Radiosurgery for Cerebral Arteriovenous Malformations with Associated Arterial Aneurysms

Ding, Dale; Xu, Zhiyuan; Starke, Robert M.; Yen, Chun-Po; Shih, Han-Hsun; Buell, Thomas J.; Sheehan, Jason P.

doi:10.1016/j.wneu.2015.11.080

Cited by 36 publications

(17 citation statements)

References 61 publications

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“…Cerebral AVMs and coexisting intracranial aneurysms have been anecdotally discussed since 1942 [19]. Pathogenesis theories largely attribute the formation of AVM-associated aneurysms to pathological hemodynamics induced by the AVM, namely high proximal blood flow [4,5,9,11].…”

Section: Discussionmentioning

confidence: 99%

“…No consensus currently exists to guide the treatment of intracranial aneurysms associated with AVMs. However, various case series discuss current treatment strategies for surgically managing AVMs with coexisting intracranial aneurysms [4,5,6,9,10,11,19,21,22]. Rammos et al [22] suggest that the spatial relationship between the AVM nidus and the associated aneurysm, in addition to the patient's clinical presentation, should guide treatment decisions and timing.…”

Section: Discussionmentioning

confidence: 99%

“…The staging of treatment modalities must, therefore, be carefully evaluated. The surgical management of the high-flow posterior temporal parietal AVM, outlined in case report 2, addressed AVM embolization initially as the vasculopathology with the highest rupture risk [4,5,6,19,24,25,26,27]. Subsequently, Pipeline embolization of the associated aneurysm with adequate antiplatelet treatment was performed before scheduled radiosurgery to decrease the risk of AVM rebleeding [12].…”

Section: Discussionmentioning

confidence: 99%

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Pipeline Flex Embolization of Flow-Related Aneurysms Associated with Arteriovenous Malformations: A Case Report

et al. 2018

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Background: An estimated 0.1% of the population harbors brain arteriovenous malformations (AVMs). Diagnosis and workup of AVMs include thorough evaluation for characterization of AVM angioarchitecture and careful assessment for concomitant aneurysms. The presence of coexisting aneurysms is associated with an increased risk of intracranial hemorrhage, with a published risk of 7% per year compared to patients with AVMs alone with a risk of 3%. Comprehensive AVM management requires recognition of concomitant aneurysms and prioritizes treatment strategies to mitigate the aggregate risk of intracranial hemorrhage associated with AVM rupture in patients with coexisting aneurysms. Endovascular treatment of these flow-related aneurysms can offer a cure, while avoiding open surgery. Successful flow-diverting embolization techniques, efficacy, and outcomes have been previously described for a variety of aneurysm types and locations. However, use of a flow diverter has not been previously described for the treatment of high-flow aneurysms on AVM-feeding vessels. Case Presentation: We report 2 cases of large AVMs within eloquent cortex associated with flow-related aneurysms in patients presenting initially with suspected intracerebral hemorrhage secondary to AVM rupture. Discussion: No consensus currently exists to guide treatment of intracranial aneurysms associated with AVMs. Surgical management addressed AVM embolization initially, as the vasculopathology with the highest rupture risk. Subsequently, Pipeline embolization of the associated aneurysms with adequate antiplatelet treatment was performed before scheduled radiosurgery to decrease the risk of AVM rupture or rebleed. This represents a novel and promising use of the Pipeline Embolization Device. Additional cases and longer follow-up will be needed to further assess the efficacy of this technique.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Pipeline Flex Embolization of Flow-Related Aneurysms Associated with Arteriovenous Malformations: A Case Report

et al. 2018

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“…The elevated risk of both initial and repeat hemorrhage for these deep-seated CCMs compared to cortical CCMs favors intervention, whereas the relatively high rate of neurological morbidity associated with surgical resection of these lesions supports a more conservative approach 41)42). Although radiosurgery is a conceptually attractive alternative to surgical resection of eloquent CCMs, the radiosurgery-induced complication rate is significantly higher for CCMs than for AVMs, and CCMs cannot be radiologically monitored for obliteration after radiosurgery 3)5)6)8)9)10)12)13)14)15)16)17)18)19)20)21)22)23)25)26)27)28)29)30)31)32)33)34)35)36)37)43)44)49)50)52)53)56)59)63)64)65)66)67)68). Instead, the proposed effect of radiosurgery on CCMs is a decreased risk of symptomatic hemorrhages, which is controversial due to temporal clustering of CCM hemorrhages 4).…”

Section: Discussionmentioning

confidence: 99%

Surgical Approaches for Symptomatic Cerebral Cavernous Malformations of the Thalamus and Brainstem

Ding

Starke

Crowley

et al. 2017

J Cerebrovasc Endovasc Neurosurg

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ObjectiveSurgical resection of thalamic and brainstem cerebral cavernous malformations (CCMs) is associated with significant operative morbidity, but it may be outweighed, in some cases, by the neurological damage from recurrent hemorrhage in these eloquent areas. The goals of this retrospective cohort study are to describe the technical nuances of surgical approaches and determine the postoperative outcomes for CCMs of the thalamus and brainstem.Materials and MethodsWe reviewed an institutional database of patients harboring thalamic or brainstem CCMs, who underwent surgical resection from 2010 to 2014. The baseline and follow-up neuroimaging and clinical findings of each patient and the operative details of each case were evaluated.ResultsA total of eight patients, including two with thalamic and six with brainstem CCMs, were included in the study cohort. All patients had progressive neurological deterioration from recurrent CCM hemorrhage, and the median modified Rankin Scale (mRS) at presentation was 3. The median CCM maximum diameter and volume were 1.7 cm and 1.8 cm3, respectively. The thalamic CCMs were resected using the anterior transcallosal transchoroidal and supracerebellar infratentorial approaches each in one case (13%). The brainstem CCMs were resected using the retrosigmoid and suboccipital trans-cerebellomedullary fissure approaches each in three cases (38%). After a median follow-up of 11.5 months, all patients were neurologically stable or improved, with a median mRS of 2. The rate of functional independence (mRS 0-2) was 63%.ConclusionMicroneurosurgical techniques and approaches can be safely and effectively employed for the management of thalamic and brainstem CCMs in appropriately selected patients.

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“…Advances in microsurgical techniques and equipment, technologies for endovascular embolization, and stereotactic radiosurgery (SRS) have resulted in a number of safe and effective treatments, but selecting an appropriate treatment strategy remains challenging in many cases 1)2)3)4)5)12)13)14)15)16)17)18)19)20)21)22)23)24)25)26)27)28)29)30)36)37)39)40)41)49)50)51)52)54)57). Of the various interventional options for AVMs, surgical resection remains the gold standard 11)33)34)48)…”

Section: Introductionunclassified

Preoperative Embolization of Cerebral Arteriovenous Malformations with Silk Suture and Particles: Technical Considerations and Outcomes

Conger

Ding

Raper

et al. 2016

J Cerebrovasc Endovasc Neurosurg

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ObjectiveEmbolization of cerebral arteriovenous malformations (AVMs) is commonly performed prior to surgical resection in order to reduce intraoperative bleeding and improve the safety of resection. Although most modern embolization procedures utilize permanent embolic agents, silk suture and polyvinyl alcohol (PVA) particles may offer unique advantages for preoperative devascularization. The aims of this retrospective cohort study are to describe the technical considerations and determine the outcomes for preoperative silk suture and PVA particle embolization (SPE) of AVMs.Materials and MethodsWe performed a retrospective review of our AVM embolization database. AVM patients who underwent preoperative SPE and subsequent surgical resection were included for analysis. Baseline patient demographics, AVM characteristics, embolization and operative records, and post-treatment outcomes were reviewed.ResultsA total of 11 patients who underwent 12 preoperative SPE procedures were included for analysis. Five AVMs were ruptured (45%), and the median nidus volume was 3.0 cm3 (range: 1.3-42.9 cm3). The Spetzler-Martin grade was I-II in seven patients (64%) and III-IV in four patients (36%). The degree of nidal obliteration was less than 25% in two procedures (17%), 25-50% in one procedure (8%), 50-75% in eight procedures (67%), and greater than 75% in one procedure (8%). The rates of post-embolization AVM hemorrhage and mortality were 8% and 0%, respectively. The postoperative angiographic obliteration rate was 100%, and the modified Rankin Scale score improved or stable in 91% of patients (median follow-up duration 2 months).ConclusionPreoperative AVM SPE affords a reasonable risk to benefit profile for appropriately selected patients.

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Radiosurgery for Cerebral Arteriovenous Malformations with Associated Arterial Aneurysms

Cited by 36 publications

References 61 publications

Pipeline Flex Embolization of Flow-Related Aneurysms Associated with Arteriovenous Malformations: A Case Report

Pipeline Flex Embolization of Flow-Related Aneurysms Associated with Arteriovenous Malformations: A Case Report

Surgical Approaches for Symptomatic Cerebral Cavernous Malformations of the Thalamus and Brainstem

Preoperative Embolization of Cerebral Arteriovenous Malformations with Silk Suture and Particles: Technical Considerations and Outcomes

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