Complication risk of endovascular embolization for cerebral arteriovenous malformation

doi:10.1016/j.ejrad.2010.09.024

European Journal of Radiology

Volume 80, Issue 3, December 2011, Pages 776-779

https://doi.org/10.1016/j.ejrad.2010.09.024 Get rights and content

Abstract

Objective

The embolic agents currently used for the treatment of AVMs are n-butyl cyanoacrylate (NBCA) and ethylene-vinyl alcohol copolymer (ONYX). The purpose of this study was to examine the overall NBCA and ONYX embolization-related complication rate.

Methods

We retrospectively reviewed 147 consecutive patients with cerebral AVMs treated mainly with endovascular NBCA and ONYX embolization. Demographics, including age, sex, presenting symptoms, and angiographic factors including AVM size, deep venous drainage, and involvement of eloquent cortex were recorded. Number of pedicles embolized, the obliteration rate, and any complications were recorded. Complications were classified as the following: bleeding and ischemic complications. The ischemic complications were also classified as transient neurologic deficit, and permanent deficits. Modified Rankin Scale (mRS) scores were collected pre- and postembolization on all patients. Univariate regression analysis of determinants of complications was performed.

Results

We reviewed 147 patients with BAVM (58.5% male; mean age ± SD at treatment: 27.5 ± 11.1years) treated with endovascular embolization. Two hundred twenty embolization, 144 NBCA and 76 ONYX embolizations were performed. Complete obliteration of BAVMs were achieved in 29 patients (19.7%). Additional gamma-knife radiosurgery were performed for 32 (21.8%) patients. There were 5 Spetzler–Martin grade I (3.4%), 20 grade II (13.6%), 54 grade III (36.7%), 44 grade IV (30%), and 24 grade V (16.3%) AVMs. There were a total of 7 (4.8% per patient, 3.2% per procedure) complications. There were bleeding complications in 2 patients (1.4% per patient, 0.9% per procedure), transient neurologic deficits in 4 (2.7% per patient, 1.8% per procedure) and 1 permanent deficit (0.7% per patient, 0.5% per procedure). Of the 147 patients, 141 (95.9%) were mRS 0–2, 6 (4.1%) were mRS = 3 at discharge. Univariate analysis of risk factors for embolic agent showed that ONYX was not significantly associated with complications (X² = 0.3, P > 0.5).

Conclusions

Embolization of brain AVMs is safe, 95.9% of patients had excellent or good outcomes at discharge after AVM embolization using liquid embolic agents, with a complication rate of 4.8%. ONYX embolization was not associated a higher rate of complications comparing with NBCA embolization.

Section snippets

Patients and methods

Between January, 2001, and September, 2006, consecutive 147 patients mainly treated with endovascular NBCA and ONYX embolization were retrospectively reviewed. Patients with vein of Galen malformations and dural arteriovenous fistulas were excluded. We retrospectively reviewed each patient's medical records, operative reports, endovascular reports, radiographic images, and data from a detailed brain AVM database. We studied the following factors: demographics including age, sex, date of

Management of AVM

Endovascular embolization procedures were performed intra-arterially via a transfemoral route with the patients under general endotracheal anesthesia. Standard transfemoral angiographic technique was used to obtain global angiographic images of the internal carotid arteries and vertebral arteries as appropriate. Systemic heparinization was initiated before microcatheter navigation, to achieve an activated clotting time (ACT) 2–3 times the normal clotting time. Superselective catheterization was

Statistical analysis

We analyzed patient age, sex, history of rupture, history of seizure, associated aneurysms, periprocedural hemorrhage, AVM size, deep venous drainage, deep location (basal ganglia/infratentorial), the eloquence of the adjacent brain, Spetzler–Martin grade, number of stages, and primary treatment modality to determine whether these factors were predictive of complications and unfavorable outcomes after embolization. Univariate tests (X² test) and a multivariate logistic regression model were

Results

In our series, 147 patients underwent 220 embolization sessions, with a total of 396 pedicles embolized. There were 86 male (58.5%) and 61 female (41.5%) patients, with a mean age of 27.5 ± 11.1 years. Presenting symptoms were hemorrhage in 69 (46.9%), seizure in 43 (29.3%), headache in 21 (14.3%), focal neurologic deficit in 11 (7.5%), and no symptom in 3 (2.0%). There were 5 (3.4%) grade I, 20 (13.6%) grade II, 54 (36.7%) grade III, 44 (30%) grade IV, and 24 (16.3%) grade V patients, separated

Discussion

In this series, there were 7 permanent complications (4.8%) with 0.7% permanent complications and 2.7% transient complications. Five of these were ischemic (3.4% of patients, 2.3% of procedures) and 2 hemorrhagic (1.4% of patients, 0.9% of procedures). There was no mortality in this study. The rate of permanent disabling complications or death in this series is somewhat less than those of many of the more recent series. The reasons for this can be multifactorial and can include patient

Conclusions

NBCA and ONYX AVM embolization is a safer and more efficacious for AVM embolization. The permanent neurological deficits rate was low. In a multivariate analysis, and ONYX embolization with a higher volume reduction was not a predictive factor for complications after AVM embolization.

Conflict of interest

We had declared that there was no conflict of interest.

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Preoperative embolization of cerebral arteriovenous malformations with Onyx
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Neurologic complications of arteriovenous malformation embolization using liquid embolic agents
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Embolization of brain arteriovenous malformations for cure: because we could and because we should
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Complication risk of endovascular embolization for cerebral arteriovenous malformation

Abstract

Objective

Methods

Results

Conclusions

Section snippets

Patients and methods

Management of AVM

Statistical analysis

Results

Discussion

Conclusions

Conflict of interest

Lancet Neurol

Clinical outcome after first and recurrent hemorrhage in patients with untreated brain arteriovenous malformation

Stroke

The natural history and predictive features of hemorrhage from brain arteriovenous malformations

Stroke

The role of neuroendovascular therapy for the treatment of brain arteriovenous malformations

Neurosurgery

Ten-year detection rate of brain arteriovenous malformations in a large, multiethnic, defined population

Stroke

Risk of endovascular treatment of brain arteriovenous malformations

Stroke

Preoperative embolization of cerebral arteriovenous malformations with Onyx

AJNR Am J Neuroradiol

Neurologic complications of arteriovenous malformation embolization using liquid embolic agents

AJNR Am J Neuroradiol

Embolization of brain arteriovenous malformations for cure: because we could and because we should

AJNR Am J Neuroradiol

Long-term excess mortality in 623 patients with brain arteriovenous malformations

Neurosurgery