Role of digital subtraction angiography in surgical treatment of intracranial arteriovenous malformations in children / 中国脑血管病杂志

Objective To investigate the safety and effectiveness of digital subtraction angiography (DSA) in the surgical treatment of intracranial arteriovenous malformations (AVMs) in children.Methods Between December 2015 and February 2017,the clinical and imaging data of 9 children with AVM (2-14 years) underwent hybrid surgery at the Department of Neurosurgery,Xuanwu Hospital,Capital Medical University were analyzed retrospectively.According to the Spetzler-Martin grade,there were 2 patients with grade Ⅰ,3 with grade Ⅱ,2 with grade Ⅲ,and 2 with grade Ⅳ.All the children were treated with microsurgery,and their AVMs were removed by real-time assistance using DSA technique during the operation.The imaging cure rate of surgical treatment and the complications of intraoperative angiography of the children were analyzed.The children were followed up clinically after procedure.According to the modified Rankin scale (mRS) score,their prognoses were evaluated.Results Intraoperative angiography revealed that the AVMs in 8 of 9 children were resected completely,and 1 had a residual lesion,then it was resected completely.Immediately after the resection of the nidi,the angiography confirmed that the nidi of 9 children were resected completely.No related complications caused by intraoperative angiography were observed.Nominal aphasia occurred in 1 child after procedure,and he recovered gradually after 6 months.Pulmonary infection occurred in 2 children,and they were cured after anti-infection treatments.Postoperative follow-up mRS scores were 0-1 in 8 children,2 in 1 child,and no rebleeding was observed.Conclusions In children undergoing AVM surgery,initial observation of DSA is safe and effective.Intraoperative angiography can guide the complete resection of the lesions in real time,improve the surgical cure rate of AVMs,and improve the prognosis of children.

Preoperative Embolization of Cerebral Arteriovenous Malformations with Silk Suture and Particles: Technical Considerations and Outcomes

OBJECTIVE: Embolization of cerebral arteriovenous malformations (AVMs) is commonly performed prior to surgical resection in order to reduce intraoperative bleeding and improve the safety of resection. Although most modern embolization procedures utilize permanent embolic agents, silk suture and polyvinyl alcohol (PVA) particles may offer unique advantages for preoperative devascularization. The aims of this retrospective cohort study are to describe the technical considerations and determine the outcomes for preoperative silk suture and PVA particle embolization (SPE) of AVMs. MATERIALS AND METHODS: We performed a retrospective review of our AVM embolization database. AVM patients who underwent preoperative SPE and subsequent surgical resection were included for analysis. Baseline patient demographics, AVM characteristics, embolization and operative records, and post-treatment outcomes were reviewed. RESULTS: A total of 11 patients who underwent 12 preoperative SPE procedures were included for analysis. Five AVMs were ruptured (45%), and the median nidus volume was 3.0 cm3 (range: 1.3-42.9 cm³). The Spetzler-Martin grade was I-II in seven patients (64%) and III-IV in four patients (36%). The degree of nidal obliteration was less than 25% in two procedures (17%), 25-50% in one procedure (8%), 50-75% in eight procedures (67%), and greater than 75% in one procedure (8%). The rates of post-embolization AVM hemorrhage and mortality were 8% and 0%, respectively. The postoperative angiographic obliteration rate was 100%, and the modified Rankin Scale score improved or stable in 91% of patients (median follow-up duration 2 months). CONCLUSION: Preoperative AVM SPE affords a reasonable risk to benefit profile for appropriately selected patients.

Preoperative Embolization of Cerebral Arteriovenous Malformations with Silk Suture and Particles: Technical Considerations and Outcomes

OBJECTIVE: Embolization of cerebral arteriovenous malformations (AVMs) is commonly performed prior to surgical resection in order to reduce intraoperative bleeding and improve the safety of resection. Although most modern embolization procedures utilize permanent embolic agents, silk suture and polyvinyl alcohol (PVA) particles may offer unique advantages for preoperative devascularization. The aims of this retrospective cohort study are to describe the technical considerations and determine the outcomes for preoperative silk suture and PVA particle embolization (SPE) of AVMs. MATERIALS AND METHODS: We performed a retrospective review of our AVM embolization database. AVM patients who underwent preoperative SPE and subsequent surgical resection were included for analysis. Baseline patient demographics, AVM characteristics, embolization and operative records, and post-treatment outcomes were reviewed. RESULTS: A total of 11 patients who underwent 12 preoperative SPE procedures were included for analysis. Five AVMs were ruptured (45%), and the median nidus volume was 3.0 cm3 (range: 1.3-42.9 cm³). The Spetzler-Martin grade was I-II in seven patients (64%) and III-IV in four patients (36%). The degree of nidal obliteration was less than 25% in two procedures (17%), 25-50% in one procedure (8%), 50-75% in eight procedures (67%), and greater than 75% in one procedure (8%). The rates of post-embolization AVM hemorrhage and mortality were 8% and 0%, respectively. The postoperative angiographic obliteration rate was 100%, and the modified Rankin Scale score improved or stable in 91% of patients (median follow-up duration 2 months). CONCLUSION: Preoperative AVM SPE affords a reasonable risk to benefit profile for appropriately selected patients.

Growing Organized Hematomas Following Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformation : Five Cases of Surgical Excision

Organized hematoma is a rare complication that can develop following gamma knife radiosurgery (GKS) for cerebral arteriovenous malformation (AVM). Here, we describe 5 patients with growing organized hematomas that developed from completely obliterated AVMs several years after GKS. The patients were 15, 16, 30, 36, and 38 years old at the time of GKS, respectively, and 3 patients were female. Four AVMs were located in the lobe of the brain, and the remaining AVM were in the thalamus. Between 2-12 years after GKS, patients developed progressive symptoms such intractable headache or hemiparesis and enhancing mass lesions were identified. Follow-up visits revealed the slow expansion of the hematomas and surrounding edema. Steroids were ineffective, and thus surgery was performed. Histology revealed organized hematomas with a capsule, but there was no evidence of residual AVMs or vascular malformation. After surgery, the neurological symptoms of all patients improved and the surrounding edema resolved. However, the hematoma continued to expand and intraventricular hemorrhage developed in 1 patient whose hematoma was only partially removed. GKS for cerebral AVM can be complicated by growing, organized hematomas that develop after complete obliteration. Growing hematomas should be surgically evacuated if they are symptomatic. Radical resection of the hematoma capsule is also strongly recommended.

Pressure cooker technique for curative embolization of intracranial arteriovenous malformation / 中国脑血管病杂志

Objective To preliminarily discuss the technical points and clinical efficacy of the pressure cooker technique (PCT)for embolization of intracranial arteriovenous malformation (AVM). Methods From April 2015 to May 2015,7 patients with AVM were treated at the Department of Neurosurgery, Shanghai Deji Hospital. The AVMs of 2 patients were embolized with PCT. (both were Spetzler-Martin gradeⅡ). A sonic and an echelon microcatheter were implanted side by side into the same blood supply artery of an AVM. A coil + α-isobutyl cyanoacrylate (NBCA)plug was formed between the sonic microcatheter tip and the detachable point through the echelon microcatheter in order to prevent Onyx reflux when the glue was injected into a nidus via a sonic microcatheter,achieving the embolization effect of sustained,rapid and high efficient. Results Two patients achieved complete embolization immediately. The symptoms of the patients improved or disappeared within 1 month. The whole brain DSA showed the AVM of one patient did not have recurrence at 4 month after embolization. Two patients did not have any complications or sequelae at the follow-up study. Conclusion PCT can improve the efficiency of embolization. It is suitable for small, medium,superficial,non-major functional area,less feeding artery AVMs,and AVMs with less blood flow in nidus. Its safety and clinical effect still need to be observed with more samples.

Assessed values of color-coded digital subtraction angiography for intracranial arteriovenous malformation / 中国脑血管病杂志

Objective To investigate the preoperative and intraoperative assessed values of the color-coded digital subtraction angiography (DSA ) for intracranial arteriovenous malformation (AVM). Methods Fifteen patients with AVM performed preoperative routine whole brain DSA were analyzed retrospectively,and the iFlow software was used to perform color-coded DSA of image post-processing. A comprehensive analysis such as the range of lesions,vascular architecture and hemodynamics of AVM was conducted on the two-dimensional DSA images and color-coded DSA. Results Of the 15 patients with AVM,9 were small-sized (including 4 nidi showed diffuse type),3 were medium-sized,and 3 were large-sized;8 patients had single feeding artery,and 7 had multiple feeding arteries;11 had single draining vein,and 4 had multiple draining veins. When showing the size of AVM nidus,particularly diffuse type nidus, the color-coded DSA was clearer than the two-dimensional image. The color-coded DSA could visually display the traveling of the superficial and deep draining veins,at the same time,the primary and secondary draining veins could be identified according to the size of the area under the curve and the full width at half maximum,and intuitively reflected the complete cycle of cerebral blood flow. Conclusion The color-coded DSA can quickly and accurately depict the range of AVM,angioarchitecture features and intraoperative hemodynamic changes.

Clinical and morphological analysis of intracranial arteriovenous malformation in childhood / 介入放射学杂志

Objective To discuss the clinical manifestations and the morphological features of intracranial arteriovenous malformation (AVM) in childhood. Methods During the period from Jan. 2012 to June 2013, a total of 14 AVM patients under the age of 14 years were admitted to authors’ hospital. Of the 14 patients, 11 had a history of spontaneous intracerebral hemorrhage (78.6%), 7 complained of headache (50.5% ), 5 showed signs of unilateral limb weakness (35.7% ), and 2 was accompanied with epileptic attacks (14.3% ). The clinical characteristics, the preoperative imaging features and DSA findings were retrospectively analyzed. Results DSA showed that terminal feeding branches were visualized in 9 cases and blood supply from perforating branches was seen in the remaining 5 cases. In seven cases the feeding artery was single, while in the remaining 7 cases the feeding artery was multiple, and in four of them combination blood supply from both anterior and posterior circulation was found. The lesions were situated at the lateral or convex surface of cerebral hemisphere (n = 5), lateral ventricle (n = 4), cerebral bottom (n = 3) or medial surface of cerebral hemisphere (n = 2). The lesion’s diameter was < 30 mm in 10 cases and (30 -60) mm in 4 cases. According to Spetzler- Martin grading, grade Ⅰ was seen in 4 cases, grade Ⅱ in 2 cases, grade Ⅲ in 5 cases and grade Ⅳ in 3 cases. Conclusion Although in childhood AVM lesion is small in size and lower in grading, its onset is early and the lesion is prone to bleeding. DSA findings indicate that most AVMs in childhood take the form of immature type. Nevertheless, its natural course needs to be further studied.

Early diagnosis and microsurgical treatment of cerebral arteriovenous malformation hemorrhage in childhood / 重庆医学

Objective To investigate the diagnostic method,microsurgical operation time and effect of brain arteriovenous mal-formation(AVM)rupture hemorrhage in childhood.Methods 72 children (≤16 years old)of AVM hemorrhage from 2003 to 2013 were retrospectively analyzed.Results The CT diagnosis rate was 48.6%(35/72),the MRI diagnosis rate was 78.3%(47/60),56 cases were performed the early whole brain DSA under the condition permitting,its diagnosis rate was 98.2%(55/56).All the cases were performed the hematoma clearance plus the pertinent lesion resection.70 cases were re-examined by DSA/CTA/MRA during postoperative perioperation period.The lesion resection rate was 91.5%,the partial resection rate was 8.6%.60 cases(85.7%) were successfully followed up for 6 months to 6 years and assessed by the Glasgow outcome scale,5 points in 5 5 cases,4 points in 2 cases,3 points in 2 cases and 2 points in 1 cases.Conclusion DSA is the main detection measure for early diagnosing AVM hem-orrhage and the microsurgical operation in the acute stage can reduce the fatality and improve the prognosis.

Abordagem anestésica de grávida com malformação arteriovenosa cerebral e hemorragia subaracnoidea durante a gravidez: relato de caso / Anesthetic approach of pregnant woman with cerebral arteriovenous malformation and subarachnoid hemorrhage during pregnancy: case report / Abordaje anestésico de embarazada con malformación arteriovenosa cerebral y hemorragia subaracnoidea durante el embarazo: relato de caso

JUSTIFICATIVA E OBJETIVOS: A ocorrência de hemorragia subaracnoidea (HSA) durante a gravidez é rara, sendo que cerca de metade é devida a malformações arteriovenosas (MAV). Os autores descrevem a abordagem anestésica de uma grávida de 39 semanas proposta para cesárea, com história de HSA por MAV às 22 semanas. RELATO DO CASO: Grávida de 39 semanas, saudável previamente à gravidez, com antecedentes de HSA às 22 semanas de gestação, manifestada por cefaleias, vômitos e tonturas, sem perda de consciência ou outros déficits à admissão no serviço de urgência. A ressonância magnética (RM) revelou MAV frontal esquerda. Após curto internamento para estabilização e diagnóstico, decidiu-se manter a gravidez e o seguimento ambulatorial multidisciplinar por neurocirurgia e obstetrícia em consulta de alto risco. Optou-se por fazer cesárea eletiva às 39 semanas sob anestesia peridural lombar. No intraoperatório ocorreu um episódio de hipotensão rapidamente revertida com fenilefrina. O Índice de Apgar do recém-nascido foi de 10/10. O cateter peridural foi usado para analgesia pós-operatória, também sem intercorrências. CONCLUSÕES: São muito raros os casos publicados de abordagem anestésica de grávidas com MAV sintomáticas. Todas as decisões tomadas pela equipe multidisciplinar, desde optar por continuar a gravidez ao momento ideal para intervir na MAV, passando pelo tipo de anestesia e analgesia, foram ponderadas em função do risco de dano cerebral. Do ponto de vista anestésico, os autores enfatizam a necessidade de estabilidade hemodinâmica.

BACKGROUND AND OBJECTIVES: Subarachnoid hemorrhage (SAH) during pregnancy is a rare event, and about half the cases are due to arteriovenous malformations (AVM). The authors describe the anesthetic approach of a 39 week pregnant patient scheduled for cesarean section, with a history of SAH due to AVM at 22 week gestation. CASE REPORT: 39 week pregnant patient, healthy prior to pregnancy, with a history of SAH at 22 week gestation, manifested by headache, vomiting, and dizziness without loss of consciousness or other deficits on admission to the emergency room. Magnetic resonance imaging (MRI) revealed a left frontal AVM. After a short hospital stay for stabilization and diagnosis, the final medical decision was to maintain the pregnancy and a multidisciplinary follow-up by neurosurgery and high-risk obstetric consultation. An elective cesarean section was performed at 39 weeks under epidural anesthesia. During the intraoperative period, an episode of hypotension rapidly reversed with phenylephrine occurred. The newborn Apgar score was 10/10. An epidural catheter was used for postoperative analgesia, also uneventful. CONCLUSIONS: There are very few published cases of anesthetic approach for pregnant women with symptomatic AVM. All decisions made by the multidisciplinary team, from choosing to continue the pregnancy to the ideal time for AVM intervention and type of anesthesia and analgesia, were weighted according to the risk of brain damage. Regarding the anesthetic procedure, the authors emphasize the need for hemodynamic stability.

JUSTIFICATIVA Y OBJETIVOS: El aparecimiento de la hemorragia subaracnoidea (HSA) durante el embarazo es algo raro, siendo que aproximadamente la mitad se debe a malformaciones arteriovenosas (MAV). Los autores describen el abordaje anestésico de una embarazada de 39 semanas programada para cesárea, con un historial de HSA por MAV a las 22 semanas. RELATO DEL CASO: Embarazada de 39 semanas, sana antes del embarazo, con antecedentes de HSA a las 22 semanas de gestación que se manifestó por medio de cefaleas, vómitos y mareos, sin la pérdida de la consciencia u otros déficits a la hora de su entrada en el servicio de urgencia. La resonancia magnética (RM) arrojó MAV frontal izquierda. Después de un breve período de ingreso para la estabilización y el diagnóstico, se decidió mantener el embarazo y el acompañamiento ambulatorio multidisciplinario por neurocirugía y obstetricia en consulta de alto riesgo. Se optó por realizar la cesárea electiva a las 39 semanas bajo anestesia epidural lumbar. En el intraoperatorio ocurrió un episodio de hipotensión que fue rápidamente revertido con fenilefrina. El Índice de Apgar del recién nacido fue de 10/10. El catéter epidural fue usado para la analgesia postoperatoria, que también cursó sin intercurrencias. CONCLUSIONES: Son muy raros los casos publicados de abordaje anestésico de embarazadas con MAV sintomáticas. Todas las decisiones tomadas por el equipo multidisciplinario, desde optar por continuar con el embarazo, hasta el momento ideal para intervenir la MAV, pasando por el tipo de anestesia y analgesia, fueron sopesadas en función del riesgo de daño cerebral. Desde el punto de vista anestésico, los autores enfatizan la necesidad de estabilidad hemodinámica.

Strategies of microsurgical treatment of intracranial arteriovenous malformation / 中华显微外科杂志

Objective To analyse clinical features of 86 cases of intracranial arteriovenous malformation (AVM) and explore strategies and methods of the microsurgical treatment of intracranial arteriovenous malformations.Methods The clinical data of 86 intracranial arteriovenous malformation from January 2010 to January 2013 were retrospectively reviewed.For diagnosis,computed tomography (CT) with angiography (CTA),and DSA were used,which could provide real size,location,feeding arteries and draining veins of AVM,and apply NEPM to evaluate the nerve function,assess the qualitative and quantitative flow rate of AVM and surrounding blood vessels by Doppler ultrasonography and fluorescein angiography,and reveal opography of AVM.Operative techniques were used including embolization,feeding artery control.Results Eighty-six cases of AVM were resected successfully under mutitechnology.Following-up demonstrated excellent neurological outcomes in 70 cases,nine case had mild disability,five cases had severe disability,two dead cases.DSA shows resected completely,and long-term follow-up was still in progress,conclusion Multi-technology combined microsurgical techniques which can effective improve the outcomes of intracranial arteriovenous malformations.

Analysis of risk factors of cerebral arteriovenous malformation with hemorrhage in 127 cases / 重庆医学

Objective To analyze the relevantly risk factors of cerebral arteriovenous malformation (AVM ) with hemorrhage . Methods The clinical data of 127 patients with cerebral arteriovenous malformation were retrospectively analyzed .71 patients with hemorrhage were divided into the hemorrhage group while 56 patients without hemorrhage were divided into the control group .The clinical data of the two groups were compared and analyzed .Results Univariate analysis indicated that the differences of location and size of the AVM masses ,location of the feeding arteries ,direction of the draining vein ,combining with aneurysms and size of aneurysms were statistically significant (P1) .Conclusion The patients with deep AVM masses ,small-sized AVM masses(<3 cm) ,deep draining veins and combining with aneurysms should be operated as soon as possible to avoid hemorrhage .

The Spetzler-Martin Grading System and Management of Patients with Intracranial Arteriovenous Malformation in a Tertiary Referral Hospital

Introduction:An arteriovenous malformation (AVM) is an abnormal collection of blood vessels in which arterial blood flows directly into the draining vein without the normal interposed capillaries. The Spetzler-Martin grading system has been widely accepted worldwide to estimate the pretreatment risks and predict the outcome of patients with intracranial AVM. In Malaysia, we still do not have the baseline data of this grading system. Methods: A total of 33 patients from a tertiary referral hospital diagnosed with intracranial AVM based on neuroimaging findings over a 4-year period were studied. Medical records were traced and neuroimaging findings were analysed. The AVMs were graded according to the Spetzler-Martin grading system and Fisher's exact test was used to assess statistical difference between the grades of the AVM and management plan for the patients. Results: Four patients were graded as Grade 1, 9 patients as Grade II, 10 patients as Grade III, 6 patients as Grade IV and 4 patients as grade V.Ten patients were treated conservatively; six patients underwent surgery and embolisationrespectively. Statistically significant difference (p=0.016) was found between the Spetzler-Martin grading system and the management of intracranial AVMs. Conclusion: The management decision was not made based on the grading of the AVMs. It is recommended that all AVM patients be routinely graded according to this system prior to treatment

Recent progress in establishment and application of animal models of cerebral arteriovenous malformation / 国际脑血管病杂志

A cerebral arteriovenous malformation is a congenital disorder characterised by an abnormal connection between the arteries and the veins in the brain. It causes intracranial bleeding, seizures, severe headache, and progressive neurological deficits. The therapeutic strategies were usually established on the basis of clinical experiences due to lack of ideal models of arteriovenous malformation in the past .In order to further increase the success rate of surgery and decrease complications, this article reviews the advances in establishment and application of animal models of cerebral arteriovenous malformation in recent years.

Etiological analysis of spontaneous sub-cortical hemorrhage / 中国基层医药

Objective To discuss the frequent etiology of spontaneous sub-cortical hemorrhage and its diag- nosis.Methods The clinical materials of 79 cases of spontaneous sub-cortical hemorrhage were analyzed.Results 56% of the hemorrhage was caused by arterial-venous malformation.48% of the hemorrhage was caused by occult AVM.Conclusion AVM is the most frequent etiology of spontaneous sub-cortical hemorrhage.CTA plays a special role in its diagnosis.

Vein of Galen Aneurysmal Malformation: Treatment by Transarterial Venous Sac and Fistula Embolization Using Coils and Glue / 신경중재치료의학

The endovascular treatment goal of vein of Galen aneurysmal malformation (VGAM) is to occlude the shunt. We present a case of successfully treated mural type VGAM by transarterial coil embolization of the ectatic venous pouch, followed by additional transarterial coil and glue embolizations of the ectatic vein and shunt due to recurrence.

Analysis of cerebral arteriovenous malformation correlated with intracerebral hemorrhage / 中国基层医药

Objective To discuss the diagnosis and treatment of AVM bleeding without DSA in the basic hospital.Methods Clinical difference of intracerebral hemorrhage was revienly analyzed between arteriovenous malformation and hypertensive intracerebral hemorrhage.Results Boths were different at sick ages,position and shape of haematoma,change of blood pressure after bleeding,CT scan of preoperative and view in operative.Surgery was effective.Conclusion Initial diagnosised of AVM bleeding is affirmed,according to patient's age,using mannitol is effective to control blood pressure after bleeding and display of CT scans preoperative.Final diagnosis is confirmed in operation without DSA at basic hospital.Treatment of AVM bleeding with surgery is effective.

Analysis of the Influencing Factors of AVM Bleeding for Surgical Treatment / 昆明医科大学学报

Objective To analyze the influencing factors of AVM bleeding for surgical treatment.Methods The 64 cases of bleeding AVM patients,clinical informations,condition of surgery and inspection of pathology were summarized.Results The prognosis was evaluated by Glasgow outcome scale(GOS)for every patient after the operation.36(53.3 %)recovered well,13(20.3 %)moderately disabled,4(6.4 %)severely disabled,and 11(17.3 %)died.Conclusions The effect of surgical treatment in patients with the age of onset,the site of hematoma,the bleeding volume and timing of surgery-related.The incidence between the ages of 8～14 years of age,the amount of bleeding

The embolization of intracranial arteriovenous malformations with N-butylcyanoacrylate / 介入放射学杂志

90%) in 57, 70%-90% in 27 cases, 50～70% in 8 cases,

Advancement in interventional neuroradiology / 第二军医大学学报

After rapid development over the past few years,interventional neuroradiology has become an important branch of mini invasive neurosurgery,it brought new methods and approaches in the treatment of intracranial aneurysms,intracranial arteriovenous malformations,duramater arteriovenous fistula,ischemic cerebrovascular diseases and so on.Particularly,the technique has also made impressive headways in the embolization of intracranial wide necked aneurysms and development of new embolizing materials.To accelerate its development,more emphasis should to be put on the basic theories of interventional neuroradiology,and more efforts should be made to develop new techniques,new materials and new equipments in the area.Finally,doctors should be trained and the manipulation regulations and quality control system should be established.