Role of Embolization for Cerebral Arteriovenous Malformations

Ellis, Jason A.; Lavine, Sean D.

doi:10.14797/mdcj-10-4-234

Cited by 35 publications

(34 citation statements)

References 62 publications

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“…The goals of presurgical embolization are as follows: 1) to eliminate deep arterial pedicles encountered only at the later stages of resection, and 2) to secure AVM-related aneurysms, especially if they are remote from the area of resection. 4 Surgical access to AChAs can be difficult because of their depth, 7,10 and surgeons might encounter AVMs superficial to choroidal feeding arteries that could hinder surgical manipulation. In this situation, preoperative AChA embolization could be beneficial.…”

Section: Role Of Embolization Through Choroidal Arteriesmentioning

confidence: 99%

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

Elkordy

Endo²,

Sato

et al. 2017

JNS

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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.

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Section: Role Of Embolization Through Choroidal Arteriesmentioning

confidence: 99%

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

Elkordy

Endo²,

Sato

et al. 2017

JNS

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“…AVM affects not only the local region surrounding the nidus, but also the total amount of flow to the brain and the distribution of flow in extranidal vessels . Treatment options for AVM include staged endovascular embolization of individual feeding arteries to reduce AVM flow, which is associated with 5–15% overall risk of hemorrhage . Embolization treatment alters the distribution of cerebral blood flow .…”

mentioning

confidence: 99%

“…1 Treatment options for AVM include staged endovascular embolization of individual feeding arteries to reduce AVM flow, which is associated with 5-15% overall risk of hemorrhage. 2 Embolization treatment alters the distribution of cerebral blood flow. 3 As specific treatment recommendations continue to evolve, 4 there is a lack of quantitative data relating hemodynamic parameters to AVM hemorrhage risk.…”

mentioning

confidence: 99%

Standardized Evaluation of Cerebral Arteriovenous Malformations Using Flow Distribution Network Graphs and Dual‐venc 4D Flow MRI

Aristova

Vali

Ansari

et al. 2019

Magnetic Resonance Imaging

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Background Cerebral arteriovenous malformations (AVMs) are pathological connections between arteries and veins. Dual‐venc 4D flow MRI, an extended 4D flow MRI method with improved velocity dynamic range, provides time‐resolved 3D cerebral hemodynamics. Purpose To optimize dual‐venc 4D flow imaging parameters for AVM; to assess the relationship between spatial resolution, acceleration, and flow quantification accuracy; and to introduce and apply the flow distribution network graph (FDNG) paradigm for storing and analyzing complex neurovascular 4D flow data. Study Type Retrospective cohort study. Subjects/Phantom Scans were performed in a specialized flow phantom: 26 healthy subjects (age 41 ± 17 years) and five AVM patients (age 27–68 years). Field Strength/Sequence Dual‐venc 4D flow with varying spatial resolution and acceleration factors were performed at 3T field strength. Assessment Quantification accuracy was assessed in vitro by direct comparison to measured flow. FDNGs were used to quantify and compare flow, peak velocity (PV), and pulsatility index (PI) between healthy controls with various Circle of Willis (CoW) anatomy and AVM patients. Statistical Tests In vitro measurements were compared to ground truth with Student's t‐test. In vivo groups were compared with Wilcoxon rank‐sum test and Kruskal–Wallis test. Results Flow was overestimated in all in vitro experiments, by an average 7.1 ± 1.4% for all measurement conditions. Error in flow measurement was significantly correlated with number of voxels across the channel (P = 3.11 × 10−28) but not with acceleration factor (P = 0.74). For the venous‐arterial PV and PI ratios, a significant difference was found between AVM nidal and extranidal circulation (P = 0.008 and 0.05, respectively), and between AVM nidal and healthy control circulation (P = 0.005 and 0.003, respectively). Data Conclusion Dual‐venc 4D flow MRI and standardized FDNG analysis might be feasible in clinical applications. Venous‐arterial ratios of PV and PI are proposed as network‐based biomarkers characterizing AVM nidal hemodynamics. Level of Evidence: 3 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2019;50:1718–1730.

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“…The method dynamically displays vascular transitions and is uniquely able to delineate the size and number of feeding arteries and their origins, measure the nidus size and compactness, and evaluate venous drainage locations [42]. In addition to its significant diagnostic role, angiography is the main technique used by interventional radiologists to accurately navigate through the neurovascular environment and assess treatment progression and related events through interventional sessions [43,44]. DSA is performed using selective (the catheter used for contrast administration is only advanced to the AVM vicinity) or super-selective (the catheter is further advanced to the AVM feeding arteries) approaches [23].…”

Section: Digital Subtraction Angiographymentioning

confidence: 99%

Advocating Intraluminal Radiation Therapy in Cerebral Arteriovenous Malformation Treatment

Hirsh¹,

Arthur²,

Golan³

2020

Vascular Malformations of the Central Nervous System

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In 2014, ARUBA (a randomized trial on cerebral Arteriovenous Malformation-AVM) found patients treated using prevalent interventional strategies are three times more likely to suffer a stroke/die compared with those treated conservatively (blood pressure reduction). Subsequent controversy led the European societies dealing with AVM to organize a consensus conference. Among the statements made was: "There may be indications for treating patients with higher Spetzler-Martin (SM) grades, based on a case-to-case consensus decision of the experienced team". Thus, a clear accord emerges. There is a lacuna/weakness of interventional modalities when addressing high SM grade AVMs. This lack of a clear treatment choice originated our review. We attempt to identify the advantages and challenges of each present treatment/evaluation modality and highlight core requirements for future strategies. We conclude that existing modalities provide substantial recent improvements, yet the core challenge persists. Finally, we advocate testing a novel modality-intraluminal radiotherapy (active implants) by exploiting the "candy wrapper" or edge effect. If proven effective, this approach could offer gradual vessel occlusion with minimal abrupt hemodynamic changes known to induce hemorrhage, the lowest recurring session number (reduced costs), minimally invasive attributes and very low radiation (dose/dose rate) kinetics minimizing potential Adverse Radiation Effects (AREs).

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Role of Embolization for Cerebral Arteriovenous Malformations

Cited by 35 publications

References 62 publications

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

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

Standardized Evaluation of Cerebral Arteriovenous Malformations Using Flow Distribution Network Graphs and Dual‐venc 4D Flow MRI

Advocating Intraluminal Radiation Therapy in Cerebral Arteriovenous Malformation Treatment

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