Endovascular treatment in the multimodality management of brain arteriovenous malformations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee

Abstract

BackgroundThe purpose of this review is to summarize the data available for the role of angiography and embolization in the comprehensive multidisciplinary management of brain arteriovenous malformations (AVMsMethodsWe performed a structured literature review for studies examining the indications, efficacy, and outcomes for patients undergoing endovascular therapy in the context of brain AVM management. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee and the SNIS Board of Directors.ResultsThe multidisciplinary evaluation and treatment of brain AVMs continues to evolve. Recommendations include: (1) Digital subtraction catheter cerebral angiography (DSA)—including 2D, 3D, and reformatted cross-sectional views when appropriate—is recommended in the pre-treatment assessment of cerebral AVMs. (I, B-NR). (2) It is recommended that endovascular embolization of cerebral arteriovenous malformations be performed in the context of a complete multidisciplinary treatment plan aiming for obliteration of the AVM and cure. (I, B-NR). (3) Embolization of brain AVMs before surgical resection can be useful to reduce intraoperative blood loss, morbidity, and surgical complexity. (IIa, B-NR). (4) The role of primary curative embolization of cerebral arteriovenous malformations is uncertain, particularly as compared with microsurgery and radiosurgery with or without adjunctive embolization. Further research is needed, particularly with regard to risk for AVM recurrence. (III equivocal, C-LD). (5) Targeted embolization of high-risk features of ruptured brain AVMs may be considered to reduce the risk for recurrent hemorrhage. (IIb, C-LD). (6) Palliative embolization may be useful to treat symptomatic AVMs in which curative therapy is otherwise not possible. (IIb, B-NR). (7) The role of AVM embolization as an adjunct to radiosurgery is not well-established. Further research is needed. (III equivocal, C-LD). (8) Imaging follow-up after apparent cure of brain AVMs is recommended to assess for recurrence. Although non-invasive imaging may be used for longitudinal follow-up, DSA remains the gold standard for residual or recurrent AVM detection in patients with concerning imaging and/or clinical findings. (I, C-LD). (9) Improved national and international reporting of patients of all ages with brain AVMs, their treatments, side effects from treatment, and their long-term outcomes would enhance the ability to perform clinical trials and improve the rigor of research into this rare condition. (I, C-EO).ConclusionsAlthough the quality of evidence is lower than for more common conditions subjected to multiple randomized controlled trials, endovascular therapy has an important role in the management of brain AVMs. Prospective studies are needed to strengthen the data supporting these recommendations.

State of the Art in the Role of Endovascular Embolization in the Management of Brain Arteriovenous Malformations—A Systematic Review

“…Most commonly, patients demonstrate decreased levels of health, anxiety, depression, pain, and discomfort [ 78 ]. For this reason, in cases of large bAVMs, which may lead to neurological symptoms and decline due to chronic venous hypertension and vascular stealing from surrounding tissues, the endovascular embolization of high-flow fistulae with nidal flow reduction might be an effective tool to improve the quality of life [ 67 , 79 ].…”

“…Presurgical embolization of the arteries at the bAVM margins and in deep compartments of the chosen surgical exposure with partial embolization of the nidus is used to reduce intraoperative bleeding, thereby facilitating a safe and effective resection and mitigating the risk of a normal perfusion pressure breakthrough postoperatively [ 79 ]. The decision to perform preoperative embolization is strongly dependent on the location, size, and complexity of the bAVM angioarchitecture [ 79 ].…”

Intra- and post-operative acute hemorrhagic complications of Onyx embolization of brain arteriovenous malformations: A single-center experience

“…Except for SM grade IV or V BAVMs, which are generally monitored by observation unless ruptured, EVT plays an important role in securing high-risk bleeding points (such as flow-related or intranidal aneurysms and fistulous components) or reducing the flow to help shrink the nidus or area of perinidal angiogenesis (4,26). For SM grade I or II BAVMs, EVT can be used as a curative treatment, resulting in total occlusion of the nidus and filling of the proximal part of the draining vein (27)(28)(29)(30). However, curative embolization of BAVMs should be considered an unanticipated benefit of such therapy rather than a goal (31).…”

“…In our study, among eight post-operative hemorrhages, the degree of nidus embolization with Onyx was more than 2/3 of the nidus or the complete nidus in 87.5% of cases. Therefore, complete embolization of the nidus should not be pursued in EVT for BAVMs (27,30,31). Staged embolization with Onyx over 4-6 months can be helpful, with <30% obliteration of the nidus every time (7,26).…”

Segmentation techniques of brain arteriovenous malformations for 3D visualization: a systematic review

“…The best imaging tools for the characterization of bAVMs are digital subtraction angiography (DSA) and magnetic resonance angiography (MRA) [5]. Both imaging modalities play a role in the diagnostic and perioperative management of these lesions, highlighting bAVMs' features that drive their therapeutic management [6][7][8]. In neurosurgery, based on clinical and imaging findings, the severity of bAVMs, their predicted risk of rupture and necessity for intervention are mostly rated according to the classical Spetzler-Martin classification and its supplementation provided by Lawton et al in 2010, demonstrating a stronger correlation with surgical outcomes [9][10][11].…”