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

Abstract

As a significant cause of intracerebral hemorrhages, seizures, and neurological decline, brain arteriovenous malformations (bAVMs) are a rare group of complex vascular lesions with devastating implications for patients’ quality of life. Although the concerted effort of the scientific community has improved our understanding of bAVM biology, the exact mechanism continues to be elucidated. Furthermore, to this day, due to the high heterogeneity of bAVMs as well as the lack of objective data brought by the lack of evaluative and comparative studies, there is no clear consensus on the treatment of this life-threatening and dynamic disease. As a consequence, patients often fall short of obtaining the optimal treatment. Endovascular embolization is an inherent part of multidisciplinary bAVM management that can be used in various clinical scenarios, each with different objectives. Well-trained neuro-interventional centers are proficient at curing bAVMs that are smaller than 3 cm; are located superficially in noneloquent areas; and have fewer, larger, and less tortuous feeding arteries. The transvenous approach is an emerging effective and safe technique that potentially offers a chance to cure previously untreatable bAVMs. This review provides the state of the art in all aspects of endovascular embolization in the management of bAVMs.

Real-Time MRI Monitoring of Liquid Embolic Agent (Onyx) Injection in a Swine Arteriovenous Malformation Model

“…The long-term success of curative endovascular AVM embolization ultimately depends on the complete occlusion of the nidus, feeding arteries, and draining veins without disrupting any functional vessels of the brain [4]. In high grades IV and V (Spetzler-Mar- Supplementary Material Video S2: Real-time, dynamic EPI-GRE T2 scan of the whole brain volume during Onyx injection.…”

“…Constituting a rare group of complex vascular lesions, brain arteriovenous malformations (bAVM), can have devastating implications on a patient’s quality of life for the risk of intracerebral hemorrhages, seizures, and neurological decline [ 1 , 2 , 3 , 4 ]. Therefore, endovascular embolization constitutes an indispensable part of multidisciplinary bAVM management and can be employed for various purposes.…”

“…Therefore, endovascular embolization constitutes an indispensable part of multidisciplinary bAVM management and can be employed for various purposes. Although it has been primarily used preoperatively to support radiosurgery and microsurgery, the substantial advances in catheter technology have significantly improved the safety and efficacy of endovascular embolization of bAVMs [ 1 , 2 , 3 , 4 , 5 ]. Even though the dominant number of neurosurgical centers continues to rely on microsurgery and radiosurgery in the majority of cases, neurointerventional centers effectively employ endovascular embolization as a single curative treatment of bAVMs smaller than 3 cm, located superficially in non-eloquent areas, and with fewer, larger, and less tortuous feeding arteries [ 1 , 2 , 3 , 4 , 5 ].…”

“…Although it has been primarily used preoperatively to support radiosurgery and microsurgery, the substantial advances in catheter technology have significantly improved the safety and efficacy of endovascular embolization of bAVMs [ 1 , 2 , 3 , 4 , 5 ]. Even though the dominant number of neurosurgical centers continues to rely on microsurgery and radiosurgery in the majority of cases, neurointerventional centers effectively employ endovascular embolization as a single curative treatment of bAVMs smaller than 3 cm, located superficially in non-eloquent areas, and with fewer, larger, and less tortuous feeding arteries [ 1 , 2 , 3 , 4 , 5 ]. Moreover, although the results of large clinical trials have yet to be published, transvenous embolization of arteriovenous malformations is emerging as an effective technique with a high rate of total AVM occlusions [ 6 , 7 ].…”

Pediatric Cerebral Vascular Malformations : Current and Future Perspectives

“…Stand-alone embolization as definitive treatment of highflow vascular lesions has increasingly been reported. While this approach is often successful for VOGM (typically requiring multiple rounds of embolization), or single-hole fistulae, it is more controversial with nidal AVMs [ 4 , 41 , 47 , 48 ]. Initial data suggests that attempts to cure complex nidal AVMs with embolization alone may actually worsen the bleeding risk and outcomes relative to natural history – and, as such, it is increasingly discouraged in many high-volume centers [ 20 , 22 , 48 ].…”