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Comparison of embolization strategies for mixed plexiform and fistulous brain arteriovenous malformations: a computational model analysis of theoretical risks of nidus rupture
  1. Mika S Jain1,
  2. Nicholas A Telischak2,
  3. Jeremy J Heit2,
  4. Huy M Do2,
  5. Tarik F Massoud3
  1. 1Departments of Physics and Computer Science, Stanford University School of Humanities and Sciences, Stanford, California, USA
  2. 2Division of Neuroimaging and Neurointervention, Department of Radiology, and Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
  3. 3Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
  1. Correspondence to Dr Tarik F Massoud, Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford University School of Medicine, Stanford, CA 94304, USA; tmassoud{at}


Background High-flow fistulas related to plexiform nidi are found in 40% of large brain arteriovenous malformations (AVMs). Endovascular occlusion of intranidal fistulas before plexiform components is empirically considered safe, but potential ensuing dangerous re-routing of flow through plexiform vessels may in theory raise their rupture risk. It remains unclear whether it is safer to embolize plexiform or fistulous vessels initially. We used a novel biomathematical AVM model to compare theoretical hemodynamic changes and rupture risks on sequential embolizations of both types of nidus vessels.

Methods We computationally modeled a theoretical AVM as an electrical circuit containing a nidus consisting of a massive stochastic network ensemble comprising 1000 vessels. We sampled and individually simulated 10 000 different nidus morphologies with a fistula angioarchitecturally isolated from its adjacent plexiform nidus. We used network analysis to calculate mean intravascular pressure (Pmean) and flow rate within each nidus vessel; and Monte Carlo analysis to assess overall risks of nidus rupture when simulating sequential occlusions of vessel types in all 10 000 nidi.

Results We consistently observed lower nidus rupture risks with initial fistula occlusion in different network morphologies. Intranidal fistula occlusion simultaneously reduced Pmean and flow rate within draining veins.

Conclusions Initial occlusion of AVM fistulas theoretically reduces downstream draining vessel hypertension and lowers the risk of rupture of an adjoining plexiform nidus component. This mitigates the theoretical concern that fistula occlusion may cause dangerous redistribution of hemodynamic forces into plexiform nidus vessels, and supports a clinical strategy favoring AVM fistula occlusion before plexiform nidus embolization.

  • arteriovenous malformation
  • blood flow
  • blood pressure
  • liquid embolic material
  • hemorrhage

Data availability statement

Data are available upon reasonable request. Not applicable.

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Data availability statement

Data are available upon reasonable request. Not applicable.

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  • Contributors Guarantor of the integrity of entire study, TFM; Study concepts/study design or data acquisition or data analysis/interpretation, all authors; Literature research, MSJ, TFM; Experimental studies, MSJ, TFM; Manuscript drafting or manuscript revision for important intellectual content, all authors; Manuscript final version approval and accountability of accuracy and integrity, all authors; Manuscript editing, 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 None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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