Embolization of the choroidal artery in the treatment of cerebral arteriovenous malformations

Abstract

OBJECTIVE The anterior and posterior choroidal arteries are often recruited to supply arteriovenous malformations (AVMs) involving important paraventricular structures, such as the basal ganglia, internal capsule, optic radiation, lateral geniculate body, and medial temporal lobe. Endovascular embolization through these arteries is theoretically dangerous because they supply eloquent territories, are of small caliber, and lack collaterals. This study aimed to investigate the safety and efficacy of embolization through these arteries. METHODS This study retrospectively reviewed 13 patients with cerebral AVMs who underwent endovascular embolization through the choroidal arteries between 2006 and 2014. Embolization was performed as a palliative procedure before open surgery or Gamma Knife radiosurgery. Computed tomography and MRI were performed the day after embolization to assess any surgical complications. The incidence and type of complications and their association with clinical outcomes were analyzed. RESULTS Decreased blood flow was achieved in all patients after embolization. Postoperative CT detected no hemorrhagic complications. In contrast, postoperative MRI detected that 4 of the 13 patients (30.7%) developed infarctions: 3 patients after embolization through the anterior choroidal artery, and 1 patient after embolization through the lateral posterior choroidal artery. Two of the 4 patients in whom embolization was from the cisternal segment of the anterior choroidal artery (proximal to the plexal point) developed symptomatic infarction of the posterior limb of the internal capsule, 1 of whom developed morbidity (7.7%). The treatment-related mortality rate was 0%. Additional treatment was performed in 12 patients: open surgery in 9 and Gamma Knife radiosurgery in 3 patients. Complete obliteration was confirmed by angiography at the last follow-up in 10 patients. Recurrent bleeding from the AVMs did not occur in any of the cases during the follow-up period. CONCLUSIONS Ischemic complications are possible following the embolization of cerebral AVMs through the choroidal artery, even with modern neurointerventional devices and techniques. Although further study is needed, embolization through the choroidal artery may be an appropriate treatment option when the risk of surgery or radiosurgery is considered to outweigh the risk of embolization.

Clinical importance of the anterior choroidal artery: a review of the literature

“…However, even following this recommendation, the risks of ischemia are high. For instance, in 2017, Elkordy et al performed 8 embolizations of ruptured AVMs through the AChA; among these cases, 2 patients suffered persistent hemiparesis 72 . Approximately 38% of capsulo-thalamic arteries arising from the AChA originate from the first part of the plexal segment, and this variation could be an important risk factor 73 .…”

Tumor Volume Decrease via Feeder Occlusion for Treating a Large, Firm Trigone Meningioma

“…However, it has been recognized that embolization of feeders originating from the choroidal arteries carries considerable risk of ischemic complications, and superselective embolization has been attempted only by some experts. 4 , 15 – 17) In the present case, we thought that it would be possible to occlude most of feeders microsurgically with less risk than attempting endovascular feeder embolization.…”

“…It is generally considered that branches of the anterior choroidal artery supplying eloquent territories arise from the cisternal segment. 4 , 16 , 17) On the contrary, Fernandez-Miranda et al have reported that 38% of the capsulothalamic artery originated from the first part of the plexal segment in a cadaveric study. 18) To safely occlude feeding arteries originating from choroidal arteries, intraoperative MEP monitoring would be recommended even when such an attempt is carried out distal to the plexal point.…”

Choroidal Arteriovenous Malformation: Spontaneous Hippocampal and Intraventricular Hemorrhage from a Choroidal Arteriovenous Malformation – Embolization Through the Anterior Choroidal Artery with Flow-Guided Microcatheter Glue Embolization, Complete AVM Occlusion, and Excellent Evolution

“…Embolizations performed from the cisternal AChoA segment frequently complicate with ischemic stroke. In one recent study on choroidal AVM embolization, two of four patients in whom embolization was performed from the cisternal segment of the AChoA, proximal to the plexal point, developed symptomatic infarction of the posterior limb of the internal capsule, with morbidity in one case (Elkordy et al 2017). Overall, 2/5 cases treated with nBCA and 2/8 cases treated with Onyx developed ischemic complications (Elkordy et al 2017).…”