Tissue reactions induced by different embolising agents in cerebral arteriovenous malformations: a histopathological follow-up

doi:10.1080/00313020500455795

Pathology

Volume 38, Issue 1, February 2006, Pages 28-32

https://doi.org/10.1080/00313020500455795 Get rights and content

Summary

Aims

Comparative histopathological analysis was performed in 47 incompletely embolised and resected cerebral arteriovenous malformations (AVMs).

Methods

Thirty-three AVMs were embolised with n-butyl- cyanoacrylate (NBCA), four with iso-butyl-cyanoacrylate (IBCA), seven with polyvinyl alcohol particles (PVA), one with a fibrin mixture, one with silicon pellets, and one with microcatheter balloons. Maximum exposure time (MET) of the embolising agent (interval between embolisation and surgery) ranged from <24 hours to 80 months. All AVMs were investigated regarding angionecrosis, angiofibrosis, acute inflammation, chronic inflammation, foreign-body reactions, vascular calcification, blood admixture to embolis- ing cast, and capillary recanalisation within the AVMs. These parameters were correlated with MET, comparing different embolising agents, age, and sex.

Results

A typical sequence of events depending on MET is observed in all embolised AVMs: acute inflammation with mural angionecrosis is soon replaced by prominent chronic granulomatous vasculitis, which remains stable and is detectable for a very long time, even in AVMs with a MET of more than 6 years.

Conclusion

Capillary recanalisation is always present in incompletely embolised AVMs, detectable after 3 months of MET, irrespective of the embolising agent used. Age and sex does not influence pattern and time course of tissue lesions and recanalisation in incompletely embolised AVMs.

References (22)

BerthelsenB. et al.
Embolization of cerebral arteriovenous malformations with bucrylate: Experiences in a first series of 29 patients
Acta Radiol
(1990)
FournierD. et al.
Endovascular treatment of intracerebral arteriovenous malformations
J Neurosurg
(1991)
HurstR.W. et al.
Deep central arteriovenous malformations of the brain: The role of endovascular treatment
J Neurosurg
(1995)
WikholmG.
Occlusion of cerebral arteriovenous malformations with N-butyl cyano-acrylate is permanent
AJNR Am J Neuroradiol
(1995)
WilmsG. et al.
Embolization of arteriovenous malformations of the brain: preliminary experience
J Belge Radiol
(1993)
LunsfordL.D. et al.
Stereotactic radiosurgery for arteriovenous malformations of the brain
J Neurosurg
(1991)
DerutyR. et al.
Embolisation preoperatoire des malformations arterio-veineuses cerebrales par le butyl-cyanoacrylate
Neurochirurgie
(1985)
SpetzlerR.F. et al.
Surgical management of large AVMs by staged embolization and operative excision
J Neurosurg
(1987)
VinuelaF. et al.
Combined endovascular embolization and surgery in the management of cerebral arteriovenous malformations: experience with 101 cases
J Neurosurg
(1991)
GruberA. et al.
Repermeations of partially embolized cerebral arteriovenous malformations: A clinical, radiologic, and histologic study
AJNR Am J Neuroradiol
(1996)

SamsonD. et al.

Carcinogenic potential of isobutyl-2- cyanoacrylate

J Neurosurg

(1986)

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View full text

Tissue reactions induced by different embolising agents in cerebral arteriovenous malformations: a histopathological follow-up

Summary

Aims

Methods

Results

Conclusion

Embolization of cerebral arteriovenous malformations with bucrylate: Experiences in a first series of 29 patients

Acta Radiol

Endovascular treatment of intracerebral arteriovenous malformations

J Neurosurg

Deep central arteriovenous malformations of the brain: The role of endovascular treatment

J Neurosurg

Occlusion of cerebral arteriovenous malformations with N-butyl cyano-acrylate is permanent

AJNR Am J Neuroradiol

Embolization of arteriovenous malformations of the brain: preliminary experience

J Belge Radiol

Stereotactic radiosurgery for arteriovenous malformations of the brain

J Neurosurg

Embolisation preoperatoire des malformations arterio-veineuses cerebrales par le butyl-cyanoacrylate

Neurochirurgie

Surgical management of large AVMs by staged embolization and operative excision

J Neurosurg

Combined endovascular embolization and surgery in the management of cerebral arteriovenous malformations: experience with 101 cases

J Neurosurg

Repermeations of partially embolized cerebral arteriovenous malformations: A clinical, radiologic, and histologic study

AJNR Am J Neuroradiol

Carcinogenic potential of isobutyl-2- cyanoacrylate

J Neurosurg