Chapter 68 - Endovascular treatment of arteriovenous malformations
Introduction
McCormick's classic histopathologic classification of cerebral vascular malformations defined arteriovenous malformations (AVM) as a tangle of blood vessels permitting the shunting of blood from the arterial to venous phase without intervening capillaries (McCormick, 1966, McCormick and Nofzinger, 1966, Morris, 2013). AVMs are often intermingled with gliotic brain parenchyma (Decker et al., 2010). The primary treatment is microsurgical resection of the AVM, relegating endovascular approaches to largely diagnostic or as an adjunct. Significant improvements in endovascular technology since the first description of cranial AVM embolization by Luessenhop and Spence (1960) have increased the role of embolization to include: palliative, adjunct to microsurgical resection, adjunct to stereotactic radiosurgery (SRS), or, in some cases, curative.
The majority of AVMs are sporadic and thought to be congenital, though the precise etiology is unknown (Van der Eecken and Adams, 1953, Alexander, 1988, Mullan et al., 1996, Lasjaunias, 2001, Novakovic et al., 2013, Robert et al., 2014). Posttraumatic and other de novo AVMs have been reported, challenging the classic school of thought (Gonzalez et al., 2005, Mahajan et al., 2009, Miller et al., 2014). Rarely, AVMs may be associated with genetic disorders such as Osler–Weber–Rendu and Wyburn–Mayson syndrome (Thomas-Sohl et al., 2004, Leblanc et al., 2009, McDonald et al., 2011).
Epidemiologic estimates are difficult given the rarity of cerebral AVMs; the occurrence rate for symptomatic disease is estimated at 0.94 per 100 000 person-years with a prevalence of less than 10.3 per 100 000 (Berman et al., 2000). Hemorrhage is the most common clinical presentation of AVMs, followed by seizure (Fults and Kelly, 1984, Jane et al., 1985, Itoyama et al., 1989, Turjman et al., 1995, Mohr et al., 2014). The hemorrhage rate of AVMs is reported to be between 1% and 4% (Ondra et al., 1990, Halim et al., 2004, Stapf et al., 2006). Prospective data from a randomized trial of unruptured brain AVMs (ARUBA) report a rate of 2.2% per year (Mohr et al., 2014). After rupture, the hemorrhage risk increases to 6–18% for the first year, then 2–4% per year thereafter (Graf et al., 1983, Nishioka et al., 1984, Jane et al., 1985, Mast et al., 1999). Ruptured AVMs have around 10% mortality rate and 20–30% morbidity rate, less than aneurysmal rupture (Graf et al., 1983, Itoyama et al., 1989). Infratentorial AVMs deserve special mention, as the mortality rate after hemorrhage approaches 50% and patients have a poorer acute and long-term prognosis than supratentorial AVMs (Graf et al., 1983, Wilkins, 1985, Ondra et al., 1990, Abla et al., 2014).
Section snippets
Anatomy and classification
Cerebral AVMs have three components: arterial feeder(s), nidus, and venous drainage (Fig. 68.1). They cause neurologic injury through two mechanisms: hemorrhage (from flow-related aneurysms, weakened arterial walls, the nidus, or the venous drainage) and vascular steal from the high-flow state, leading to ischemia or seizure. Aneurysms are associated with cerebral AVMs, have a 7% rate of hemorrhage, and should be obliterated when possible whether the goal is palliative, curative, or in
Microsurgical resection
Microsurgical resection is the historic gold standard for AVM treatment but requires careful planning and patient selection, and not all patients are candidates. Spetzler–Martin grades I and II (class A) are ideal for microsurgical resection and many grade III (class B) AVMs can be considered as well. Operator experience and center volume should be taken into account, as not all surgical series results are generalizable and patients should be referred to a more experienced operator if
Endovascular treatment
Endovascular treatment of AVMs is most often performed with liquid embolic material such as Onyx or N-butyl cyanoacrylate (NBCA) to occlude the nidus while avoiding migration or extravasation into the draining veins (Fig. 68.2). Total endovascular treatment is achieved in approximately 20% of cases; reports range from 10% to 58% (Roberts et al., 1998, Yu et al., 2004, Song et al., 2005, Katsaridis et al., 2008, Levy et al., 2015). Embolization complication rates range from 9% to 30% and the
Stereotactic radiosurgery
SRS for the treatment of cerebral AVMs began as early as 1972, with much improvement since (Steiner et al., 1972). Modalities commonly employed in SRS include Gamma Knife, proton bean radiosurgery, and linear particle accelerators. SRS can be used as a primary modality or an adjunct to embolization or microsurgical resection. AVM obliteration rates after single treatment SRS vary from 70% to 90% after 3 years (Lunsford et al., 1991, Friedman and Bova, 1992, Flickinger et al., 1996, Kano et al.,
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Cited by (10)
Interest of awake surgery for ruptured cerebral arteriovenous malformations close to speech areas – Surgical note
2022, NeurochirurgieCitation Excerpt :In many cases, the diagnosis of AVMs is made incidentally (12.2%) [4]. Ruptured AVMs are managed using one or more of the following interventional modalities: endovascular embolization, stereotactic radiation therapy, and microsurgery with the following respective complete occlusion rates: 18 to 49% [5], 70 to 93% [6] and 96% [7]. Awake surgery with cortical mapping is a well-established treatment of low-grade gliomas located close or in eloquent areas [8].
Endovascular Management of a Ruptured Basilar Perforator Artery Aneurysm Associated with a Pontine Arteriovenous Malformation: Case Report and Review of the Literature
2018, World NeurosurgeryCitation Excerpt :Embolization of this AVM would be particularly challenging due to the risks of reflux into the basilar artery and stroke resulting from obliteration of the basilar perforators. Although radiosurgery inherently carries a risk of transient or permanent neurologic deficit secondary to edema and radiation necrosis,14 the small of size of the AVM and its superficial location on the ventral pons in this case make it a particularly suitable target15 (Figure 3). Basilar perforator aneurysms represent a management challenge due to the critical territory supplied by the parent arteries and the need for complex skull base approaches for microsurgical access.16
Usefulness and Stability of Intraoperative Digital Subtraction Angiography Using the Transradial Route in Arteriovenous Malformation Surgery
2018, World NeurosurgeryCitation Excerpt :Although endovascular embolization and stereotactic radiosurgery are now frequently used to treat cerebral arteriovenous malformations (AVMs),1,2 microsurgery is still the mainstay of AVM treatment.3
Clinical Experience with Intraoperative Ultrasonographic Image in Microsurgical Resection of Cerebral Arteriovenous Malformations
2017, World NeurosurgeryCitation Excerpt :All AVMs were radically removed without new permanent morbidity. Although endovascular embolization and stereotactic radiosurgery were used to treat AVMs,14,15 microsurgery remains the mainstay of AVM treatment.16 AVM surgery, which is often more complex than expected, has benefited from neuroimaging guidance and intraoperative monitoring techniques.
Untangling the Modern Treatment Paradigm for Unruptured Brain Arteriovenous Malformations
2022, Journal of Personalized MedicineThe Effect of Flow-Related Aneurysms on Hemorrhagic Risk of Intracranial Arteriovenous Malformations
2019, Clinical Neurosurgery