleeding, 27 patients presented with seizure, and 31 patients presented with headache. The mean volume of the lesion was 4.3 cm(3) (0.1-29.3 cm(3)). The median radiation dose delivered to the margin was 20.0 Gy (13-32 Gy). Mean follow-up period was 37.5 months (5-63 months). Angiographic follow-up was performed in 48 patients at least 2 years after GKS. Sixteen patients were lost in follow up following 2 years from GKS. Twenty-eight of 48 patients (58%) showed complete obliteration and 20 patients (42%) showed partial obliteration. Seven patients presented with post-GKS hemorrhage. Adverse radiation effect (ARE) was observed at follow-up MRI in 25 of 76 patients, and it was symptomatic in 5 patients. Complete obliteration was confirmed in 24 of 31 (77%) patients with volume less than 4 cm(3), meanwhile only 4 of 17 (24%) patients with volume of 4 cm(3) or more showed complete obliteration. Complete obliteration rate was 67% with 20 Gy or higher marginal dose, 63% with 15-20 Gy, and 17% with less than 15 Gy. GKS can provide high rates of obliteration with acceptable risk of morbidity in a subgroup of small AVMs. However, overall outcome in whole spectrum of AVMs, in which large proportion of cases have unfavorable characteristics for radiosurgery, is much worse. More effective therapeutic strategy needs to be developed for large AVMs that are difficult to be managed with current available treatment modalities.

Seizure control after radiosurgery on cerebral arteriovenous malformations

Among 462 cases of cerebral arteriovenous malformation (AVM) treated with gamma-radiosurgery, the initial presentations were haemorrhage in 68%, epilepsy in 12.8%, neurological deficits in 3.2%, minor symptoms in 7.6% and asymptomatic in 4.5% respectively. There were 79 cases (17.1%) who had had a convulsive seizure before radiosurgery and they were classified into two groups: 58 cases presented with seizure as an initial symptoms (group A) and the other 21 cases mostly had seizures following intracranial haemorrhage (group B). Before radiosurgery, generalised seizure was the predominant seizure pattern in both groups, followed by pure partial and complex partial seizures. There was no major difference in seizure patterns or seizure frequency in group A and B. At radiosurgery AVMs were treated with a mean maximum dose of 37.2 Gy and a marginal dose of 19.8 Gy. Seizures had apparently decreased in most of the cases at the last follow-up (mean 24 months) according to the obliteration of the nidus. Seizures were either decreased or had disappeared in 91.6% of group A and 62.5% of group B patients. The overall results indicate that seizures improved in 85.5%, were changed in 11.6% and deteriorated in 2.9% of patients. Radiosurgery is effective not only for the obliteration of nidus of cerebral AVM, but also for seizure control, even before complete occlusion of the nidus.

Surgical resection of a cerebral arteriovenous malformation for treatment of superficial siderosis: case report

BACKGROUND To our knowledge, there are only two reported cases of cerebral arteriovenous malformation associated with superficial siderosis. In both cases, the patients were asymptomatic and were discovered on retrospective review of magnetic resonance imaging. CASE DESCRIPTION We describe a case of superficial siderosis in a 47-year-old male with a remote history of closed head injury that presented with progressive hearing loss, cerebellar ataxia, and urinary incontinence. Lumbar puncture was indicative of active subarachnoid bleeding. Cerebral angiography revealed a small vascular malformation that was resected. RESULTS Pathological examination confirmed the diagnosis of the arteriovenous malformation. Six months after surgery the patient is neurologically stable with no further progression of clinical signs or symptoms. CONCLUSIONS We report the first case of surgical resection of an intracranial arteriovenous malformation for the treatment of superficial siderosis. We emphasize the necessity of a detailed evaluation when superficial siderosis is suspected to localize and resect potential bleeding sources, because the disease is progressive and often irreversible.

Treatment selection for cerebral arteriovenous malformations: radiosurgery or microsurgery

The clinical results and patient characteristics of 318 cases of cerebral arteriovenous malformations (AVMs) were analyzed: 138 patients were treated by surgery including 98 cases of total removal and 17 cases of subtotal removal; 37 patients were treated conservatively; 139 patients were treated by gamma-knife and 6 patients were treated by linac-knife radiosurgery using stereotactic multi-converging arcs systems. Clinical data analysis was performed using the same protocol in both of the surgery and the radiosurgery groups. Operative mortality for total removal was one out of 98 cases (1%). There was one death by hemorrhage, one case of symptomatic rebleeding and two cases of asymptomatic bleeding in patients treated by radiosurgery. Thus, mortality was 1 out of 145 (0.7%). Patients with total resection of AVMs had the best clinical results in comparison with subtotal resection or with conservative treatment. Morbidity was the lowest in the patients treated by radiosurgery. However, the total obliteration rate was lower than the surgical cure rate. The decision for treatment should be based on an estimation of mortality, morbidity and cure rate for each treatment.

Seizure outcome in patients with surgically treated cerebral arteriovenous malformations.

A series of 280 cases of cerebral arteriovenous malformations (AVM's) treated surgically between June, 1970, and June, 1989, is reviewed with particular focus on the preoperative seizure history and follow-up seizure status. Follow-up evaluation (mean duration 7.5 years) was achieved in 98% of cases and was accomplished through re-examinations, telephone interviews, and written questionnaires. Overall, 89% of the surviving patients with a follow-up period of greater than 2 years were free of seizures at last examination. Of the 280 patients in this series, 163 had experienced no seizures preoperatively. A recent follow-up study (with a minimum duration of 2 years or to death) was available in 157 of these 163 cases; 21 patients had died. Of the 136 surviving patients, only eight (6%) were having new ongoing seizures. In the 128 (94%) who had remained seizure-free, 73% were receiving no anticonvulsant agents while 27% were taking anticonvulsant prophylaxis. The 2-year minimum follow-up study in 110 of the 117 patients with preoperative seizures revealed that eight (7%) had died. Of the 102 surviving patients, 85 (83%) were seizure-free (with 48% no longer receiving anticonvulsant therapy), while 17 (17%) still suffered intermittent seizures. However, of these 17 patients, 13 reported their seizures to be improved compared to preoperatively; the seizures were the same in two patients and were worse in two patients. An actuarial analysis was conducted comparing the life expectancy of patients following surgery for AVM's with the expected survival of a general white population of the same age and sex in the West Northcentral region of the United States. No statistically significant difference was found. There were seven perioperative deaths (three from cerebral hemorrhage, two from pulmonary emboli, and two from obstruction of venous drainage) and 22 deaths during the follow-up period. Of these 22 deaths, the cause was unknown in four patients, apparently unrelated to the AVM in 13, and directly or indirectly related to the patient's neurological condition prior to surgery or due to surgery performed for resection of the AVM in five. There was a statistically significant relationship between the size and location of the AVM and the clinical presentation. Patients with small AVM's (< 3 cm) were more likely to present with hemorrhage whereas those with large AVM's were more likely to present with seizures.(ABSTRACT TRUNCATED AT 400 WORDS)

前頭葉底部病変で健忘症候群を呈した脳動静脈奇形の１例

前頭葉底部への出血により健忘症候群を呈した, 脳動静脈奇形の1例を報告した.患者は17歳の右利き女性で, 意識障害のため近医を受診し, 脳室ドレナージ術を施行された.脳血管写で前大脳動脈および前交通動脈より流入する脳動静脈奇形と診断され, 根治手術の目的で当院に転院した.初診時, 意識は清明で, 時間や場所に関する見当識障害を認めた.また, 一般知識, 即時記銘, 遠隔記憶などは保たれていたが, 前向き健忘に由来する近時の記憶障害は高度であり, また軽度の逆行性健忘を合併した.脳神経系に異常を認めず, 麻痺や知覚障害も認めなかった.CTでは, 右前頭葉側面とくにrectal gyrusからcingulate gyrus, subcallosal areaに血腫を認めた.全摘出後5ヵ月で記銘力障害は改善を認めたが, 軽度の前向き健忘は残存した.本症例では, AVMからの出血によるseptal-hippocampal damageによって, 記憶系の回路に障害を生じたものと考えた.

脳動静脈奇形に対するintravascular surgery

Twelve cases of cerebral arteriovenous malformation (AVM) were managed with intravascular surgery preoperatively, in order to facilitate surgical removal. In 10 of these cases, preoperative balloon occlusion of the feeding arteries was performed by means of detachable balloon catheter. In the rest of the cases, preoperative embolization of the AVM was performed by EVAL through Tracker infusion catheter. There was no complication after preoperative balloon occlusion and one transient aphasia related to preoperative embolization. None of the cases developed normal perfusion pressure breakthrough. Preoperative balloon occlusion was thought to be safe and to decrease the difficulty in surgical resection of the AVM. Preoperative embolization seems to be more effective than balloon occlusion; however, it should be performed carefully without causing complications.

脳動静脈奇形と脳動脈瘤・脳動静脈瘤の合併例

We have experienced 11 cases of cerebral arteriovenous malformation (AVM) associated with an aneurysm or an arterio-venous varix(AVV). Five of the patients were male and six were female, and the mean age was 42. Eight cases were supratentorial, and three were infratentorial. Initial symptoms were bleeding in seven cases, seizure in one, and involuntary movement in one. Among the seven cases with bleeding as the initial symptom, bleeding occured from the aneurysm in three cases, and from the AVM in two cases; in two cases the source of bleeding was undetermined. A two-stage operation was performed in five cases of initial bleeding lesions. Surgical results were excellent in all but one case, in which neither the AVM nor the aneurysm was accessible. The etiology of these combinations of lesions could be explained by the hemodynamic theory. In high flow AVMs, the probability of formation of an aneurysm or the risk of rupture of the aneurysm should be considered during the follow-up period. And in such cases, to prevent rupture of the aneurysm, radical surgery of the AVM should be considered, taking into account the risk of postoperative neurological deficits.

Intra-operative embolization of cerebral arteriovenous malformations by means of isobutylcyanoacrylate (experience in 20 cases).

20 cases of cerebral arteriovenous malformations (AVM's) are reported, treated by direct intraoperative embolization. A 50% mixture of butyl-2-cyanoacrylate (IBC) and ethyl mono-iodostearate (Duroliopaque) was used. The clinical history of the patients was a long history of seizures in 10 cases, a haemorrhage in 9 cases, and a motor deficit in 1 case. In the immediate post-operative course, 1 patient died, 3 patients had a serious post-operative haemorrhage, 6 patients presented with a transient post-operative deficit, and in 10 patients the post-operative course was uneventful. During the following years, a late haemorrhage occurred after incomplete AVM eradication in 3 patients, leading to AVM resection. The AVM eradication was eventually complete in 3 cases with embolization only, and in 7 cases with embolization and AVM resection. The overall management of AVM in all 20 patients was: embolization only in 13 cases, embolization and resection in 7 cases. The long term results are: operative death 1, late death 3, long lasting deficit 1; uneventful 15. The authors discuss the technique of embolization, the effect of IBC on the vessel walls, the evolution of their general management of AVM's after this experience. Eventually the intra-operative embolization may be helpful after incomplete intra vascular embolization, to facilitate the AVM eradication.

Radioisotopic study of arteriovenous anomalies.

Tc99m sequential scintigraphy of the brain detected all of 17 cases of cerebral arteriovenous malformations and racemose angiomas of the scalp. The focus was best shown in the earliest phase of studies and particularly in the first stage films. The detection rate decreased with the passage of time after administration of Tc99m.The data-store/playback accessory further permits the analysis of circulatory dynamics of the brain. Transit time and local cerebral blood flow are determined, in the multiple regions of interest, for various size and location. Size of the arteriovenous shunt is estimated by I131 macroaggregated albumin brain-lung scintigraphy.Although the individual techniques described are not new, combined use of these 3 studies is easy to perform with the gamma-ray scintillation camera and data processing equipment. These physiologic data seem to be of value in the neuroradiologic examination of cerebral arteriovenous fistulas.