Onyx resorbtion with AVM recanalization after complete AVM obliteration

Brain arteriovenous malformations (BAVM) are some of the most complex lesions treated by clinical neuroscientists. The recent publication of the ARUBA trial, showing higher complication rates with treatment compared with the natural history over a short period of follow-up, puts even more pressure on the physician to achieve complete BAVM eradication without complication. These lesions are often treated by multimodality therapy with some combination of endovascular embolization, radiosurgery, and microsurgical resection; however, multimodality therapy involves the additive risk of procedural complication with each procedure. While surgical resection has long been accepted as monotherapy with good cure rates, staged pre-operative endovascular embolization has facilitated microsurgical resection with lower blood loss. Endovascular embolization is more often utilized in conjunction with surgical resection, and often the portions of the AVM and feeders that are completely embolized with Onyx or glue may not be surgically resected since they have been “internally obliterated.” We present a case where the AVM was preoperatively embolized with Onyx and subsequently partially surgically resected. Post-operative angiography showed complete obliteration or “cure” of the AVM with no filling of the nidus or early venous drainage. The patient presented 12 months later with seizures and imaging showed volume loss in the residual Onyx cast and recanalization of the AVM nidus. The patient subsequently underwent repeat resection with complete removal of the residual AVM and Onyx cast. To our knowledge this is the first published report of volume loss within the Onyx cast leading to recanalization of the AVM nidus. This suggests that extreme care should be taken with partial resection of the AVM nidus or with embolization for cure, as late recanalization may occur.     

Microcatheter entrapment retrieval from Onyx embolization in brain arteriovenous malformations: A technical note

Objective

Many techniques have been use for retrieval of an entrapped microcatheter during Onyx (eV3 Neurovascular) embolization of brain arteriovenous malformations (BAVMs). We report our technique that we term “pull-push-pull” that can be utilized as first management in retrieving the microcatheter.

Method

We analyzed a total of 37 patients that underwent BAVM embolization with either Onyx 18 or 34 at our institution. Standard embolization techniques were utilized with the use of Marathon (eV3 Neurovascular) microcatheter. When difficulty in retrieving the microcatheter arose, we used the “pull-push-pull” technique. The technique comprises the eV3 protocol of retraction. In addition, the microcatheter is stretched causing the Onyx cast to stretch in its inner core, creating a more thorough cohesive property amongst the Onyx mixture. Then the microcatheter is pushed back and to its point of embolization origin. Afterwards, retraction of the microcatheter is enabled as it can be easily dislodged from the cast. Multiple attempts can be repeated as needed.

Result and discussion

We had three patients that had difficulty with removal of microcatheter (8.1%). Utilization of the “pull-push-pull” technique was used on two of those patients. No neurological complication was observed with our technique. We believe the cohesive property of Onyx solution helps in the retrieval of the catheter by our method and technique.

Conclusion

We believe the “pull-push-pull” can be utilized and be an additional technique before attempting other catheter retrieval techniques in Onyx BAVM embolization.     

脑动静脉畸形栓塞术后迟发性脑炎1例并文献复习

目的 探讨栓塞材料相关性脑炎这一罕见不良反应的诊断和治疗。方法 回顾性分析脑动静脉畸形(brain arteriovenous malformations,BAVM)栓塞术后出现迟发性脑炎患者1例,并复习相关文献。结果 患者男性,52岁,BAVM栓塞术后1个月内先后出现全身皮疹及左侧肢体无力,抗病毒治疗无效,排除其他疾病后考虑患者为栓塞材料相关的迟发性脑炎,经激素治疗后患者痊愈。结论 血管内栓塞治疗可诱发严重的中枢神经系统迟发性炎症反应,有必要对患者延长术后随访期限。     

应用Onyx-18行血管内栓塞脑动静脉畸形的临床分析

目的探讨应用Onyx-18血管内栓塞脑动静脉畸形的临床治疗经验。方法回顾性分析我科近5年来应用Onyx-18治疗脑动静脉畸形患者16例,就其临床表现、影像学、治疗策略及结果进行临床研究。结果Spetzler分级：Ⅱ级3例,Ⅲ级4例,Ⅳ级7例,Ⅴ级2例。16例患者中共进行20次栓塞,完全栓塞5例（31.2%）,90%栓塞5例（31.2%）差6例。7例患者出现术后头痛,给予甘露醇脱水后症状缓解;3例出现一过性肢体偏瘫、麻木,给予相应处理后其中3例完全恢复;2例出现一过性言语不利,对症处理后症状消失;2例发生微导管拔管失败,滞留体内,术后其中1例患者出现残留右上肢轻瘫。所有患者随访6~36个月,经全脑血管造影证实未发现畸形血管团再通现象。13例格拉斯哥预后评分（GOS）=5;1例GOS=4;2例GOS=3。结论Onyx-18行血管内栓塞脑动静脉畸形安全可行,在临床上能够取得令人满意的脑血管畸形治愈率,可以有效将大的血管畸形减容,为进一步治疗创造条件。熟练掌握栓塞操作技巧及预防措施,可以使脑动静脉畸形获得更高的治愈率。     

多层螺旋CT血管造影在颅内动静脉畸形诊断中的价值

目的评价多层螺旋CT血管造影（MSCTA）对脑动静脉畸形（AVM）的诊断价值。方法62例均于发病后1周以内完成血管造影检查,其中40例先行MSCTA检查后行数字减影血管造影术（DsA）;22例先行DSA检查后行MSCTA检查。以手术或者DsA结果为金标准,依照wH0的S-M分级标准作出AVM的5种分级。对比观察MSCTA与DsA在AVM诊断中的不同作用。结果MSCTA与DsA都能清晰显示AVM的引流血管及其与邻近血管和骨性组织间的解剖关系,MSCTA区分AVM高危组比DSA更有意义。结论MSCTA优于DSA,可清晰显示脑动静脉畸形、血管钙化等细节情况,对于脑动静脉畸形的诊断及治疗有重要意义。     

Onyx血管内栓塞治疗脑动静脉畸型

目的 探讨Onyx胶在治疗脑动静脉畸形中的应用价值。方法采用Onyx-18胶栓塞治疗17例脑动静脉畸形患者,畸形血管团大小均在3cm以上,其中6cm及以上者11例,所有畸形血管团为多支血管供血。结果17例BAVM中达到完全（100％）栓塞者9例,治愈率为53％,包括Ⅱ级全部和Ⅲ级5例患者;栓塞80％者6例,包括Ⅲ级2例,Ⅳ级3例,Ⅴ级1例;50％者2例,均为Ⅴ级患者。全组无死亡和神经功能缺失等并发症。结论Onyx胶是治疗脑动静脉畸形较为理想的栓塞材料,但需注意掌握栓塞技巧,减少并发症的发生。     

颅内肿瘤、脑血管畸形的X刀治疗

目的:探讨 X 刀治疗颅内肿瘤、脑血管畸形的方法与疗效。方法:X 刀治疗颅内肿瘤、血管畸形302例,单次治疗219例,分次83例。结果:平均随访16.36月,1年生存率87.35%,平均生存期21.69月,实际肿瘤控制率88.35%,血管畸形闭塞率90%。小病变肿瘤控制好,水肿率低(P<0.05)。大病变分次治疗优于单次,且水肿率低(P<0.05)。结论:临床和影像学结果肯定了 X 刀对颅内肿瘤、血管畸形的治疗作用。严格治疗指征,合理使用分次、多靶点治疗,注意治疗给量、综合治疗及联合手术治疗,有益于提高局部控制率和降低并发症。     

Intraoperative sonography of intracranial arteriovenous malformations: how we do it.

OBJECTIVE: We have advanced the application of intraoperative neurosonography by combining gray scale sonographic imaging with pulsed wave Doppler and color flow Doppler imaging to guide and confirm resection of arteriovenous malformations of the brain. We want to share our technique with the imaging community. METHODS: We present a review of our scan technique as it has evolved over the 3 years during which we have been assisting our neurosurgical team. RESULTS AND CONCLUSIONS: Our experience has indicated that a combination of sonographic imaging and color and spectral Doppler imaging improves surgical resection of such lesions.     

Angioarchitectural features amongst patients with unruptured brain arteriovenous malformations presenting with headache: findings from a single center retrospective review of 76 patients

BackgroundBrain arteriovenous malformations (AVMs) consist of abnormal connections between arteries and veins via an interposing nidus. While hemorrhage is the most common presentation, unruptured AVMs can present with headaches, seizures, neurological deficits, or be found incidentally. It remains unclear as to what AVM characteristics contribute to pain generation amongst unruptured AVM patients with headaches.MethodsTo assess this relationship, the current study evaluates angiographic and clinical features amongst patients with unruptured brain AVMs presenting with headache. Loyola University Medical Center medical records were queried for diagnostic codes corresponding to AVMs. In patients with unruptured AVMs, we analyzed the correlation between the presenting symptom of headache and various demographic and angiographic features.ResultsOf the 144 AVMs treated at our institution between 1980 and 2017, 76 were unruptured and had sufficient clinical data available. Twenty-three presented with headaches, while 53 patients had other presenting symptoms. Patients presenting with headache were less likely to have venous stenosis compared to those with a non-headache presentation (13 % vs. 36 %, p = 0.044).ConclusionsOur study suggests that the absence of venous stenosis may contribute to headache symptomatology. This serves as a basis for further study of correlations between AVM angioarchitecture and symptomatology to direct headache management in AVM patients.     

Embolization of a superior sagittal sinus dural arteriovenous fistula under intrasinus balloon protection: A case report

Endovascular embolization has evolved to become the primary therapeutic option for dural arteriovenous fistulas (DAVFs). While guaranteeing complete occlusion of the fistula orifice, the goal of DAVF embolization is also to ensure the patency of normal cerebral venous drainage. This paper describes a case of successful embolization of a complex DAVF in the superior sagittal sinus with a multistaged approach using a combination of transvenous and transarterial tactics. The strategies and techniques are discussed.     

Onxy胶术前栓塞联合显微手术治疗高级别脑动静脉畸形的效果

目的 总结术前栓塞联合显微手术治疗高级别脑动静脉畸形(BAVM)的效果.方法 选取2016年1月至2018年12月我院收治的58例高级别BAVM患者为研究对象,按随机数字表法将其分为对照组和治疗组,每组29例.对照组单纯行显微手术治疗,治疗组在Onxy胶栓塞后再行显微手术治疗.比较两组患者的病灶全切率、复发率、术后神经...     

Uterine arteriovenous malformations: from diagnosis to treatment.

OBJECTIVE: The purpose of this study was to describe the sonographic features of uterine arteriovenous malformations (AVMs) and to describe the role and clinical outcome after transcatheter arterial embolization of symptomatic uterine AVMs. METHODS: In our institution, over a 4-year period, symptomatic uterine AVMs were diagnosed in 21 women. Endovaginal sonography with gray scale, color, and spectral Doppler imaging was performed on all patients. Fourteen patients required therapeutic angiography/embolization to control bleeding. These 14 patients had follow-up endovaginal sonography 24 hours after the procedure. RESULTS: The sonographic gray scale findings of uterine AVMs were nonspecific. The most common finding was subtle myometrial heterogeneity (n = 14), whereas other patients had small anechoic spaces in the myometrium (n = 7). Color Doppler sonography showed a tangle of vessels with multidirectional high-velocity flow that produced a "color mosaic" pattern. Spectral Doppler analysis showed arteriovenous shunting with high-velocity, low-resistance flow. Fourteen patients required transcatheter arterial embolization to control bleeding. Thirteen of 14 patients had no sonographic evidence of a residual AVM 24 hours after the procedure. One of 14 patients had a residual AVM requiring additional embolization. One patient had recurrent bleeding at 4 months and required further embolization. The remaining 7 patients were treated conservatively. CONCLUSIONS: Endovaginal sonography is the imaging modality of choice in patients with abnormal uterine bleeding. Routine use of color and spectral Doppler sonography allows one to confidently make the correct diagnosis. Transcatheter arterial embolization is an excellent treatment option. Endovaginal sonography should be used to monitor postembolization outcomes.     

血管内Onyx栓塞脑动静脉畸形的护理

目的 探讨Onyx介入治疗的护理方法.方法 回顾14例行Onyx介入治疗脑动静脉畸形患者的护理方法.结果 术后无远期并发症,3～6 d出院.结论 以控制性低血压为核心的整体护理是保证栓塞效果的重要环节.     

Tentorial dural arteriovenous fistula presenting as myelopathy: Case series and review of literature

Dural arteriovenous fistula (DAVF) is a rare type of cerebral arteriovenous malformation. Common presenting symptoms are related to hemorrhage. However, rarely these patients may present with myelopathy. We present two cases of DAVF presenting as rapidly progressive myelopathy. Two treatment options are available: microsurgical interruption of the fistula and endovascular embolization. These treatment options of DAVFs have improved significantly in the last decade. The optimal treatment of DAVFs remains controversial, and there is an ongoing debate as to whether primary endovascular or primary microsurgical treatment is the optimal management for these lesions. However, despite treatment a high percentage of patients are still left with severe disability. The potential for functional ambulation in patients with DAVF is related to the time of intervention. This emphasizes the important of early diagnosis and early intervention in DAVF. The eventual outcome may depend on several factors, such as the duration of symptoms, the degree of disability before treatment, and the success of the initial procedure to close the fistula. The usage of magnetic resonance imaging and selective angiography has significantly improved the ability to characterize DAVFs, however, these lesions remain inefficiently diagnosed. If intervention is delayed even prolonged time in rehabilitation does not change the grave prognosis. This review outlines the presentation, classication and management of DAVF as well as discussing patient outcomes.     

Targeted embolization reduces hemorrhage complications in partially embolized cerebral AVM combined with gamma knife surgery

This study investigated the effect and safety of targeted embolization in partially embolized cerebral arteriovenous malformation (AVM) followed by gamma knife surgery (GKS). We retrospectively analyzed 86 AVM patients who were targeted embolized by Onyx followed by GKS for residual nidus. Embolization-related complications were collected and the clinical effect was evaluated. During targeted embolization, intranidus or hemodynamic aneurysms and AVM-related fistula were evaluated and targeted embolized. Patients with AVM-related aneurysms and fistula were divided into a targeted embolization group and non-targeted embolization group based on the retrospectively determined treatment strategy. The effect of targeted embolization on hemorrhage risk was evaluated. The overall annual hemorrhage rate was 1.66% with 2.26% for ruptured AVMs and 1.08% for unruptured lesions. The annual mortality rate was 0.4%. Only one in 16 patients with embolization-related complications had permanent neurologic deficit. Twenty-four of 29 cases with intranidus aneurysms were targeted embolized, four of five cases with hemodynamic aneurysms were targeted embolized and eight of nine cases with arteriovenous fistula were targeted embolized. Chi square results showed the hemorrhage complications in the target embolization group were significantly lower than those in the non-target embolization group (p < 0.01). Targeted embolization combined with GKS treatment decreased the annual hemorrhage rate and improved clinical outcome with low permanent complications in partially embolized AVMs. This method could be proposed for the treatment of large brain AVMs when a single-technique treatment is not feasible.