The effect of embolization with N-butyl cyanoacrylate prior to surgical resection of cerebral arteriovenous malformations

Abstract

Endovascular therapy of cerebral arteriovenous malformations (AVM's) is an accepted adjunct to surgical therapy. However, the literature has not characterized the benefits or the liabilities of preoperative embolization. This series compares two groups of patients who underwent surgical resection of a cerebral AVM; one group (20 patients) received preoperative transfemoral selective embolization with N-butyl cyanoacrylate (NBCA) and the other group (13 patients) did not. In the group with preoperative embolization, the AVM's were larger (3.9 vs. 2.3 cm) and of a higher Spetzler-Martin grade (3.2 vs. 2.5) as compared to the nonembolized group. The NBCA embolization facilitated surgical resection. Arteries supplying the vascular malformation were readily distinguished from those supplying the normal brain parenchyma. Embolized vessels were compressible and easily cut with microscissors. No bleeding occurred from transected vessels. Operative time and intraoperative blood loss for the two groups were not statistically different, despite the significant differences in lesion size and grade. Endovascular complications included immediate and delayed hemorrhage (15%) and transient ischemia (5%); there were no embolization-related deaths. Postoperative complications for both groups included hemorrhage (15%), residual AVM (6%), and cerebrospinal fluid leak (3%); the mortality rate was 3%. There was no statistically significant difference in surgical complications between the embolized and nonembolized groups. Most patients (91%) in both groups had an excellent or good late neurological outcome, with no significant difference between the groups. This study concludes that preoperative NBCA embolization of AVM's makes lesions of larger size and higher grade the surgical equivalent of lesions of smaller size and lower grade by reducing operative time and intraoperative blood loss, with no statistically significant difference in surgical complications or long-term neurological outcome.

Combined treatment of brain avms by onyx embolization and gamma knife radiosurgery decreased hemorrhage risk with lowered obliteration rate

“…Embolization aiming to decrease the size of the nidus and the blood flow by occluding its critical feeders to facilitate the surgical removal by significantly shorten surgical time and to reduce blood loss or as an adjunct to surgical or radiosurgical treatment, with a concurrent reduction in morbidity and mortality (5,13,20,23,29). Onyx is a precipitating agent and allows for longer injection durations and makes it possible to achieve better occlusion of the nidus in 1 injection.…”

Recomendaciones para el manejo de las malformaciones arteriovenosas cerebrales

“…En un caso como este, la terapia endovascular, con oclusión de parte del ovillo, puede determinar para algunos autores una disminución del riesgo de sangrado 6,12 . Esto no es aceptado por otros, que plantean que posterior a la embolización, al ocluir vasos anormales de mayor calibre, se transformaría una MAV de alto flujo y baja resistencia en una de alta resistencia, con el consiguiente aumento de riesgo de sangrado 16,18 .…”

“…A este respecto la conducta a seguir, cirugía complementaria o radiocirugía, dependerá de la topografía del resto de MAV, la condición del paciente y la angioarquitectura de ese remanente. Estos por lo general son pequeños, profundos y quedan en cirugías de MAV grandes 16 . Es en estos casos en que se recomienda la complementación con radiocirugía estereotáxica.…”

“…Se puede complementar este tratamiento con radiocirugía del sector no embolizado. Varios trabajos se han publicado con la combinación de estas dos técnicas, pero también han aparecido otros en que se demuestran malos resultados, con reaparición del ovillo, sangrados, etc 16,19,25,27,33,34,39 . En resumen: si es una lesión sintomática, con o sin sangrado, pero que pone en riesgo la vida del paciente se opta por terapias alternativas, paliativas (neurocirugía endovascular y radiocirugía).…”

Preoperative silk suture embolization of cerebral and dural arteriovenous malformations

“…4,9,20,21,30 Although immediate or delayed hemorrhage associated with embolization can be a devestating complication, the direct relation between inflammatory response and subsequent hemorrhage remains unclear. 7,11,17 Deveikis, et al, 4 have described hemorrhage-related complications in a few cases in which silk suture was one of the preoperative embolic agents. 4 We report our experience with the use of No.…”