Hemorrhagic Complications after Endovascular Treatment of Cerebral Arteriovenous Malformations

Baharvahdat, Humain; Blanc, Raphaël; Termechi, R.; Pistocchi, Silvia; Bartolini, Bruno; Redjem, Hocine; Piotin, Michel

doi:10.3174/ajnr.a3906

Cited by 104 publications

(46 citation statements)

References 25 publications

(50 reference statements)

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“…Endovascular embolization is not innocent. Published combined procedural morbidity and mortality rates are reported around 10 % also in the more recent series [2,6,13,17,18]. It is unclear whether the risk of subsequent surgical resection decreases correspondingly.…”

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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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: 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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“…Baharvahdat et al reported an 11% complication rate after 846 intervention in 408 patients. New permanent disability and death related to hemorrhage after embolization were reported in 7.6% and 1.6% of patients, respectively (18). A meta-analysis by van Beijnum et al reported that complications leading to persistent neurological deficits or death occurred in 6.6% (range 0% -18%) of patients after AVM embolization (19).…”

Section: Discussionmentioning

confidence: 99%

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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“…Since the report by Willinsky et al, 19 Onyx has been introduced; neuroendovascular techniques have evolved; and myriad factors, including the Spetzler-Martin grade, periprocedural hemorrhage, deep venous drainage, number of embolized branches, age, absence of neurologic deficit, hemorrhagic presentation, small bAVM size, the presence of deep arterial feeders, eloquent location, the presence of arteriovenous fistula components, and venous penetration of embolic agents, have been associated with endovascular complications and unfavorable outcomes. 15,[19][20][21][22][23] Furthermore, adding to our understanding of the mechanisms underlying complications and their frequencies following bAVM transarterial embolization, Baharvahdat et al 24 noted in their series of 846 cases primarily treated with…”

Section: Discussionmentioning

confidence: 99%

“…Notably, complications did not correlate with increasing Spetzler-Martin grade. 24 Intuitively then, increasing numbers of arterial feeders requiring multiple microcatheterizations and/or multistage procedures, the presence of an arteriovenous fistula component increasing the likelihood of premature venous embolization, and eloquent regions intolerant to insult are likely to be associated with complications and poor outcomes following transarterial embolization.…”

Section: Discussionmentioning

confidence: 99%

Application of a Novel Brain Arteriovenous Malformation Endovascular Grading Scale for Transarterial Embolization

Bell¹,

Leslie‐Mazwi²,

Yoo³

et al. 2015

American Journal of Neuroradiology

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BACKGROUND AND PURPOSE:The advent of modern neuroendovascular techniques has highlighted the need for a simple, effective, and reliable brain arteriovenous malformation endovascular grading scale. A novel scale of this type has recently been described. It incorporates the number of feeding arteries, eloquence, and the presence of an arteriovenous fistula component. Our aim is to assess the validity of this grading scale.

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Hemorrhagic Complications after Endovascular Treatment of Cerebral Arteriovenous Malformations

Cited by 104 publications

References 25 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

Embolization of Intracranial Arteriovenous Malformations Using Onyx in 53 Patients

Application of a Novel Brain Arteriovenous Malformation Endovascular Grading Scale for Transarterial Embolization

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