Microsurgical treatment for cerebellomesencephalic fissure arteriovenous malformations after multiple sessions of endovascular treatment
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ABSTRACT: Background:
Arteriovenous malformations (AVMs) are relatively uncommon congenital vascular anomalies, and only 7–15% of AVMs occur in the posterior fossa. Most posterior fossa AVMs clinically present with hemorrhage and are associated with a high risk of neurological deficits and mortality. These malformations are associated with a high incidence of flow-related aneurysms. Endovascular treatment of infratentorial AVMs is challenging in pediatric patients. Case Description:
We describe an 11-year-old female adolescent with cerebellar syndrome [Video 1], who was diagnosed with a cerebellomesencephalic fissure AVM. We observed a sequential increase in the size of the AVM after multiple sessions of endovascular treatment and performed successful microsurgical resection of the lesion. Conclusion:
This illustrative video highlights the role of microsurgery as a feasible therapeutic strategy for complete resection of cerebellar AVMs after endovascular embolization.
SUBMITTER: Lessa S
PROVIDER: S-EPMC8168656 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundCerebral arteriovenous malformations (AVMs) can be a heterogeneous pathological entity whose management requires a complex decision-making process due to the risks associated with their treatment and natural history. Despite the recently published conclusions of the aborted Randomized Trial of Brain Unruptured AVMs (ARUBA) trial, the authors of this article believe multimodality intervention in general and microsurgical resection in particular continue to play a major role in the management of carefully selected ruptured or unruptured AVMs.MethodsThe authors provide an overview of their methodology for endovascular intervention and microsurgical resection and share their technical nuances for successful embolization and microsurgical resection of AVMs with special emphasis on complication avoidance.ResultsThe authors have achieved successful outcomes in embolization and resection of cerebral AVMs when using their methodology.ConclusionsThese lesions are among the most technically difficult pathological entities handled by the cerebrovascular specialist, and an overview of technical concepts to help systematize this challenging and variable endeavor can improve the safety of their treatment.
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| S-EPMC9372674 | biostudies-literature
Project description:Background and purposeSurgical resection is usually considered as the first-line curative strategy for low-grade (Spetzler-Martin grade I-II) brain arteriovenous malformations because it has a high cure rate and low complications. The role of endovascular treatment remains to be clarified in this indication, especially after A Randomized Trial of Unruptured Brain Arteriovenous Malformations. Our objective was to assess the safety and efficacy of first-line endovascular treatment in low-grade brain arteriovenous malformation management at our institution.Materials and methodsPatients with low-grade brain arteriovenous malformations treated primarily with embolization in our department between January 2005 and December 2015 were retrieved from our prospectively collected registry. The primary outcome was the brain arteriovenous malformation obliteration rate, and secondary outcomes were disability or death secondary to brain arteriovenous malformation embolization assessed through modification of the modified Rankin Scale.ResultsTwo hundred twenty-four patients completed endovascular treatment during the study period and represent our study population. Complete exclusion of brain arteriovenous malformations was achieved in 205 patients (92%), including 62.1% of brain arteriovenous malformation exclusions after a single endovascular treatment session. One patient died of a hemorrhagic complication after endovascular treatment, leading to a mortality rate of 0.4%. Twelve patients (5%) kept a permanent neurologic deficit secondary to a complication of the endovascular treatment. An overall good outcome (mRS 0-2) was reported in 179 patients (80%).ConclusionsEndovascular treatment might be a suitable alternative to surgical resection for complete exclusion of selected low-grade brain arteriovenous malformations.
| S-EPMC7048507 | biostudies-literature
Project description:Purpose:To assess the immediate efficacy of distinct embolisation devices in the endovascular treatment of pulmonary arteriovenous malformations as well as to identify and analyse the possible determinants of the technical success of the procedure. Material and methods:Prospective analysis of 16 consecutive patients was carried out, who underwent transcatheter endovascular embolisation therapy for pulmonary arteriovenous malformations between 2005 and 2017. Pre- and post-procedural angiography studies were implemented to confirm the diagnosis and to evaluate the technical success defined as the complete occlusion of the feeding artery. Embolisation devices - coils, microcoils, occluders, or combination of the above - were used. All the patients were advised to conduct a follow-up computed tomography evaluation 12 months after the procedure. Results:A total of 40 pulmonary arteriovenous malformations (PAVMs) were observed and embolised. The immediate technical success was achieved in all (n = 40; 100%) treated PAVMs, as confirmed by the post-procedural angiographic result. The statistical analysis revealed no significant impact of the number of PAVMs per patient (p > 0.05), their angioarchitecture (p > 0.05), localisation within the lung (p > 0.05) or particular lobe (p > 0.05), and the selection of embolisation device (p > 0.05) on the procedural success rates. The procedure-related complication rate was equal to 6.25%. Conclusions:The immediate success rate of the transcatheter PAVM embolisation reached 100% in this study. The statistical model of logistic regression revealed no significant impact of the number of PAVMs per patient, their angioarchitecture, localisation, and distribution pattern, as well as device selection, on the immediate technical success of the procedure.
| S-EPMC6323602 | biostudies-other
Project description:IntroductionAlthough microsurgical resection is currently the first-line treatment modality for arteriovenous malformations (AVMs), microsurgery of these lesions is complicated due to the fact that they are very heterogeneous vascular anomalies. The Spetzler-Martin grading system and the supplementary grading system have demonstrated excellent performances in predicting the risk of AVM surgery. However, there are currently no predictive models based on multimodal MRI techniques. The purpose of this study is to propose a predictive model based on multimodal MRI techniques to assess the microsurgical risk of intracranial AVMs.Methods and analysisThe study consists of 2 parts: the first part is to conduct a single-centre retrospective analysis of 201 eligible patients to create a predictive model of AVM surgery based on multimodal functional MRIs (fMRIs); the second part is to validate the efficacy of the predictive model in a prospective multicentre cohort study of 400 eligible patients. Patient characteristics, AVM features and multimodal fMRI data will be collected. The functional status at pretreatment and 6 months after surgery will be analysed using the modified Rankin Scale (mRS) score. The patients in each part of this study will be dichotomised into 2 groups: those with improved or unchanged functional status (a decreased or unchanged mRS 6 months after surgery) and those with worsened functional status (an increased mRS). The first part will determine the risk factors of worsened functional status after surgery and create a predictive model. The second part will validate the predictive model and then a new AVM grading system will be proposed.Ethics and disseminationThe study protocol and informed consent form have been reviewed and approved by the Institutional Review Board of Beijing Tiantan Hospital Affiliated to Capital Medical University (KY2016-031-01). The results of this study will be disseminated through printed media.Trial registration numberNCT02868008.
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Project description:Background and purposePalpebral AVMs (pAVMs) are rare vascular lesions for which the treatment is challenging. Our aim was to present the technical aspects of the presurgical treatment by interventional neuroradiology of pAVMs and to report the clinical and angiographic results of combined (interventional neuroradiology/surgery) treatment of these malformations.Materials and methodsNine patients (5 females, 4 males) with a mean age of 22 years (range, 12-35 years) were treated in our department from December 1992 to April 2007 for superficial pAVMs. Seven patients presented with isolated pAVMs, while 2 had hemifacial AVMs. Ten TAE procedures, by using a liquid embolic agent (glue or Onyx) or microparticles, were performed in 7 patients. Six patients underwent absolute alcohol, glue, or sclerotic agent injection by direct puncture in 8 procedures. Clinical and angiographic follow-up were performed with a mean delay of, respectively, 6.3 and 5 years.ResultsThree patients had a single EVT. Iterative procedures were performed in 5 patients. In 1 patient, EVT was not performed because of the risk of occlusion of the central retinal artery. No complication occurred except 1 case of transient palpebral hematoma. No visual acuity loss related to an endovascular procedure was reported. Exclusion of the AVMs at the end of the procedure was >75% in all cases and total in 3/8 cases. All the patients except 2 underwent at least 1 surgical procedure after the embolization. Good clinical regression of the mass was obtained in all patients at long-term follow-up.ConclusionsCombined endovascular and surgical treatment of pAVMs is an effective and safe technique with good clinical results at long-term follow-up.
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Project description:Extracranial arteriovenous malformations (AVMs) are regarded as rare diseases and are prone to complications such as pain, bleeding, relentless growth, and high volume of shunted blood. Due to the high vascular pressure endothelial cells of AVMs are exposed to mechanical stress. To control symptoms and lesion growth pharmacological treatment strategies are urgently needed in addition to surgery and interventional radiology. AVM cells were isolated from three patients and exposed to cyclic mechanical stretching for 24 h. Thalidomide and bevacizumab, both VEGF inhibitors, were tested for their ability to prevent the formation of circular networks and proliferation of CD31+ endothelial AVM cells. Furthermore, the effect of thalidomide and bevacizumab on stretched endothelial AVM cells was evaluated. In response to mechanical stress, VEGF gene and protein expression increased in patient AVM endothelial cells. Thalidomide and bevacizumab reduced endothelial AVM cell proliferation. Bevacizumab inhibited circular network formation of endothelial AVM cells and lowered VEGF gene and protein expression, even though the cells were exposed to mechanical stress. With promising in vitro results, bevacizumab was used to treat three patients with unresectable AVMs or to prevent regrowth after incomplete resection. Bevacizumab controlled bleeding, pulsation, and pain over the follow up of eight months with no patient-reported side effects. Overall, mechanical stress increases VEGF expression in the microenvironment of AVM cells. The monoclonal VEGF antibody bevacizumab alleviates this effect, prevents circular network formation and proliferation of AVM endothelial cells in vitro. The clinical application of bevacizumab in AVM treatment demonstrates effective symptom control with no side effects.
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Project description:A 40-year-old man presented with years of progressive leg swelling and venous varicosities. Lower limb computed tomography angiography and subsequent digital subtraction angiography demonstrated a large popliteal arteriovenous fistula (AVF). This was treated successfully by endovascular technique with a Viabahn stent (W. L. Gore & Associates, Flagstaff, Ariz) in the popliteal artery to exclude the AVF. AVFs of this size and chronicity are rare, and this case demonstrates a successful endovascular method of treatment.
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Project description:Arteriovenous malformations (AVMs) are rare congenital vascular anomalies where rupture can be fatal. This report describes a case of a 69-year-old woman who presented with sudden severe lower back pain radiating to her left buttock and thigh and an inability to move her left leg. Computed tomography angiography (CTA) showed an extensive ruptured retroperitoneal AVM on the left paravertebral side with active bleeding and a large hematoma. Cardiopulmonary resuscitation with considerable blood transfusion was required. The AVM was effectively treated with coil embolization of the feeding lumbar arteries. Shortly after the intervention, the patient developed abdominal compartment syndrome. Urgent laparotomy with evacuation of the retroperitoneal hematoma was required. The patient was discharged 16 days after admission in a good physical condition and has been free of symptoms for more than a year after intervention. However, follow-up CTA showed residual contrast enhancement in the AVM and further surveillance is required.
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Project description:Abnormalities in arterial versus venous endothelial cell identity and dysregulation of angiogenesis are deemed important in the pathophysiology of brain arteriovenous malformations (AVMs). The Sonic hedgehog (Shh) pathway is crucial for both angiogenesis and arterial versus venous differentiation of endothelial cells, through its dual role on the vascular endothelial growth factor/Notch signaling and the nuclear orphan receptor COUP-TFII. In this study, we show that Shh, Gli1 (the main transcription factor of the Shh pathway), and COUP-TFII (a target of the non-canonical Shh pathway) are aberrantly expressed in human brain AVMs. We also show that implantation of pellets containing Shh in the cornea of Efnb2/LacZ mice induces growth of distinct arteries and veins, interconnected by complex sets of arteriovenous shunts, without an interposed capillary bed, as seen in AVMs. We also demonstrate that injection in the rat brain of a plasmid containing the human Shh gene induces the growth of tangles of tortuous and dilated vessels, in part positive and in part negative for the arterial marker αSMA, with direct connections between αSMA-positive and -negative vessels. In summary, we show that the Shh pathway is active in human brain AVMs and that Shh-induced angiogenesis has characteristics reminiscent of those seen in AVMs in humans.
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