The treatment of arteriovenous malformations (AVMs) requires a multidisciplinary management including microsurgery, endovascular embolization, and stereotactic radiosurgery (SRS). This article reviews the recent advancements in the multimodality treatment of patients with AVMs using endovascular neurosurgery and SRS. We describe the natural history of AVMs and the role of endovascular and radiosurgical treatment as well as their interplay in the management of these complex vascular lesions. Also, we present some representative cases treated at our institution.

Background:Endovascular embolization represents the method of choice for the treatment of carotid-cavernous fistulas (CCFs).Methods:We report our experience using the endovascular technique in 24 patients harboring 25 CCFs treated between October 1994 and April 2010, with an emphasis on the role of detachable balloons for the treatment of direct CCFs.Results:Of the 16 patients who presented with direct CCFs (Barrow Type A CCFs) (age range, 7–62 years; mean age, 34.3 years), 14 were caused by traumatic injury and 2 by a ruptured internal carotid artery (ICA) aneurysm. Eight patients (age range, 32–71 years; mean age, 46.5 years) presented with nine indirect CCFs (Barrow Types B, C, and D). The clinical follow-up after endovascular treatment ranged from 2 to 108 months (mean, 35.2 months). In two cases (8%), the endovascular approach failed. Symptomatic complications related to the procedure occurred in three patients (12.5%): transient cranial nerve palsy in two patients and a permanent neurological deficit in one patient. Detachable balloons were used in 13 out of 16 (81.3%) direct CCFs and were associated with a cure rate of 92.3%. Overall, the angiographic cure rate was obtained in 22 out of 25 (88%) fistulas. Patients presenting with III nerve palsy improved gradually between 1 day and 6 months after treatment. Good clinical outcomes [modified Rankin scale (mRS) ≤ 2] were observed in 22 out of 24 (91.6%) patients at last follow-up.Conclusions:Endovascular treatment using detachable balloons still constitutes a safe and effective method to treat direct carotid-cavernous fistulas.

A 37-year-old male with known Parkes Weber syndrome involving the upper limb characterized by cutaneous warmth, pale discoloration, bruit, and nonhealing ulcerative lesions of the posterolateral forearm and fourth finger presented with symptoms of brachial plexus compression including sharp pain, paresthesias, and paresis with decreased grip strength. Parenteral narcotics were administered without complete pain resolution. A right upper limb computed tomography angiogram and an angiography showed a high-flow arteriovenous fistula at the axillary level with a cluster of giant varices (A/Cover and B). In the first stage of embolization, twenty-three 30 Â 100-mm Vein of Galen coils (Boston Scientific/Target Therapeutics, Inc, Fremont, Calif) and 2 number 12 Gold-Valve detachable balloons (Nycomed Ingenor, Paris, France) were deployed at the site of the fistula. The second stage of embolization consisted in reaching the fistula site with a 3F microcatheter (Microferret; Cook Inc, Bloomington, Ill). Then, a transient circulatory arrest at the axillary artery was achieved using a 20-mm polyethylene balloon (Mansfield Scientific Co, Watertown, Mass) to inject 50% n-BCA (Histoacryl; Braun, Melsungen, Germany) under flow control (C) producing a marked decreased in fistula flow (D). Postoperative analgesia was not needed by the patient and a significant recovery of sensation, motor movements, skin color, and temperature was obtained. Parkes Weber syndrome is a rare disease 1,2 characterized by the presence of high-flow arteriovenous fistulas, limb hypertrophy, varices, and ulcerations that may lead to major amputation. 3,4 In this case, a dramatic improvement of vascular and neurologic symptoms was observed after endovascular treatment.

Objectives: The aim of this study was to evaluate the results of transarterial embolization (TAE) as a stand-alone treatment for large parotid and cheek infantile hemangiomas (IHs) that are refractory to medical treatment. Material and Methods: We retrospectively reviewed patients with head and neck IHs who underwent TAE at two single tertiary centers. We then analyzed the clinical and angiographic data of those patients with IHs located in the parotid and/or cheek regions. Results: A total of 38 patients with head and neck IHs were treated with TAE. Sixteen patients had a follow-up 2 months or more after treatment; from these patients, 6 IHs were located in the parotid or cheek regions. Four of the six tumors were in the proliferative phase. After TAE, almost 100% of angiographic obliteration of the IHs was attained. There was a complete shrinking of the tumor mass in all patients within a period of 2–5 months. One partially reversible complication occurred. Conclusion: Our preliminary results showed that TAE may be a useful therapeutic treatment not only before surgery but also as upfront and definitive therapy for parotid and cheek IHs.

No abstract