Critical appraisal of endovascular treatment of brain arteriovenous malformation using Onyx in a series of 92 consecutive patients

Strauss, Ido; Frolov, Vladimir; Buchbut, Dana; Gonen, Lior; Maimon, S.

doi:10.1007/s00701-013-1633-0

Cited by 42 publications

(27 citation statements)

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“…The recent work of Bervini and colleagues, Nerva and colleagues, as well as the report in the current issue provide sufficient substance to recommend microsurgery to patients with unruptured AVM Spetzler-Martin grade 1 and 2 (corresponding to Spetzler-Ponce class A) [3,11,14,16]. In contrast, treatment of unruptured Spetzler-Martin grade 3 and 4 AVMs needs to be seen critically.…”

mentioning

confidence: 81%

“…It was soon realized, however, that complete elimination could not be routinely achieved. The introduction of Onyx, offering more controllable intranidal dispersion, did not change the picture fundamentally, achieving complete elimination in maximally 50 % [5,13,16]. Embolization also remained associated with substantial complications despite technical advances.…”

mentioning

confidence: 99%

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Treatment of unruptured brain AVM in the aftermath of ARUBA and the Scottish Audit of Intracranial Vascular Malformations

Steiger

Schaller

2015

Acta Neurochir

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We appreciate the thoughtful comments of T.R. Meling and the support of a constructive strategy regarding unruptured brain AVM. The results of the ARUBA trial have been widely commented on and the weaknesses of the study have been pointed out, i.e., the lack of differentiation between Spetzler-Martin grades and treatment modalities, and the fact that the effect of microsurgical removal was not assessed by the study design [4,8,9]. The report of the Scottish Audit of Intracranial Vascular Malformations drew less attention, but provided essentially the same result that intervention led to a worse outcome compared to the natural history [1]. The results of ARUBA and the Scottish Audit of Intracranial Vascular Malformations showed an almost identical pattern of strokes following intervention, with initially a higher rate of events than in untreated patients and secondary regression to the rate of the natural history. Therefore, we have to accept that the way we have been treating unruptured AVM was not right and needs correction.As pointed out by Meling, the treatment-associated morbidity rates as given in the ARUBA trial, and also the Scottish Audit, are very different from the rates given in microsurgical series. The high morbidity rates of ARUBA and the Scottish Audit are the footprint of destabilized and incompletely eliminated AVM, i.e., the pattern of endovascular embolization [19]. Without any doubt, radiosurgery contributed to the continuing stroke rate in the interventional cohorts but was unlikely a major factor for the increased rate following intervention.Despite the obvious pattern of the delayed hemorrhages in the ARUBA and the Scottish Audit cohorts, questions remain. All non-randomized series provided rates of stroke after microsurgery, radiosurgery, and embolization far below the 9-10 % per year rate of ARUBA and the Scottish Audit. Probability of hemorrhage after successful microsurgery appears, however, to be approximately one-tenth the rate after endovascular embolization, according to the meta-analysis of van Beijnum [19]. Although the numbers of hemorrhages given in nonrandomized series remain far below the incidence rates in ARUBA and the Scottish cohort, it appears likely that endovascular therapy was the primary factor for the exorbitant event rate following intervention. Analyzing all published series, van Beijnum and coworkers found reported annual hemorrhage rates of 0.18 % after microsurgery 1.7 % after stereotactic radiosurgery and 1.7 % after embolization. The obvious destabilizing effect resulting from treatment as seen in the ARUBA and Scottish Audit cohorts is hardly explainable by radiosurgery.Endovascular intranidal embolization emerged in the 1980s as a minimally invasive alternative to surgical elimination. It was soon realized, however, that complete elimination could not be routinely achieved. The introduction of Onyx, offering more controllable intranidal dispersion, did not change the picture fundamentally, achieving complete elimination in maximally 50 % [5,13,16]. Emboliza...

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confidence: 81%

mentioning

confidence: 99%

Treatment of unruptured brain AVM in the aftermath of ARUBA and the Scottish Audit of Intracranial Vascular Malformations

Steiger

Schaller

2015

Acta Neurochir

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“…54 Strauss et al also found that large pedicles (defined as twice the normal diameter) had an odds ratio of 4.6 of complete obliteration compared with small pedicles. 60 Feeding artery location is likewise associated with complete obliteration, with superficial arteries positively associated with cure 60 while feeders arising from lenticulostriate and thalamoperforating arteries were associated with an inability to achieve complete occlusion. 69 Importantly, the presence of en passage arteries was found to be negatively associated with complete embolization.…”

Section: Feeding Arteriesmentioning

confidence: 95%

“…30 Other studies adopt a general approach of attempting endovascular cure with all or most AVMs without stating specific guiding principles and then refer the failures for surgery or radiosurgery. 26,60,69 Still other studies report broad guidelines used to select AVMs for curative embolization but do not specifically report outcomes for that subset. 38,53 In general, these studies confirm that complete occlusion using embolization is possible and they begin to define the AVM characteristics most predictive of endovascular cure.…”

Section: Endovascular Embolization In Avm Managementmentioning

confidence: 96%

Curing arteriovenous malformations using embolization

Potts

Zumofen

Raz

et al. 2014

FOC

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Endovascular embolization is typically reserved as an adjuvant therapy in the management of cerebral arteriovenous malformations (AVMs), either for preoperative devascularization or preradiosurgical volume reduction. Curative embolization plays a limited role in AVM treatment but several studies have shown that it is possible, especially with later-generation liquid embolic agents. Given the complexity of AVM anatomy and the recent controversies over the role of any intervention in AVM management, it is critical that the cerebrovascular community better define the indications of each treatment modality to provide quality AVM management. In this review, the authors evaluate the role of curative AVM embolization. Important considerations in the feasibility of curative AVM embolization include whether it can be performed reliably and safely, and whether it is a durable cure. Studies over the past 20 years have begun to define the anatomical factors that are amenable to complete endovascular occlusion, including size, feeding artery anatomy, AVM morphology, and endovascular accessibility. More recent studies have shown that highly selected patients with AVMs can be treated with curative intent, leading to occlusion rates as high as 100% of such prospectively identified lesions with minimal morbidity. Advances in endovascular technology and techniques that support the efficacy and safety of curative embolization are discussed, as is the importance of superselective diagnostic angiography. Finally, the durability of curative embolization is analyzed. Overall, while still unproven, endovascular embolization has the potential to be a safe, effective, and durable curative treatment for select AVMs, broadening the armamentarium with which one can treat this disease.

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“…In another series of 82 patients by Panagiotopoulos et al, 20 AVMs (24.4%) were completely embolized with Onyx (13). Strauss et al in their series of 92 cases reported a 27% cure rate and concluded that complete obliteration rates were significantly higher in lesions with superficial big feeding arteries (14). According to the published experience up to now, complete obliteration rates of AVMs with Onyx range obviously above the reported average of 10% of angiographic cure after embolization with n-BCA (15).…”

Section: Discussionmentioning

confidence: 96%

Embolization of Intracranial Arteriovenous Malformations Using Onyx in 53 Patients

et al. 2016

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Background: Endovascular embolization is one of the main modalities in the treatment of brain arteriovenous malformations (AVMs). Onyx (ethylene-vinyl alcohol copolymer) is a new embolic agent with some advantages of slow injection and better control of penetration. Objectives: To report our experience in the embolization of brain AVMs with Onyx. Patients and Methods: From August 2012 to October 2014, 53 consecutive patients harboring brain AVM were treated with Onyx as the sole embolic agent during 85 procedures. There were 27 males and 26 females with a mean age of 27.2 years (range, 8 -65 years). Results: The presenting symptom was headache in 25 (47%), neurological deficit in 18 (35%), and seizure in ten (18%) patients. According to the Spetzler-Martin grading scale, three of the AVMs were ranked as grades I, 11 as grade II, 22 as grade III, 14 as grade IV, and three as grade V. An average of 1.8 feeding pedicles were embolized in each case, whereas a mean of 2.23-mL Onyx was used per patient. Initial complete obliteration at the end of all embolization procedures was achieved in 11 patients (20.08%). The rate of complete embolization at 6-month follow-up was 15%. After completion of embolization, the neurologic status was unchanged or improved in 46 (87%) patients. We observed treatment-related neurologic deficit in seven (13%) patients, of whom five were permanent (10%). There was no procedure-related death. Conclusion: Our experience with Onyx used for embolizing AVMs was satisfactory. Controlled injections that protect the draining veins make the therapy safe even in complex AVMs.

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Critical appraisal of endovascular treatment of brain arteriovenous malformation using Onyx in a series of 92 consecutive patients

Abstract: Embolization of brain AVM using Onyx and detachable tip microcatheters results in a relatively high rate of complete obliteration. Angioarchitecture of the lesion can predict treatment success. Higher amounts of Onyx injected per session increase the bleeding risk.

Cited by 42 publications

References 20 publications

Treatment of unruptured brain AVM in the aftermath of ARUBA and the Scottish Audit of Intracranial Vascular Malformations

Treatment of unruptured brain AVM in the aftermath of ARUBA and the Scottish Audit of Intracranial Vascular Malformations

Curing arteriovenous malformations using embolization

Embolization of Intracranial Arteriovenous Malformations Using Onyx in 53 Patients

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