Endovascular treatment of brain arteriovenous malformations: Our clinical experience

Aim: The aim of this study is to evaluate the preoperative characteristics and postoperative results of cerebral arteriovenous malformations (cAVM) cases that we treated endovascularly. Endovascular embolization has started to be used as an adjuvant therapy to other treatments in the treatment of cAVM. However, with the increase of technical developments and professional experience over time; endovascular techniques have started to be the primary treatment method in the treatment of AVMs. Materials and Methods: Complaints, angiographic evaluation and treatment data of 12 patients with cAVM who were treated with endovascular methods between January 2018 and December 2020 were retrospectively reviewed. Results: Eight of the patients (66.6%) were male and 4 (33.3%) were female. AVM localizations were cerebral in eleven (91.6%) patients and cerebellar in one (8.3%) patient. According to the Spetzler-Martin grading system; 5 cases (41.6%) were classified as grade 2, 4 cases (33.3%) as grade 3, 2 cases (16.6%) as grade 4 and 1 case (8.3%) as grade 5. During the endovascular treatment procedure, iatrogenic rupture occurred in the AVM nidus in one patient. No other intraoperative or postoperative complications developed in any of the other cases. Total thrombosis was achieved in 5 cases (41.6%) and partial thrombosis in 7 cases (58.3). These 7 cases with partially thrombosis achieved (58.3%), were referred to radiosurgery after endovascular procedure. Total thrombosis was seen in 3 of these 7 patients (42.8%) after radiosurgery. The total thrombosis rate in all cases was 66.6% (n:8). The mean follow-up period was 23.8 months (12-40). Conclusion: Therapeutic embolization may be a viable option for cAVMs in selected cases. In complex cAVM cases, embolization is thought to provide a high rate of thrombosis or excision of the lesions, reducing the risks of bleeding and other complications before surgical treatment or radiosurgery.

PDF

___

1. Mouchtouris N, Jabbour PM, Starke RM, et al. Biology of cerebral arteriovenous malformations with a focus on inflammation. Journal of cerebral blood flow and metabolism. 2015;35(2), 167-75.
2. Soulez G, Gilbert MD FRCPC P, Giroux MD FRCPC M, Racicot MD FRCPC J, Dubois J. Interventional Management of Arteriovenous Malformations. Techniques in Vascular and Interventional Radiology. 2019;22(4), 100633.
3. Hernesniemi JA, Dashti R, Juvela S, Väärt K, Niemelä M, Laakso A. Natural history of brain arteriovenous malformations: a long-term follow-up study of risk of hemorrhage in 238 patients. Neurosurgery. 2008;63(5), 823-9; discussion 829-31.
4. Robert T, Blanc R, Ciccio G, et al. Angiographic factors influencing the success of endovascular treatment of arteriovenous malformations involving the corpus callosum. Journal of neurointerventional surgery. 2015;7(10), 715-20.
5. Berman MF, Sciacca RR, Pile-Spellman J, et al. The epidemiology of brain arteriovenous malformations. Neurosurgery. 2000; 47(2), 389-96; discussion 397.
6. Ding D, Starke RM, Kano H, et al. International multicenter cohort study of pediatric brain arteriovenous malformations. Part 1: Predictors of hemorrhagic presentation. Journal of neurosurgery. Pediatrics. 2017;19(2), 127-35.
7. Laakso A, Hernesniemi J. Arteriovenous malformations: epidemiology and clinical presentation. Neurosurgery clinics of North America. 2012;23(1), 1-6.
8. Nataraj A, Mohamed MB, Gholkar A, et al. Multimodality treatment of cerebral arteriovenous malformations. World neurosurgery. 2014;82(1-2), 149-59.
9. Gross BA, Moon K, Mcdougall CG. Endovascular management of arteriovenous malformations. Handbook of clinical neurology. 2017;143, 59-68.
10. Baharvahdat H, Blanc R, Fahed R, et al. Endovascular treatment as the main approach for Spetzler–Martin grade III brain arteriovenous malformations. Journal of NeuroInterventional Surgery. 2021;13(3), 241-6.
11. Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. Journal of neurosurgery. 1986;65(4), 476-83.
12. Hoh BL, Chapman PH, Loeffler JS, Carter BS, Ogilvy CS. Results of multimodality treatment for 141 patients with brain arteriovenous malformations and seizures: factors associated with seizure incidence and seizure outcomes. Neurosurgery. 2002;51(2), 303-9; discussion 309-11.
13. Byun J, Kwon DH, Lee DH, Park W, Park JC, Ahn JS. Radiosurgery for Cerebral Arteriovenous Malformation (AVM) : Current Treatment Strategy and Radiosurgical Technique for Large Cerebral AVM. Journal of Korean Neurosurgical Society. 2020;63(4), 415-26.
14. Ding D, Starke RM, Kano H, et al. Radiosurgery for Unruptured Brain Arteriovenous Malformations: An International Multicenter Retrospective Cohort Study. Neurosurgery. 2017;80(6), 888- 98.
15. Lawton MT, Du R, Tran MN, et al. Effect of presenting hemorrhage on outcome after microsurgical resection of brain arteriovenous malformations. Neurosurgery. 2005;56(3), 485-93; discussion 485-93.
16. Patibandla MR, Ding D, Kano H, et al. Stereotactic radiosurgery for Spetzler-Martin Grade IV and V arteriovenous malformations: an international multicenter study. Journal of neurosurgery. 2018;129(2), 498-507.
17. Bendok BR, El Tecle NE, El Ahmadieh TY, et al. Advances and innovations in brain arteriovenous malformation surgery. Neurosurgery. 2014; 74 Suppl 1, S60-73.
18. Van Rooij WJ, Jacobs S, Sluzewski M, van der Pol B, Beute GN, Sprengers ME. Curative embolization of brain arteriovenous malformations with onyx: patient selection, embolization technique, and results. AJNR. American journal of neuroradiology. 2012;33(7), 1299-304.
19. Weber W, Kis B, Siekmann R, Jans P, Laumer R, Kühne D. Preoperative embolization of intracranial arteriovenous malformations with Onyx. Neurosurgery. 2007;61(2), 244-52; discussion 252-4.
20. Saatci I, Geyik S, Yavuz K, Cekirge HS. Endovascular treatment of brain arteriovenous malformations with prolonged intranidal Onyx injection technique: long-term results in 350 consecutive patients with completed endovascular treatment course. Journal of neurosurgery. 2011;115(1), 78-88.
21. Lawton MT, Kim H, McCulloch CE, Mikhak B, Young WL. A supplementary grading scale for selecting patients with brain arteriovenous malformations for surgery. Neurosurgery. 2010;66(4), 702-13; discussion 713.
22. Spetzler RF, Ponce FA. A 3-tier classification of cerebral arteriovenous malformations. Clinical article. Journal of neurosurgery. 2011;114(3), 842-9.
23. Lawton MT, Hamilton MG, Spetzler RF. Multimodality treatment of deep arteriovenous malformations: thalamus, basal ganglia, and brain stem. Neurosurgery. 1995;37(1), 29-35; discussion 35-6.
24. Sanchez-Mejia RO, McDermott MW, Tan J, Kim H, Young WL, Lawton MT. Radiosurgery facilitates resection of brain arteriovenous malformations and reduces surgical morbidity. Neurosurgery. 2009;64(2), 231-8; discussion 238-40.
25. Luzzi S, Del Maestro M, Bongetta D, et al. Onyx embolization before the surgical treatment of grade III Spetzler–Martin brain arteriovenous malformations: singlecenter experience and technical nuances. World Neurosurg 2018;116:e340–53.
26. Crowley RW, Ducruet AF, Kalani MY, Kim LJ, Albuquerque FC, McDougall CG. Neurological morbidity and mortality associated with the endovascular treatment of cerebral arteriovenous malformations before and during the Onyx era. Journal of neurosurgery. 2015;122(6), 1492-7.
27. Saeed Kilani M, Lepennec V, Petit P, et al. Embolization of peripheral high-flow arteriovenous malformations with Onyx. Diagnostic and interventional imaging. 2017;98(3), 217-26.
28. Mendes GAC, Kalani MYS, Iosif C, et al. Transvenous Curative Embolization of Cerebral Arteriovenous Malformations: A 443 Prospective Cohort Study. Neurosurgery. 2018;83(5), 957-64.
29. Mosimann PJ, Chapot R. Contemporary endovascular techniques for the curative treatment of cerebral arteriovenous malformations and review of neurointerventional outcomes. Journal of neurosurgical sciences. 2018;62(4), 505-13.
30. Ozpar R, Nas O, Hacikurt K, Taskapilioglu M, Kocaeli H, Hakyemez B. Endovascular treatment of intracranial arteriovenous malformations using detachable-tip microcatheters and Onyx 18®. Diagnostic and Interventional Imaging.2019;100(6), 353- 61.
31. Strauss I, Frolov V, Buchbut D, Gonen L, Maimon S. Critical appraisal of endovascular treatment of brain arteriovenous malformation using Onyx in a series of 92 consecutive patients. Acta neurochirurgica. 2013;155(4), 611-7.
32. Marks MP, Marcellus ML, Santarelli J, et al. Embolization Followed by Radiosurgery for the Treatment of Brain Arteriovenous Malformations (AVMs). World neurosurgery. 2017;99, 471-6.
33. Pierot L, Cognard C, Herbreteau D, et al. Endovascular treatment of brain arteriovenous malformations using a liquid embolic agent: results of a prospective, multicentre study (BRAVO). European radiology. 2013;23(10), 2838-45.
34. Spetzler RF, Hargraves RW, McCormick PW, Zabramski JM, Flom RA, Zimmerman RS. Relationship of perfusion pressure and size to risk of hemorrhage from arteriovenous malformations. Journal of neurosurgery. 1992;76(6), 918-23.
35. Panagiotopoulos V, Gizewski E, Asgari S, Regel J, Forsting M, Wanke I. Embolization of intracranial arteriovenous malformations with ethylene-vinyl alcohol copolymer (Onyx). AJNR. American journal of neuroradiology. 2009;30(1), 99-106.
36. Wu EM, El Ahmadieh TY, McDougall CM, et al. Embolization of brain arteriovenous malformations with intent to cure: a systematic review. Journal of Neurosurgery. 2020;132(2), 388-99.
37. Lv M, Sun Y, Chang Q, et al. Endovascular treatment of cerebellar arteriovenous malformations: A single-center experience of 75 consecutive patients. Neurology India. 2020;68(2), 440.