The Safety and Effectiveness of Brain Arteriovenous Malformation Embolization Using Acrylic and Particles

Abstract

The purpose of this article is to report on the safety and effectiveness of brain arteriovenous malformation (AVM) embolization for two series of patients, of which one was treated with particulate embolization and the other with acrylic embolization. Sixty-five consecutive patients from embolization logs and patient records from 1988 to 1993 were reviewed. AVMs were routinely treated with particulate embolization early in the review (1988-1991), and after a transition period, the technique was changed to acrylic embolization for the remainder of the study period (1992-1993). All patients were treated with the ultimate goal of complete AVM obliteration. AVMs were embolized and resected, if possible, and if unresectable, they were reduced in size with embolization and radiated. The course of treatment for each patient was reviewed. The effectiveness at the end of treatment was analyzed for the ability to resect the AVM and, if unresectable, the ability to reduce the AVM to radiation size. Additionally, the safety of each embolization technique was evaluated in the context of comprehensive care, in terms of the safety of the procedure itself, the surgical resection after embolization, and the outcome at the end of comprehensive treatment. This article outlines the safety and effectiveness of acrylic and particulate embolization at a single institution. The ability to surgically resect an AVM after embolization and to reduce nidus size with acrylic was at least comparable with that with particulate embolization. Comprehensive complication rates were lower after acrylic embolization and were heavily influenced by a decreased number of surgical complications in the acrylic series. These data support the need to conduct a randomized prospective clinical trial to compare the relative safety and effectiveness of the two methods of embolization.

Periprocedural Bleeding Complications of Brain AVM Embolization with Onyx

“…Thanks to the improvement of endovascular materials and experience, endovascular therapy has become increasingly important in 51 the management of cerebral AVMs. The main goals of AVM embolization are nidus reduction before surgery or radiosurgery, curative embolization, and palliative embolization 3,25,[27][28] . Since the pioneers in the early 1960s reported using methyl methacrylate to embolize the feeding pedicle to treat AVMs, a considerable evolution of microcatheter tools, embolization materials and techniques has proved the success of embolization.…”

“…Onyx is a new embolization material that has gradually been adopted for AVM embolization during the past decade, and some authors have already reported their initial experiences in the treatment of AVMs with Onyx [11][12][5][6][7][8][9][10][11][12][13][14][15][16]19,21,23,[25][26][27][28] . As mentioned in these articles, Onyx is a nonadhesive agent with controllable endovascular behavior, which allows more precise nidus penetration creating a solid cast, the overall initial complete obliteration rate of intracranial AVMs with Onyx is rela-tively high compared with that of other embolic agents 7,28 . Despite improvements in endovascular techniques and embolic agents, the complication profile of brain AVM embolization is of concern and not well described [2][3][4] .…”

Preoperative silk suture embolization of cerebral and dural arteriovenous malformations

“…If an intranidal microcatheter tip location can be found, the injection of NBCA is optimal. 3,28,29 With this material, however, there is always a risk of permanently gluing the catheter tip within the cerebral vessel. Also commonly used for embolization of cerebral AVMs, PVA will not provide permanent embolization, and closing large fistulas is difficult.…”

“…Silk sutures pose less of a hindrance to surgery than other agents such as microcoils or NBCA. 15,20,28 The disadvantage of silk as an embolic agent is its radiolucency. 9,30 The incidence of endovascular embolization-induced delayed hemorrhage is not frequent and ranges from 3 to 5%.…”

“…3,20,21,28 We consider silk suture to be an effective and safe embolic agent for the preoperative embolization of cerebral and dural AVMs. In this study the estimated silk suture-related complication rate was 0% for permanent deficit and 0.09% for temporary deficit; the mortality rate was 0%.…”