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Endovascular treatment in the multimodality management of brain arteriovenous malformations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee
  1. Reade De Leacy1,
  2. Sameer A Ansari2,
  3. Clemens M Schirmer3,
  4. Daniel L Cooke4,
  5. Charles J Prestigiacomo5,
  6. Ketan R Bulsara6,
  7. Steven W Hetts4
  8. SNIS Standards and Guidelines Committee, SNIS Board of Directors
    1. 1 Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
    2. 2 Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
    3. 3 Neurosurgery, Geisinger Health System, Wilkes-Barre, Pennsylvania, USA
    4. 4 Radiology and Biomedical Imaging, University California San Francisco, San Francisco, California, USA
    5. 5 Neurological Surgery, University of Cincinnati, Cincinnati, Ohio, USA
    6. 6 Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
    1. Correspondence to Dr Steven W Hetts, Radiology, UCSF, San Francisco, California, USA; steven.hetts{at}


    Background The purpose of this review is to summarize the data available for the role of angiography and embolization in the comprehensive multidisciplinary management of brain arteriovenous malformations (AVMs

    Methods We performed a structured literature review for studies examining the indications, efficacy, and outcomes for patients undergoing endovascular therapy in the context of brain AVM management. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee and the SNIS Board of Directors.

    Results The multidisciplinary evaluation and treatment of brain AVMs continues to evolve. Recommendations include: (1) Digital subtraction catheter cerebral angiography (DSA)—including 2D, 3D, and reformatted cross-sectional views when appropriate—is recommended in the pre-treatment assessment of cerebral AVMs. (I, B-NR) . (2) It is recommended that endovascular embolization of cerebral arteriovenous malformations be performed in the context of a complete multidisciplinary treatment plan aiming for obliteration of the AVM and cure. (I, B-NR) . (3) Embolization of brain AVMs before surgical resection can be useful to reduce intraoperative blood loss, morbidity, and surgical complexity. (IIa, B-NR) . (4) The role of primary curative embolization of cerebral arteriovenous malformations is uncertain, particularly as compared with microsurgery and radiosurgery with or without adjunctive embolization. Further research is needed, particularly with regard to risk for AVM recurrence. (III equivocal, C-LD) . (5) Targeted embolization of high-risk features of ruptured brain AVMs may be considered to reduce the risk for recurrent hemorrhage. (IIb, C-LD) . (6) Palliative embolization may be useful to treat symptomatic AVMs in which curative therapy is otherwise not possible. (IIb, B-NR) . (7) The role of AVM embolization as an adjunct to radiosurgery is not well-established. Further research is needed. (III equivocal, C-LD) . (8) Imaging follow-up after apparent cure of brain AVMs is recommended to assess for recurrence. Although non-invasive imaging may be used for longitudinal follow-up, DSA remains the gold standard for residual or recurrent AVM detection in patients with concerning imaging and/or clinical findings. (I, C-LD) . (9) Improved national and international reporting of patients of all ages with brain AVMs, their treatments, side effects from treatment, and their long-term outcomes would enhance the ability to perform clinical trials and improve the rigor of research into this rare condition. (I, C-EO) .

    Conclusions Although the quality of evidence is lower than for more common conditions subjected to multiple randomized controlled trials, endovascular therapy has an important role in the management of brain AVMs. Prospective studies are needed to strengthen the data supporting these recommendations.

    • Angiography
    • Brain
    • Malformation
    • Standards
    • Embolic

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    • Collaborators SNIS Standards and Guidelines Committee: Steven Hetts, Justin Fraser, Seon-Kyu Lee, Sameer Ansari, Robert Starke, Charles Prestigiacomo, Reade De Leacy, Clemens Schirmer, Neil Haranhalli, Ketan Bulsara, Stavropoula Tjoumakaris, Fawaz Al-Mufti. SNIS Board of Directors: Michael Chen, J Mocco, Mahesh Jayaraman, Guilherme Dabus, Michael Froehler, Peter Kan, Reade De Leacy, Stavropoula Tjoumakaris, Sandra Narayanan, William Mack, Richard Klucznik, Justin Fraser, Jenny Tsai, Johanna Fifi, Felipe Albuquerque, Blaise Baxter, Sameer Ansari, Steven Hetts.

    • Contributors All named authors had substantial contribution to the conception, design, or analysis of the work presented. All named authors took part in drafting or revising the manuscript critically for intellectual content. All named authors reviewed the final version of the manuscript submitted for publication. All named authors agree to be accountable for the work. Planning: RDL, SAA, CMS, DLC, CJP, KRB, SWH. Reporting: RDL, SAA, CMS, DLC, CJP, KRB, SWH. Conception and design: RDL, SAA, CMS, DLC, CJP, KRB, SWH. Data analysis: RDL, SAA, CMS, DLC, CJP, KRB, SWH. Literature interpretation: RDL, SAA, CMS, DLC, CJP, KRB, SWH. Consensus Recommendation Conference: RDL, SAA, CMS, DLC, CJP, KRB, SWH.

    • 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 SWH research is supported by NIH (R01CA194533, R42CA265316, R01EB012031). SWH has consulting agreements with Medtronic, Kaneka, Imperative, and Cerenovus. SWH’s institution has contract and grant support from Siemens, Stryker Neurovascular, and Route 92. SAA research is supported by NIH (R01NS114632, R01HL149787, R01HL115267). SAA has consulting agreements with Medtronic, Boston Scientific, Microvention, Rapid Medical, and Imperative Care. RDL has research grant support from Kaneka. RDL has consulting contracts with Cerenovus, Asahi Intec, Imperative Care, Spartan Micro and Stryker. RDL has equity interest in Synchron, Spartan Micro, Endostream, Vastrax and Q’Apel. CMS has research support from Penumbra and ownership interest in NTI.

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