Treatment Of Cerebral Arteriovenous Malformations Research Articles

Trans-radial cerebral angiography for stereotactic radiosurgery treatment of arteriovenous malformations

The popularity of trans-radial access (TRA) for cerebral angiography is growing. Potential benefits of TRA over traditional trans-femoral access (TFA) are multitude. This study aimed to evaluate discharge outcomes and patient opinion of TRA compared to TFA in patients undergoing cerebral angiography prior to stereotactic radiosurgery (SRS) treatment for cerebral arteriovenous malformations. Consecutive patients treated at the National Centre for Stereotactic Radiosurgery (Sheffield, United Kingdom) over a 22-month period were included. All patients underwent cerebral angiography with either TRA or TFA as part of treatment planning prior to SRS. TRA patients who had previously undergone TFA in other centres were surveyed for their experience of cerebral angiography using a questionnaire. SRS staff at our centre was approached for their opinion. 492 patients were included (median age=43 years, 57.5% male, median lesions treated=1). More patients underwent angiography with TFA (75.2%) than TRA (24.8%). No difference was found in accumulated dose for angiography between the groups (p>0.05). There was 17.6% reduction in overnight stay between TRA and TRF, the proportion of patients requiring overnight admission was higher for the TFA (35.2%) than TRA (17.6%, p<0.05). 101 patients were surveyed, with a response rate of 47%. Most respondents (79%) indicated preference for TRA over TFA. Use of TRA in pre-SRS cerebral angiography is feasible and improves both patient and staff experience. The adoption of TRA could have important implications for department resources and costs by reducing the proportion of overnight admissions.

Intraoperative selective cerebral angiography for microsurgical treatment of cerebral arteriovenous malformations in a hybrid operating room

Arteriovenous malformations (AVMs) of the brain are a congenital anomaly of the development of cerebral vessels, when instead of a normal capillary bed, a «network» of pathologically altered vessels is formed, through which arterial blood is shunted into the drainage venous system. Due to the thinned wall of the pathological vessels and high pressure in them, patients with AVMs are at risk of intracerebral hemorrhage up to 4 % annually, which determines the vital need for their treatment. Microsurgical removal of brain AVMs is considered the most radical and effective treatment method, the main goal of which is to completely disable the body of the malformation, since the remaining part can lead to the risk of postoperative bleeding. To ensure effective control over the completeness of AVM removal intraoperatively, two methods have been developed: selective cerebral angiography (SCAG) and indocyanine green video angiography (ICG-VA). According to the literature, SCAG provides a number of advantages in the intraoperative diagnosis of residual AVM parts compared to ICG-VA. The article analyzes our own experience in using intraoperative SCAG in the surgical treatment of AVM in a hybrid operating room and examines the literature data on the topic of the paper. Our study highlights the importance of using the method of intraoperative control through SCAG in order to improve the effectiveness of surgical treatment of cerebral AVMs.

Time-Dosed Stereotactic Radiosurgery for the Treatment of Cerebral Arteriovenous Malformations: An Early Institution Experience and Case Series

BACKGROUND AND OBJECTIVES: Stereotactic radiosurgery (SRS) is an effective treatment modality used by neurosurgeons to treat cerebral arteriovenous malformations (AVMs), particularly for treating AVMs &lt;10 cm3. Current strategies include single-staged, dose-staged, and volume-staged SRS, all of which demonstrate varying effectiveness for treating large-volume AVMs (&gt;10 cm3). We introduce a novel refinement called time-dosed SRS for the treatment of large-volume AVMs or AVMs located in eloquent areas. This study aims to detail treatment parameters, outcomes, and complications associated with time-dosed SRS in our early experience study. METHODS: We retrospectively reviewed all patients treated using time-dosed SRS at our institution. Data, including AVM location, history of hemorrhage, history of intervention, AVM volume, Spetzler-Martin grade, presence of residual disease, and occurrence of postprocedural complications, were collected. RESULTS: Sixteen patients were included. The median total AVM volumes treated were 9.64 cm3 (0.92-46.2 cm3) and 13.2 cm3 (3.0-42.2 cm3) in adults and children, respectively. The median margin doses for adults and children at each of the 3 stages were 10 Gy, 10 Gy (8-10 Gy) and 9 Gy (8-10 Gy), and 10 Gy, 10 Gy (9-10 Gy), and 10 Gy (8-10 Gy), respectively. The median total dose delivered was 29 Gy (27-30 Gy) in adults and 30 Gy (28-30 Gy) in children. The median radiological follow-up length was 35 months (9-62 months) in adults and 31 months (4-72 months) in pediatric patients. Complete obliteration was confirmed by cerebral angiogram in 6 adult patients and 1 pediatric patient. One adult patient and 2 pediatric patients suffered radiation-related toxicity. No patients suffered postprocedural hemorrhage. CONCLUSION: Time-dosed SRS seems to be effective for treating large AVMs or those in highly eloquent areas, with a low rate of complications.

Endovascular embolization for basal ganglia and thalamic arteriovenous malformations.

Basal ganglia and thalamic arteriovenous malformations (AVMs) represent a special subset of malformations. Due to the involvement of vital brain structures and the specifically fine and delicate angioarchitecture of these lesions, it presents unique therapeutic challenges and technical difficulties that require thorough treatment planning, individualized treatment strategies, and advanced techniques for good clinical outcome. In this study, we presented a series of ruptured basal ganglia and thalamic AVMs embolized via a transarterial, transvenous or combined approach. Herein, we summarized our treatment experience and clinical outcomes to further evaluate the effectiveness and safety of endovascular embolization for these AVMs as well as the indications, therapy strategies, and techniques of embolization procedures. Twelve patients with basal ganglia and thalamus AVMs were included in the study. Their average age was 23.83 ± 16.51 years (range, 4-57 years) with a female predominance of 67% at presentation. The AVMs were located in the thalamus in 3 (25%) patients, in the basal ganglia in 3 (25%) patients, and in both sites of the brain in 6 (50%) patients. There were 5 AVMs located on the left side and 7 on the right. The mean nidus diameter was 3.32 ± 1.43 cm (range 1.3-6.1 cm). According to the Spetzler-Martin grading classification, 4 (33.3%) brain AVMs were Grade III, 7 (58.3%) were Grade IV, and 1 (8.3%) was Grade V. All of them presented with bleeding at admission: four of these patients presented with an intracerebral hemorrhage (ICH), 8 ICH in combination with intraventricular hemorrhage (IVH), and no patient with subarachnoid hemorrhage (SAH). Among these patients treated with endovascular embolization, 7 patients were treated by the transarterial approach, 4 patients transvenous approach, and 1 patient underwent the combined approach. A single embolization procedure was performed in 6 patients (50%) and the other 6 cases (50%) were treated in a staged manner with up to three procedures. Procedure-related complications occurred only in two patient (16.7%). Complete AVM obliteration was obtained in 7 patients (58.3%), and partial obliteration was in 4 patients (33.3%). Overall, good or excellent outcomes were obtained in 7 patients (58.3%), and poor functional outcome was observed in 5 patients (41.7%) at the last follow-up. All survived patients achieved anatomic stabilization and there was no postoperative bleeding or recurrence in the follow-up. The management of the basal ganglia and thalamic AVMs is a great challenge, which needs multimodal individualized treatment to improve the chances of radiographic cure and good outcomes. Endovascular therapy is safe and effective in the treatment of cerebral AVMs particularly for deep-seated AVMs such as the basal ganglia and thalamus. Our results demonstrate a high rate of anatomic obliteration with an acceptable rate of complications in the endovascular treatment of these vasculopathies via a transarterial approach or a transvenous approach.

Deliberately Staged Combined Endovascular Embolization and Subsequent Microsurgery Resection for the Treatment of Cerebral Arteriovenous Malformations

Complex cerebral arteriovenous malformations (AVMs) require a combined therapy of endovascular embolization and microsurgical resection to eliminate the lesion and maximize neurological protection, while a deliberate time interval might contribute to optimal clinical outcomes. The present study aimed to explore the feasibility of this paradigm. All patients who underwent deliberately planned presurgery embolization and microsurgery resection between 2015 and 2023 were reviewed, with baseline data, postoperative complications, and follow-up outcomes recorded. The modified Rankin scale (mRS) was used to evaluate clinical outcomes, with mRS 0-2 defined as good. A total of 30 patients were included in the study (15 were ruptured AVMs). The median Spetzler-Martin grade of baseline AVMs was 3 (interquartile range: 2-3). The median interval between the last embolization and microsurgery was 5days (interquartile range: 2.25-7). The complete removal rate was 100%, and the overall permanent complication rate was 16.67%. At the last follow-up, 26 patients achieved mRS 0-2, while 28 had improved or unaltered mRS. The last follow-up mRS significantly improved from baseline and discharge (P= 0.0006 and P= 0.006). The last follow-up mRS decreased by 0.65 for each additional day of time interval before the 4.4-day inflection point (β=-0.65, P= 0.02) in the AVM ruptured cohort. The deliberately staged combined procedure of embolization and microsurgery might be a safe and efficacious strategy for Spetzler-Martin grade 2-5 AVMs, 4-5 days might be an appropriate staged time interval for ruptured AVMs, although further studies are needed to substantiate these findings.

Pressure cooker technique in cerebral AVMs and DAVFs: different treatment strategies.

The pressure cooker technique (PCT) was developed to enable safer and more extensive embolization of hypervascular lesions by simultaneously minimizing backflow of liquid embolic materials and thus reduce the risk of non-target embolization of adjacent healthy vessels. We report our experience in applying the PCT to cerebral arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs) and additionally suggest our technical adjustments. We retrospectively reviewed all patients suffering from AVMs or DAVFs that were treated with the PCT between 2018 and 2020 in two university hospitals. The endpoints of the study were clinical safety and the technical efficacy. The endpoints of the study were clinical safety and the technical efficacy. Clinical safety was the absence of death, major or minor symptomatic stroke, TIA and procedure-related intracranial bleeding (SAH) in the peri-procedural period until dismission. Good clinical outcome was defined as no deterioration of the modified Rankin Scale (mRS) score (comparing the pre- and post-procedural mRS evaluated by a trained neurologist at admission and dismission). The technical efficacy was considered as the complete embolization occlusion of the target vessels of the lesion documented on the final control angiogram. Long-term follow-up evaluation was not intended for this study as it was not available for all patients. Fifteen consecutive patients (6 women; mean age 55 y; range 20-82 y) with seven AVMs and eight DAVFs met the inclusion criteria. The primary clinical safety end point was obtained in all cases as no intraprocedural complications were encountered. All patients had a good clinical outcome with no difference between the pre- and post-mRS scores. The primary efficacy end point was reached in all cases. The PCT is a safe and effective technique in the treatment of cerebral AVMs and DAVFs. Adding an easy and fast step to the procedure, namely the injection of contrast media to test the complete obstruction by the plug, the risk of reflux seems to additionally be reduced.

Surgery in Intracerebral Arteriovenous Malformations: The Role of Preoperative Embolization.

The optimal treatment of cerebral arteriovenous malformations (AVMs) is still debated. Microsurgery and endovascular embolization can be utilized separately and in combination. However, each of these modalities harbor their own risks. In this study, we compared the outcomes of microsurgery only versus combined microsurgery+embolization approach in the treatment of AVMs. A total of 62 patients (34 men, 28 women) were recruited harboring Spetzler&Martin Grade-3 (n=44) and Grade-4 (n=18) AVMs. Among these, 37 were treated with combined microsurgery+embolization and 25 were treated with microsurgery alone. Their clinical features (ruptured/unruptured, eloquency, Modifed Rankin Scores, duration of surgery, pre- and post-op hemoglobin levels, usage of blood products) were compared. Higher number of patients with ruptured or eloquently-localized AVMs was treated with the combined approach. Duration of surgeries, pre- versus postoperative hemoglobin levels and usage of blood products did not differ between combined approach versus microsurgery alone. As eloquently located AVMs may possess higher surgical risks due to the presence of deep venous drainage or nidus size, combined treatment was more preferred. Other differences regarding selection of combined versus single approach were not associated with the lesion anatomo-physiology. Rather, we thought combined therapy was more appropriate in our initial clinical practice and planned our clinical strategy accordingly. Nonetheless, now, we found no superiority of the combined treatment in management of AVMs in parallel to recent meta-analyses. Hence, embolization before surgery is not generally advisable in the treatment of AVMs, yet some exceptions shall be considered in a patient-tailored approach.

Linac-based stereotactic radiosurgery for brain arteriovenous malformations

PurposeLinac stereotactic radiosurgery (SRS) is gaining popularity as a form of radiation treatment for cerebral arteriovenous malformations (AVMs) since the theory of combined radiosurgical and endovascular treatment poses much uncertainty and due to significant technical progress for SRS. This study focuses on how to evaluate obliteration and re-bleeding rates, and to determine factors and adverse effects influencing obliteration after linac-based SRS for cerebral AVMs.Material and methodsFrom a statistical record of 71 patients, 31 had partial embolisation, five surgery and 29 had no prior treatment. Using Kaplan–Meier survival and life table analyses, actuarial obliteration and annual bleeding hazard rates were calculated after SRS.ResultsAfter a follow up of 1, 2 and 3 years the actual obliteration rates were 22, 59 and 66%, respectively whereby it was noted that prior embolization had no effect on the obliteration rate. Annual bleeding hazard rates were further analyzed after stereotactic radiosurgery to be 2.1% and 1.4% for the first and second year respectively. Asymptomatic abnormalities were detected after imaging in 33.9% of patients. A dose of less than 18 Gy significantly reduced the obliteration probability.ConclusionSRS is a therapeutic option for intracerebral AVM. In general, there is a low rate of morbidity and a high probability of nidus obliteration.

Coil migration during pressure-cooker technique for cerebral AVM

Introduction: In recent decades, the endovascular treatment of cerebral arteriovenous malformations (AVMs) has advanced. However, it still carries risks of unanticipated complications. Coil migration is a reported complication of aneurysmal coiling procedures. Herein, we report a case of early intraprocedural coil migration during pressure cooker technique embolization of right thalamic AVM, discussing the management and potential explanations. The literature showed no report of coil migration after the pressure cooker technique in the form of coil-augmented Onyx injection technique (CAIT). Case description: An otherwise healthy 26-year-old female suddenly developed a severe headache with no loss of consciousness. Computed tomography (CT) scan of the head illustrated intraventricular haemorrhage. Magnetic resonance imaging (MRI) showed the bag of worms' sign in the right thalamic area. The size and location of the AVM prompted the decision for multistage endovascular embolization using onyx. In the anterior circulation, the right A5 arterial feeder has a high flow which indicates the pressure cooker technique embolization in the form of CAIT. In the procedure, early detachment and migration of the coil occurred in the medial prefrontal branch through the anterior cerebral artery. No intervention to retrieve the coil was carried out because the detachment piece is small and lodged distally. Onyx was injected directly without the coil because of the risk of radiation to the patient. Otherwise, the intraprocedural and postprocedural courses went uneventful. Conclusion: This is the first report of coil migration during the pressure cooker technique with CAIT for the right thalamic AVM.

Experimental investigation of transvenous embolization of arteriovenous malformations using different in vivo models

BackgroundTransvenous embolization (TVE) is an emerging technique for the endovascular treatment of cerebral arteriovenous malformations (AVMs). The aim of this study was to investigate two in vivo AVM models and...

A Rational Approach to the Management of Cerebral Arteriovenous Malformations

Cerebral arteriovenous malformations (AVMs) typify the delicate balance cerebrovascular specialists face in weighing the treatment risk against the natural history of a pathologic lesion. The goal of our review was to provide an overview of the current evidence for the treatment of cerebral AVMs and describe a contemporary approach to developing a treatment strategy according to individual AVM characteristics. A review of the contemporary literature on the natural history and treatment of cerebral AVMs was completed through the PubMed and Google Scholar databases. The studies were reviewed for original advances in the characterization and treatment of cerebral AVMs. The overall risk of hemorrhage for cerebral AVMs is 2%-4% per year. Individual AVM characteristics, including small size, exclusive deep venous drainage, deep or posterior fossa location, venous ectasia, and the presence of a flow-associated aneurysm, appear to confer a greater risk of presentation with rupture. A diverse array of modalities have been developed to achieve the goal of complete lesion obliteration, including microsurgery, endovascular therapy, and radiosurgery. Advances in treatment strategies and technology have continued to decrease the morbidity associated with lesion obliteration. Microsurgical or multimodal treatment strategies are often required to achieve complete obliteration; however, it remains critical that each treatment approach is individualized by the specific AVM characteristics.

Endovascular embolization of cerebral arteriovenous malformations

Endovascular embolization is a critical component in the treatment of cerebral arteriovenous malformations. It can be used as an independent treatment modality or as an adjunct to microurgery or radiosurgery. The published literature in the PubMed database until September 2021 was reviewed with reference to the results of cerebral arteriovenous malformations embolization using liquid embolic agents. More scientific data reporting about total embolization of the cerebral arteriovenous malformations with a final cure. Although complications and mortality after arteriovenous malformations embolization have decreased significantly, but they still exist, and decisions about it usage should be weighed against its benefits during the planning phase. Treatment of arteriovenous malformations of the brain requires a multidisciplinary approach involving vascular neurosurgeons, endovascular interventionists and radiation oncologists, with a deep understanding of the natural course and combination of risks of multimodal treatment. Only such approach can increase the likelihood of a positive outcome of the cerebral arteriovenous malformations treatment.

Airway management in general anesthesia for endovascular treatment of cerebral arteriovenous malformation: a retrospective observational study

Background and objectiveThis retrospective and observational study aimed to retrospectively evaluate the use of the endotracheal tube (ETT) and the Laryngeal Mask Airway (LMA) for the airway management with respect to airway safety, hemodynamic stability, adverse respiratory events, and recovery characteristics in patients who underwent endovascular treatment (EVT) for cerebrovascular arteriovenous malformation under general anesthesia between 2011 and 2018. MethodsThe study included data from the patient's electronic medical records and anesthesia files. The primary outcome measure was the incidence of hemodynamic disturbances and respiratory adverse events during airway management. The secondary outcome measure was the comparison of recovery characteristics. ResultsThe airway was secured using ETT in 41 patients and LMA in 39 patients. Airway safety was established in all patients without a complication throughout the procedure. Mean arterial blood pressure and heart rate were increased to > 20% of baseline levels at intubation and extubation periods in more patients in the ETT group than the LMA group (27 vs. 3; p = 0.07, and 11 vs. 2; p = 0.021). Respiratory adverse events including straining and coughing were observed in ten patients in the ETT group but only in one patient in the LMA group (p = 0.013). Time to extubation, to neurological assessment, and to discharge from the angiography unit were similar (p > 0.05). ConclusionIt was concluded that LMA provided sufficient airway safety as with ETT and may be used as an alternative to ETT for EVTs under general anesthesia.

First Experience in the Control of the Venous Side of the Brain AVM.

Background and purpose: Brain arteriovenous malformations (AVM) are increasingly curable with endovascular embolization. This study examines the preliminary experience with a novel double-sided hybrid approach in the treatment of cerebral arteriovenous malformations (AVM) versus a purely single-sided intra-arterial approach. Materials and methods: The single-center study cohort included 18 patients with brain AVMs (Spetzler–Martin Grade 2 or 3) having stand-alone endovascular treatment with either the arterial-side-only pressure cooker technique (aPCT) (group 1; n = 9) or a double-sided hybrid intra-arterial and transvenous approach (HIPRENE) (group 2; n = 9). Results: Patients belonging to group 2 had lower rates of intra-procedural hemorrhaging (66.7% vs. 33.3%, p = 0.169) and needed fewer treatment sessions to achieve nidus occlusion (1.7 vs. 1.2, p = 0.136). The HIPRENE treatment regime led to higher nidus occlusion rates after the initial treatment compared to aPCT (77.7% vs. 44.4%, p = 0.167). Group 2 patients had a lower rate of neuromonitoring events (22.2% vs. 44.4%, p = 0.310) and fewer accounts of blood flow obstruction in post-operative MRIs (33.3% vs. 55.6%, p = 0.319). Conclusion: A double-sided hybrid intra-arterial and transvenous approach might have benefits for curative endovascular brain AVM treatment in patients with Spetzler–Martin Grade 2 or 3. In our small study cohort, the HIPRENE treatment regime had higher nidus occlusion rates after the first treatment, which reduces the number of treatment sessions and lowers intra- and post-operative complication rates. Further randomized controlled studies are awaited to corroborate our preliminary outcomes.

Single-center experience with endovascular treatment of cerebral arteriovenous malformations with intent to cure in pediatric patients.

This study aimed to report the incidence of technical complications and immediate complete angiographic occlusion, identify associated factors with failure of complete occlusion and identify predictors of technical complications in a single-center experience of pediatric arteriovenous malformations (AVM) treated with endovascular treatment with intent to cure. Patients between 1 and 18years of age undergoing endovascular embolization between 2011 and 2020 were included. A total of 120 embolizations were performed in 69 patients. The most frequent clinical presentation was intracerebral hemorrhage (76.8%). Immediate obliteration of the malformations was achieved in 40 (58%) cases. The technical complication rate was 15%. AVM nidus size between 3 and 6cm (OR: 3.91; 95% CI 1.1-13.85; p = 0.035) and the presence of multiple feeders (OR: 5.08; 95% CI 1.41-18.28; p = 0.074) were predictive of failure of immediate complete occlusion. The location of the temporal lobe (OR: 7.83; p = 0.048), deep venous drainage (OR: 4.67; p = 0.112), and the presence of an intranidal aneurysm (OR: 3.58; p = 0.134) were predictors of technical complications. Embolization of pediatric AVMs with intent to cure shows a high rate of technical complications and acceptable immediate occlusion rates. Nidus size and the presence of multiple feeders were predictive of failure of complete occlusion, while temporal lobe location, deep venous drainage, and the presence of an intranidal aneurysm were predictors of technical complications. Further studies are needed to determine the best therapeutic approach in the pediatric population.

The efficacy of surgical treatment of cerebral arteriovenous malformations in a single academic institution: a case series

AimTo report on patients who underwent surgical treatment of arteriovenous malformations (AVMs) at our institution.MethodsThis retrospective single-center case series enrolled the patients who underwent surgical treatment of pial AVM at the Department of Neurosurgery, University Hospital Brno, between 2005 and 2019. The data are summarized as descriptive statistics presenting basic characteristics in all the patients and in sex or age subgroups.ResultsFifty patients were enrolled. The majority of AVMs were of Spetzler-Martin grade II (n = 27; 54%), localized supratentorialy (n = 43; 86%), and half of AVMs were ruptured. A total resection was performed in 48 patients (96%), and a good overall outcome was achieved in 44 patients (88%). Surgery-associated morbidity was 2%, and the mortality rate was 0% due to meticulous selection of patients for surgical treatment..ConclusionMicrosurgery is an appropriate method of treatment for S-M grade I-III pial AVMs. Microsurgery may be used to treat the majority of small-nidus AVMs with a low mortality and morbidity, when precisely planned and performed by an expert vascular team. The meticulous selection of patients for surgical treatment is crucial.

Multimodality treatment of supratentorial arteriovenous malformations with microsurgery after embolization: A retrospective two-center study in Vietnam

BackgroundPreoperative embolization with microsurgical resection has been used as a multimodality treatment of cerebral arteriovenous malformations (AVMs) in recent years. However, the role of this combined approach has not been well established. ObjectivesThis retrospective study aims to evaluate the outcomes of multimodality treatment with microsurgery after embolization for supratentorial AVMs in Vietnam. MethodsA two-center, retrospective case series of 26 patients with supratentorial AVMs who underwent treatment with surgical resection after embolization between January 2017 and August 2020 was performed. Sixty-three feeding arteries were embolized preoperatively in 29 sessions. We analyzed the AVM size, degree of preoperative obliteration, complications related to embolization, intraoperative blood loss, surgical complications, complete resection rate, and postoperative outcomes at 3 months after discharge. ResultsThe average size and Spetzler-Martin (SM) grade of AVMs were 4.98 cm (largest, 8 cm) and 3.19, respectively. The average preoperative volumetric obliteration was 55.38%. The intraoperative average blood loss was 573 ml. Complications related to embolization were post-embolization cerebral hemorrhage in 2 cases (7.69%), new-onset neurological deficits in 1 (3.38%). Surgical complications included death in 2 cases (7.69%) and new-onset neurological deficits in 5 (19.23%). At 3-month follow-up, four patients with new-onset neurological deficits had recovered completely or nearly completely. Complete resection of AVMs was confirmed by postoperative imaging modalities in 24/24 cases. Favorable outcome was achieved in 23 cases (88.46%). ConclusionMultimodality treatment with microsurgery after embolization is a relatively safe and effective method which can be considered for managing large and complex brain AVMs.

Early Outcomes and Complications of Endovascular Treatment of Cerebral Arteriovenous Malformations in Pediatric Patients

Introduction: Arteriovenous malformations (AVMs) are the commonest cause of hemorrhagic stroke in children. Endovascular embolization is a feasible treatment modality, but cure rates are heterogenous from one series to another. We aimed to describe the immediate obliteration rates and periprocedural complications of embolization of pediatric AVMs. Methods: Between 2011 and 2019, participants below 18 years of age with AVMs treated by the same neurosurgeon at a single center were included. The clinical features, immediate angiographic results, and periprocedural complications were retrospectively collected from the clinical records. Results: Thirty-four embolization sessions were performed on 20 children (12 females with a mean age of 13). Intracranial hemorrhage was the most common presentation (75%), and the majority were frontal (30%) and basal ganglia (30%) lesions. An immediate complete angiographic obliteration was achieved in 9 patients (45%) with low-grade lesions (Spetzler-Martin grade I and II). NBCA was the most common embolic agent used (52.9%). Complications were reported in 3 (8.8%) out of 34 sessions. Two of them were intraoperative perforations with clinical consequences. A slight cortical hemorrhage during the procedure was observed in 1 patient without clinical repercussions. Discussion: This single-surgeon single-center experience suggests that endovascular treatment is a safe and efficient treatment for pediatric AVMs. Pediatric prognostic scores for a suitable selection of candidates are needed. Further studies are required to validate these results.

Intraoperative Neuromonitoring for Cerebral Arteriovenous Malformation Embolization: A Propensity-Score Matched Retrospective Database Study.

IntroductionThe treatment of cerebral arteriovenous malformations (AVMs) may result in neurologic morbidity, particularly when an AVM is located in or adjacent to eloquent brain regions. Intraoperative neurophysiologic monitoring (IONM) may be utilized to reduce the risk of iatrogenic injury during endovascular AVM embolization; however, IONM for endovascular AVM embolization is not ubiquitously the standard of care.MethodsAdmissions for AVM embolization were assessed from the IBM MarketScan® Commercial and Medicare Supplemental databases (IBM Watson Health, Somers, NY). Inclusion criterion for patients was continuous enrollment six months before and after the index encounter. The use of IONM and presence of intracranial hemorrhage (ICH) were noted. Propensity-score matched cohorts with and without IONM were generated to minimize bias between treatment groups (adjusting for age, sex, and comorbidities).ResultsFrom 2007 to 2016, there were 16,279 patients diagnosed with cerebral AVM in the MarketScan database. Embolized patients were stratified into IONM and non-IONM cohorts; there were 357 patients in the IONM cohort and 1775 patients in the non-IONM cohort. Provider types were significantly different between cohorts (p<0.005). Unruptured AVMs were significantly more likely to be embolized with adjunctive IONM (17.7%) compared to ruptured AVMs (7.9%) (p<0.005). After balancing for baseline comorbidities, there were 266 patients in the IONM cohort, and 1347 patients in the non-IONM cohort. Among unruptured AVM patients, IONM was linked to a significantly shorter length of stay (2.72 versus 4.92 days; p<0.005), significantly lower rates of complications within 30 days of discharge (0.00% versus 1.88%; p=0.038), and significantly lower total payment ($40,179 versus $50,844; p<0.0001).ConclusionEndovascular embolization for unruptured AVMs performed with adjunctive IONM was associated with shorter length of stay, lower complication rates, and hospitalization costs.

Combined Use of Color Doppler Ultrasound and Contrast-Enhanced Ultrasound in the Intraoperative Armamentarium for Arteriovenous Malformation Surgery

Safety and efficacy in surgical treatment of cerebral arteriovenous malformations (AVMs) are dictated by thorough understanding of angioarchitectural features, intraoperative identification of feeding vessels, and appreciation of surrounding eloquent areas. Our aim was to describe the preliminary results of combined application of color Doppler ultrasound (CDUS) and contrast-enhanced ultrasound (CEUS) in a consecutive surgical series of AVM. We pointed out the tool's efficacy in distinguishing feeding from bystander vessels and in identifying pattern of venous drainage. We examined its role as an adjunct for semiquantitative evaluation of the nidus inflow. We used combined CDUS and CEUS in patients surgically treated for cerebral AVMs. We adopted these techniques following a designed protocol to guide safer AVM resection as an adjunct to indocyanine green videoangiography. Intraoperative assessment by ultrasound was performed before, during, and following nidus resection. Four surgically treated cerebral AVMs availed of the ultrasound protocol. Postoperative conventional angiography showed complete resection of the AVMs. CDUS and CEUS proved to be valuable adjunctive tools to indocyanine green videoangiography and micro-Doppler in properly navigating and discerning vascular structures, especially vessel feeders from bystanders. The protocol allows us to identify flow direction, estimate blood velocity within the nidus, and appreciate flow modifications following temporary clipping. Ultimately, it allows us to evaluate the degree of nidus deafferentation, residual flow, restoration of venous drainage and absence of arteriovenous shunts. The CDUS and CEUS protocol is safe and repeatable and works as real-time imaging, further supporting complete surgical resection of AVMs.