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Case series
Morbidity and mortality associated with sequential flow reduction embolization technique of cerebral arteriovenous malformations using n-butyl cyanoacrylate
  1. Alfred P See1,
  2. Mahmoud H Mohammaden1,
  3. Mark Rizko1,
  4. Christopher J Stapleton2,
  5. Sepideh Amin-Hanjani1,
  6. Fady T Charbel1,
  7. Victor Aletich1,
  8. Ali Alaraj1
  1. 1 Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60607, USA
  2. 2 Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
  1. Correspondence to Dr Ali Alaraj, Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60607, USA; alaraj{at}


Background Endovascular embolization of cerebral arteriovenous malformations (AVM) with liquid n-butyl cyanoacrylate (n-BCA) serves multiple purposes including AVM occlusion and flow reduction in preparation for other treatment modalities. The objective was to study the clinical, structural, and angiographic factors affecting complications associated with AVM treatment by sequential n-BCA embolizations for nidal occlusion versus quantitative flow reduction in preparation for surgical resection or radiosurgery.

Methods We performed a retrospective review of all patients who underwent endovascular embolization of cerebral AVM at our institution between 1998 and 2019, during which time the technique of traditional embolization evolved to a strategy of targeted sequential flow reduction guided by serial flow imaging based on quantitative magnetic resonance angiography, in conjunction with a shift away from nidal penetration.

Results Among 251 patients, 47.8% of patients presented with ruptured AVM. On average, each patient underwent 2.4 embolizations, for a total of 613 sessions. Major morbidity related to embolization occurred in 18 (7.2%) patients, but this occurred disproportionately in the traditional embolization strategy (n=16, 8%) in contrast with the flow-targeting strategy (n=2, 3.8%). Four patients (1.6%) died in the overall group, and these all occurred with the traditional embolization strategy (2% of 199 patients); no deaths occurred in the flow-targeting strategy (n=52).

Conclusion Embolization with n-BCA targeted to sequential flow reduction and feeder occlusion with limited nidal penetration prior to definitive surgical or radiosurgical treatment can be safely performed with low overall morbidity and mortality.

  • arteriovenous malformation
  • intervention
  • liquid embolic material
  • magnetic resonance angiography
  • technique

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  • Contributors Study design: MHM, SAH, FTC, VAA, AA. Data acquisition: APS, MR, MHM, CJS. Data analysis and interpretation: APS, MHM. Manuscript preparation: APS, MR. Revision of manuscript for important intellectual content: APS, SAH, FTC, AA. Approval of the final version of the manuscript: all authors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests AA is a consultant for Cerenovus, a business of Johnson & Johnson Medical Devices Companies and the current manufacturer of TruFill. VAA was a consultant for Codman Neurosurgery, a prior business of Johnson & Johnson Medical Devices Companies and prior manufacturer of TruFill.

  • Patient consent for publication Not required.

  • Ethics approval The University of Illinois at Chicago (UIC) Office for the Protection of Research Subjects (OPRS) approved this research, described in protocol #2016–0659.

  • Provenance and peer review Not commissioned; externally peer reviewed.