Endovascular transvenous cure for ruptured brain arteriovenous malformations in complex cases with high Spetzler-Martin grades

Iosif, Christina; Mendes, George A C; Saleme, Suzana; Ponomarjova, Sanita; Silveira, Eduardo Pedrolo; Caire, François; Mounayer, Charbel

doi:10.3171/2014.9.jns141714

Cited by 79 publications

(67 citation statements)

References 33 publications

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“…Intravenous heparin (3000 IU) was administered before hyperselective intracranial vessel navigation. Double arterial, venous and double arterial-and-venous techniques in our institution have been described elsewhere18 and were chosen according to the angioarchitecture and location of the AVM.…”

Section: Methodsmentioning

confidence: 99%

Curative endovascular treatment for low-grade Spetzler-Martin brain arteriovenous malformations: a single-center prospective study

Iosif

Lucena

Abreu-Mattos

et al. 2019

J NeuroIntervent Surg

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BackgroundThe treatment of low grade Spetzler-Martin (SM) brain arteriovenous malformations (AVMs) has been debated in unruptured cases. Nevertheless, in clinical practice there are cases where treatment is preferred; in these cases a very low complication rate is mandatory. In ruptured cases, early and complete obliteration of the nidus is the preferred strategy.ObjectiveTo achieve curative embolization, ideally in a single session, by dual microcatheterization techniques with arterial and/or venous access, according to the angioarchitecture.Materials and methodsThis is a prospective, single-center study carried out between January 2008 and January 2016. Patients with ruptured and unruptured brain AVMs, with SM grades I and II, treated by endovascular means, were included. Demographics, clinical presentation, angioarchitecture, and procedure-related complications were analyzed. Angiographic and clinical results were reported.ResultsSeventy-three patients, aged 40.5±17.8 years, were included. More than 60% of the patients presented with ruptured AVMs. Initial SM grades were I for 22% and II for 78% of the patients. Preprocedural modified Rankin Scale (mRS) score was 0–2 for 53 (72.6%), 3 for 12 (16.4%), 4 for 5 (6.8%) and 5 for 3 (4.1%) patients. Procedure-related morbidity was 2.7% and procedure-related mortality was 0%. Ninety percent (90.5%) of the patients were independent in their everyday lives (mRS score 0–2) at 6 months. In all but one case (95%) the embolization was curative.ConclusionStand-alone endovascular treatment for SM grade I and II brain AVMs seems safe and effective, allowing for complete obliteration of the nidus, with low complication rates. A study of larger cohorts is needed.

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Section: Methodsmentioning

confidence: 99%

Curative endovascular treatment for low-grade Spetzler-Martin brain arteriovenous malformations: a single-center prospective study

Iosif

Lucena

Abreu-Mattos

et al. 2019

J NeuroIntervent Surg

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“…8, 14,43,69 However, as endovascular technology and techniques for AVM intervention continue to evolve, the disparity between the risk-to-benefit profile of curative embolization and those of microsurgery and radiosurgery may lessen over time. 45 Sanchez-Mejia et al analyzed the surgical outcomes of 32 pediatric AVMs and compared them to those of 192 adult AVMs. 70 In the pediatric AVM cohort, the incidence of hemorrhagic presentation was 59%, the Spetzler-Martin grade was I or II in 59%, and preoperative embolization was performed in 75% of cases.…”

Section: Outcomes After Single-modality and Multimodality Treatment Omentioning

confidence: 99%

International multicenter cohort study of pediatric brain arteriovenous malformations. Part 2: Outcomes after stereotactic radiosurgery

Starke

Ding

Kano

et al. 2017

PED

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OBJECTIVE Pediatric patients (age < 18 years) harboring brain arteriovenous malformations (AVMs) are burdened with a considerably higher cumulative lifetime risk of hemorrhage than adults. Additionally, the pediatric population was excluded from recent prospective comparisons of intervention versus conservative management for unruptured AVMs. The aims of this multicenter, retrospective cohort study are to analyze the outcomes after stereotactic radiosurgery for unruptured and ruptured pediatric AVMs. METHODS We analyzed and pooled AVM radiosurgery data from 7 participating in the International Gamma Knife Research Foundation. Patients younger than 18 years of age who had at least 12 months of follow-up were included in the study cohort. Favorable outcome was defined as AVM obliteration, no post-radiosurgical hemorrhage, and no permanently symptomatic radiation-induced changes (RIC). The post-radiosurgery outcomes of unruptured versus ruptured pediatric AVMs were compared, and statistical analyses were performed to identify predictive factors. RESULTS The overall pediatric AVM cohort comprised 357 patients with a mean age of 12.6 years (range 2.8–17.9 years). AVMs were previously treated with embolization, resection, and fractionated external beam radiation therapy in 22%, 6%, and 13% of patients, respectively. The mean nidus volume was 3.5 cm3, 77% of AVMs were located in eloquent brain areas, and the Spetzler-Martin grade was III or higher in 59%. The mean radiosurgical margin dose was 21 Gy (range 5–35 Gy), and the mean follow-up was 92 months (range 12–266 months). AVM obliteration was achieved in 63%. During a cumulative latency period of 2748 years, the annual post-radiosurgery hemorrhage rate was 1.4%. Symptomatic and permanent radiation-induced changes occurred in 8% and 3%, respectively. Favorable outcome was achieved in 59%. In the multivariate logistic regression analysis, the absence of prior AVM embolization (p = 0.001) and higher margin dose (p < 0.001) were found to be independent predictors of a favorable outcome. The rates of favorable outcome for patients treated with a margin dose ≥ 22 Gy vs < 22 Gy were 78% (110/141 patients) and 47% (101/216 patients), respectively. A margin dose ≥ 22 Gy yielded a significantly higher probability of a favorable outcome (p < 0.001). The unruptured and ruptured pediatric AVM cohorts included 112 and 245 patients, respectively. Ruptured AVMs had significantly higher rates of obliteration (68% vs 53%, p = 0.005) and favorable outcome (63% vs 51%, p = 0.033), with a trend toward a higher incidence of post-radiosurgery hemorrhage (10% vs 4%, p = 0.07). The annual post-radiosurgery hemorrhage rates were 0.8% for unruptured and 1.6% for ruptured AVMs. CONCLUSIONS Radiosurgery is a reasonable treatment option for pediatric AVMs. Obliteration and favorable outcomes are achieved in the majority of patients. The annual rate of latency period hemorrhage after radiosurgery for both ruptured and unruptured pediatric AVM patients conveys a significant risk until the nidus is obliterated.

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“…The evolution of modern case series has been toward higher volumes and lower complications in the spirit of concluding that a device or treatment approach is "safe" and "effective" [6,7]. While these series may suggest technical prowess of the treating practitioners, there is often much that can be gleaned from patients that do not suffer obvious or "permanent" complications.…”

Section: Discussionmentioning

confidence: 99%

Neurointerventional “Near Morbidity”: A Candid Appraisal of an Early Case Series

et al. 2018

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Background: Modern case series often focus on emphasizing low complication rates, “safety,” and “efficacy.” Although patients may not suffer significant or obviously apparent neurological complications, many lessons are buried in the “no complications” cohort. Methods: The junior author’s prospectively maintained caselog was reviewed over a 1-year period for both symptomatic and “minor”/technical complications of neurointerventional cases, the latter referring to an intraprocedural inability to treat a lesion, suboptimal result, or potentially morbid angiographic occurrence/finding that did not result in permanent neurological morbidity – neurointerventional “near morbidity” (NNM). Results: Of 602 treatments performed over the reviewed period, 163 were interventional neuroendovascular procedures. The most common neuroendovascular procedure performed was stroke thrombectomy (67 cases). Major neurological complications, defined as symptomatic stroke or hemorrhage, occurred in 7 cases (4%). NNM, consisting of instructive, technical issues arose in an additional 9 cases that did not result in neurological morbidity (6%). Overall, in 20/163 cases (12%), there were either major neurological complications, NNM, groin complications, or major medical complications. Conclusions: “Minor”/technical complications – NNM – can be as instructive and illustrative as major complications despite not resulting in permanent morbidity. In reviewing case series, particularly early in one’s career, these cases should be highlighted.

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Endovascular transvenous cure for ruptured brain arteriovenous malformations in complex cases with high Spetzler-Martin grades

Cited by 79 publications

References 33 publications

Curative endovascular treatment for low-grade Spetzler-Martin brain arteriovenous malformations: a single-center prospective study

Curative endovascular treatment for low-grade Spetzler-Martin brain arteriovenous malformations: a single-center prospective study

International multicenter cohort study of pediatric brain arteriovenous malformations. Part 2: Outcomes after stereotactic radiosurgery

Neurointerventional “Near Morbidity”: A Candid Appraisal of an Early Case Series

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