Selection of Patients for Treatment of Brain Arteriovenous Malformations by the Transvenous Approach: Relationship with Venous Anatomy and Risk of Hemorrhagic Complications

Abstract

BACKGROUND AND PURPOSE: Intracranial hemorrhage represents a severe complication of brain arteriovenous malformation treatment. The aim of this cohort was to report the rate of hemorrhagic complications after transvenous endovascular embolization and analyze the potential angioarchitectural risk factors as well as clinical outcomes. MATERIALS AND METHODS:During an 11-year period, 57 patients underwent transvenous endovascular embolization. All cases of hemorrhagic complications were identified. We analyzed the following variables: sex, age, hemorrhagic presentation, Spetzler-Martin grade, size of the AVM before the transvenous treatment, number of venous collectors, pattern of drainage, presence of dilated veins, and technical aspects. Univariate and multivariate multiple regression analyses were performed to evaluate the potential risk factors for procedure-related hemorrhagic complications.RESULTS: Hemorrhagic complications (either intraprocedural or periprocedural) unrelated to a perforation due to micronavigation occurred in 8 (14.0%) procedures. Significant (mRS . 2) and persistent neurologic deficits were present in 2 (3.5%) patients at 6month control. Larger nidi, especially .3 cm (P ¼ .03), and a larger number of venous collectors have shown a statistically significant correlation with hemorrhagic complications. Only the number of venous collectors was identified as an independent predictor of hemorrhagic complications in the multivariate analysis (OR, 8.7; 95% confidence interval, 2.2-58.2) (P ¼ .006).CONCLUSIONS: Larger nidus sizes and an increased number of venous collectors may increase the risk of hemorrhagic complications when implementing transvenous endovascular treatment of AVMs. The technique is effective and promising, especially with small nidi and single venous collectors.

Perioperative Complications of Transvenous Embolization of Ruptured Intracranial Arteriovenous Malformations

“…Second, the patients enrolled in the current study had severe symptoms, and 40.7% patients had mRS ≥ 3 preoperatively, which was higher than 25% in the study by Mendes et al Third, 37% of the patients in this study had nidus size ≥ 3 cm preoperatively, higher than the rates in the studies by Mendes et al (28.1%) ( 15 ), Lv et al (36.7%) ( 17 ), De Sousa et al (28.1%) ( 16 ). Fourth, 77.8% of the nidus were located deep (basal ganglia, thalamus, and cerebellum) in this study, which was higher than the patients with deep AVMs in studys by Mendes et al (36%) ( 15 ) and De Sousa et al (56.1%) ( 16 ). Fifth, the AVMs included in this study were complex, and the percentage of patients with preoperative Spetzler-Martin score ≥ III in this study (66.7%) was higher than that in studys by Mendes et al (58.5%) ( 15 ) and De Sousa et al (59.6%) ( 16 ).…”

“…All patients included in this study were those with ruptured nidus preoperatively. In studys by Mendes et al ( 15 ) and De Sousa et al ( 16 ), the bleeding rate of ruptured nidus preoperatively were only 67.5 and 66.7%, respectively. Second, the patients enrolled in the current study had severe symptoms, and 40.7% patients had mRS ≥ 3 preoperatively, which was higher than 25% in the study by Mendes et al Third, 37% of the patients in this study had nidus size ≥ 3 cm preoperatively, higher than the rates in the studies by Mendes et al (28.1%) ( 15 ), Lv et al (36.7%) ( 17 ), De Sousa et al (28.1%) ( 16 ).…”

“…In studys by Mendes et al ( 15 ) and De Sousa et al ( 16 ), the bleeding rate of ruptured nidus preoperatively were only 67.5 and 66.7%, respectively. Second, the patients enrolled in the current study had severe symptoms, and 40.7% patients had mRS ≥ 3 preoperatively, which was higher than 25% in the study by Mendes et al Third, 37% of the patients in this study had nidus size ≥ 3 cm preoperatively, higher than the rates in the studies by Mendes et al (28.1%) ( 15 ), Lv et al (36.7%) ( 17 ), De Sousa et al (28.1%) ( 16 ). Fourth, 77.8% of the nidus were located deep (basal ganglia, thalamus, and cerebellum) in this study, which was higher than the patients with deep AVMs in studys by Mendes et al (36%) ( 15 ) and De Sousa et al (56.1%) ( 16 ).…”

“…A prospective cohort study by Mendes et al on AVMs treated with transvenous approach reported 3/40 (7.5%) patients with perioperative complications ( 15 ). A study from the same clinical center as Mendes's study showed that hemorrhagic complications occurred in 8 (14.0%) procedures ( 16 ). Another meta-analysis showed that the complication rate of AVMs treated by the transvenous approach was 10% ( 17 ).…”

Review of treatment and therapeutic targets in brain arteriovenous malformation

“…27 Within this curative cohort is a group using a combination of transarterial and transvenous techniques. This approach has proven effective in a select number of cases, [28][29][30] though may carry significantly higher rates of peri-procedural stroke relative to adjunctive embolization when applied to larger, more complex lesions.…”