Multimodality treatment of brain arteriovenous malformations with microsurgery after embolization with Onyx: Single-center experience and technical nuances

Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
Neurosurgery (Impact Factor: 3.62). 07/2008; 62(6):1213-25; discussion 1225-6. DOI: 10.1227/01.neu.0000333293.74986.e5
Source: PubMed

ABSTRACT To report our experience with the treatment of brain arteriovenous malformations (AVM) with microsurgical resection after embolization with Onyx liquid embolic agent (eV3, Irvine, CA).
Between August 2005 and December 2006, 28 patients were treated by the same surgical-endovascular team. Twenty-eight AVMs were embolized preoperatively in 55 sessions (71 pedicles) with Onyx. We analyzed the AVM size, volume, number of embolization sessions, degree of preoperative obliteration, time to embolization and resection after the bleed, intraprocedural complications, intraoperative blood loss, other complications, and postoperative outcome at 6 months. Technical nuances of the embolization and surgical resection of the embolized AVMs are illustrated in illustrative cases.
The average size and volume of AVMs treated with Onyx were 3.56 cm (largest, 7.6 cm), and 13.03 ml, respectively. The average Spetzler-Martin grade was 2.75. The average preoperative volumetric obliteration was 74.1%. The average blood loss during resection of embolized AVMs was 348 ml. Complications related to embolization were stuck microcatheter (two patients), proximal vessel perforation (one patient), and anterior choroidal territory stroke (one patient). Surgical complications included wound infection (one patient), residual AVM nidus (one patient), normal pressure perfusion breakthrough with worsening of neurological deficit caused by embolization (one patient), and new-onset motor deficits in five patients. At the time of the 6-month follow-up examination, four patients with new-onset motor deficits had recovered completely or nearly completely, and one patient was disabled. One patient died, never recovering from the initial poor condition due to the bleed. Pathological examination of resected AVMs showed angionecrosis in 42.9%, foreign body giant cells in 39.3%, and evidence of recanalization of Onyx-embolized vessels in 14.3% of specimens.
Multimodality treatment with microsurgery is safe and effective after embolization with Onyx. High occlusion rates and low complication rates were observed after Onyx embolization and were comparable to those in previous reports. Superselective intranidal or perinidal catheter positions and slow, controlled injections that protect the draining veins make the therapy safe even in complex AVMs and critical locations. We recommend resection of the AVM despite apparently complete embolization with Onyx. Team work and coordination between the surgeon and the interventional neuroradiologist are important to achieve a good outcome.

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    • "For instance, it is thought that reducing the AVM in a step-wise fashion with embolization lowers the risks for normal perfusion pressure break-through syndrome, where a diversion of the AVM's blood towards other vessels leads to cerebral edema and hemorrhage [8]. Also, because embolization during multimodal therapy is less aggressive than during stand-alone therapy, the morbidity (4% to 6%) and mortality (0% to 2%) tend to be lower [8,13,14]. There is a lack of studies that compare cure rates and complications of endovascular embolization with surgery versus surgery alone. "
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    ABSTRACT: Background: The development of new technology in neurosurgery, interventional neurovascular techniques, and gamma knife surgery (GKS) has dramatically changed the therapeutic alternatives for brain arteriovenous malformations (AVMs).The purpose of this study is to report the safety and efficacy of transarterial embolization of intracranial arteriovenous malformations treated with N-Butyl Cyanoacrylate (Histoacryl). Patients & Methods: We present a prospective analysis of 42 consecutive patients with brain AVMs treated in Ain Shams University from June 2005 to January 2007, (30 men, 12 women). The patients' average age was 30.5 years. Seizures was the presenting symptom in 24 patients. The average Spetzelar - Martin grade at presentation was grade 3 .The AVMs Nidus volume ranged from 2 cm 3 to 90 cm 3 . Embolization of the AVMs by N-Butyl Cyanoacrylate was done in 42 patients. All patients were treated with the ultimate goal of complete AVMs obliteration. AVMs that are not totally obliterated were embolized to reduce the size and referred to gamma knife treatment. The course of treatment for each patient was reviewed. The effectiveness at the end of treatment was analyzed if not totally occluded, and the ability to reduce the AVMs to radiation size is assessed. Additionally, the safety of each embolization technique was evaluated in terms of the safety of the procedure itself, and the outcome at the end of the treatment. Results: One hundred and four procedures were done in 42 patients. The number of sessions varied from 1 to 6 sessions. The percentage of volume reduction ranged from 100% to 78.2%. Total occlusion (cured by embolization only) was achieved in ten patients (23.8%), reduction to a volume less than 4 cm 3 (suitable for radiosurgery) was achieved in 30 patients (71.4%), while in two patients (4.8%) reduction to a volume between 4-10 cm 3 was achieved. Complications occurred in three patients (7.1%); seizures occurred in two patients; while intracerebral with intraventricular hemorrhage occurred in one patient (2.4%). There was minimal transient morbidity in one patient (2.4%) in the form of temporary decrease in visual acuity. Permanent morbidity related to the procedures observed in one patient (2.4%) in the form hemi-paresis grade 3.There was no mortality in this study. Conclusion: Intracranial arteriovenous malformation embolization with N-Butyl Cyanoacrylate (Histoacryl) is a safe and effective technique that permits complete cure of brain AVMs. However, larger AVMs are reduced in volume to be fit for radiosurgery.
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    Journal of Neurosurgery 03/2009; 111(1):114-8. DOI:10.3171/2009.1.JNS08845 · 3.74 Impact Factor
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