A population-based study of brain arteriovenous malformation: long-term treatment outcomes.

BACKGROUND AND PURPOSE: By undertaking long-term follow-up of a functionally isolated population study group, we sought to achieve a true picture of intrinsic brain arteriovenous malformation (BAVM). We sought to assess the validity of earlier population-based series and to determine the effects of newer treatment methods on the overall morbidity and mortality of BAVM. METHODS: We excluded other intracranial vascular pathologies by defining criteria. By retrospective and prospective study, 240 patients with BAVM were followed for a mean of 10.11 years from first diagnosis. RESULTS: Death rates were as follows: all causes, 12.9%; all BAVM related, 8.75%; BAVM related during conservative management, 24.6%; and BAVM related during active management, 3.9% (P=0.031). Mean diagnosis-to-death interval was 10.6 years. Oxford neurological disability scale grades of 209 survivors (July 2001) were as follows: grades 0 to 2, 74.1%; grade 3, 17.2%; and grades 4 to 5, 9.5%. Death rates were higher for patients who had bled or suffered nonhemorrhagic neurological deficit at original presentation. Incidence of first-ever hemorrhage in untreated patients was as follows: 0 to 9 years, 4.6% (P=0.0035); 30 to 39 years, 21% (P=0.02); and 60 to 69 years, 40.0% (P=0.045). The first bleed was fatal in 4.6%. CONCLUSIONS: We find no evidence of a substantial undiagnosed reservoir of nonsymptomatic BAVM. All BAVM are potentially hazardous. The great majority of BAVM patients become symptomatic during the patient's lifetime, and the majority will bleed. The risk of first hemorrhage is lifelong and rises with age. Compared with earlier population-based series, our low overall patient mortality is predominantly due to higher proportions of active treatment in the 1980s and 1990s.

Visual symptoms with dural arteriovenous malformations draining into occipital veins.

OBJECTIVE: To determine the cause of the visual dysfunction and effect of treatment on dural arteriovenous malformations (DAVMs) that secondarily involve the occipital lobe. BACKGROUND: DAVMs are an infrequent cause of visual dysfunction that should be amenable to treatment if diagnosed before permanent visual field loss. METHODS: The records of seven patients with cerebral visual disturbances associated with DAVMs were analyzed with attention to visual symptoms, visual field testing, and vascular anatomy. RESULTS: Sudden visual loss occurred in five patients, two with a hemorrhage and one with a venous infarct in the occipital lobe. Fortification images occurred in three patients, two of whom had palinopsia (one with de novo formed visual hallucinations). Homonymous quadrantic or hemianoptic field defects, some fluctuating, were found in six patients. Angiography revealed each DAVM was supplied solely by dural arteries and drained into occipital pial veins due to retrograde blood flow through the sites near or in the wall or lumen of the dural venous channels that normally drain the occipital lobe. Unlike DAVMs in other locations, only two patients had occlusion of an adjacent venous sinus. These patients, particularly the two with posterior fossa DAVMs remote to the occipital lobe, clearly demonstrate the visual and neurologic dysfunction resulting from venous hypertension. In six patients, intra-arterial embolization of the arterial feeders and nidus (one patient required additional surgery) resulted in resumption of normal occipital venous emptying. No further visual episodes occurred in five of these six patients. The visual fields normalized in three patients and improved in one with venous infarct but were unchanged in both patients with a hemorrhage. CONCLUSIONS: DAVMs that drain into occipital veins cause field loss and other visual disturbances because of venous hypertension in the occipital lobe, which can be reversed by occluding the DAVM nidus. If a venous infarct or hemorrhage has not caused irreversible damage, visual recovery should be complete.

Transarterial platinum coil occlusion of ruptured intracranial aneurysms: results in 51 patients.

Fifty-one patients with subarachnoid haemorrhage (SAH) due to ruptured intracranial aneurysm have been treated by the Guglielmi detachable platinum coil (GDC) treatment method; 36 patients within 28 days of the ictus. There was total body occlusion in 64.8%, subtotal body occlusion in 24.1% and failed coil placement in 11.1%. Technical success rates were highest in aneurysms with neck sizes up to 4 mm (75% total occlusion) and aneurysms smaller than 10 mm largest diameter (72.5% total occlusion). At discharge from primary care, there were 62.7% without deficit rising to 74.5% at follow-up assessment. Four patients are dead and one disabled (9.8%). Patient clinical outcomes relate most closely to Hunt and Hess grade at time of definitive treatment. Higher initial grades and poorer clinical outcomes are concentrated in patients treated in the first 14 days. The incidence of procedure related thrombo-embolic events has fallen from 20% in the first 30 patients to 4.8% in the next 21. Rebleeding during GDC procedures occurred in 20.6% of patients treated 1-14 days post SAH.

Spontaneous polymerisation of cyanoacrylate/lipiodol mixtures causing failed embolisation. Laboratory studies.

SUMMARY: In vitro experiments to investigate spontaneous polymerisation of n-butyl-2-cyanoacrylate when mixed with non ionic oily contrast medium are reported. The results suggest an interaction between the mixture components which is unique to one particular batch of Lipiodol Ultrafluid and Histoacryl n butyl cyanoacrylate. The interaction cannot be reproduced with other batches of Lipiodol Ultrafluid nor with an alternative preparation of n-butyl-2-cyanoacrylate. Implications for the use of the materials in neuro-interventional practice are discussed.

Cranial dural arteriovenous malformation and fistula. Radiological diagnosis and management. Review of thirty four patients.

The clinical features, imaging and angiographic findings of thirty four patients with cranial dural arteriovenous malformations and fistulae are presented in four groups. Group 1--Seven patients with anterior cavernous malformations, predominant superior ophthalmic vein drainage, and symptoms and signs of carotico-cavernous fistula. Group 2--Twelve patients with malformations of the superior petrosal, transverse and sigmoid sinus regions, presenting predominantly with bruit. Group 3--Seven patients with malformations of the basal sinuses and prominent cortical venous drainage, presenting with intracranial haemorrhage, headache and impaired cortical function. Intracranial haemorrhage never occurred in the absence of cortical venous drainage. Group 4--Eight patients with infrequent manifestations. Group 1 and 2 patients are readily recognized and diagnosed. Group 3 and 4 patients are often misdiagnosed. Treatment modalities comprised embolisation therapy, surgical excision, and carotid compression. Twenty patients were treated by one or more of these modalities with a successful outcome in thirteen patients. Group 1 patients are the most amenable to trans-arterial embolisation. Carotid compression as the sole modality of treatment was successful in four patients. Unless the fistula is successfully closed, Group 3 patients and patients who present with cervical or thoracic myelopathy carry a grave prognosis. There is need for greater radiologist awareness of Group 3 and the rarer presentations, particularly myelopathy. With the exception of one patient, the morphological features of our cases are consistent with the now-accepted view that these lesions are acquired arterio-venous fistulae and not congenital malformations.

Angiographically demonstrated arterial spasm in a case of benign sexual headache and benign exertional headache.

Benign headaches related to sexual activity and exertion are being recognised with increasing frequency. We wish to report a case of benign sexual headache (Type 2) and benign exertional headache, occurring sequentially in the same patient. Multiple areas of cerebral arterial spasm were demonstrable on angiography. This observation would support the concept that benign sexual headache (Type 2) and benign exertional headache may have a similar pathophysiology.

Glomus intravagale tumour: aspects of management.

Glomus intravagale tumours are relatively rare tumours. A case is described and some aspects of its management are discussed with emphasis on the pre-operative investigation and diagnosis of this condition. Selective embolization of the lesion before operation is an important adjunct in treatment to reduce the vascularity of the tumour during operation. Intra-operative cardiac arrest due to traction of the vagus nerve was encountered. The methods to avoid this complication are discussed.

Improved technique of bucrylate embolisation in brain arteriovenous malformation. The use of additional temporary balloon occlusion.

Problems currently limiting the success and safety of calibrated leak balloon embolisation include suboptimal occlusion of malformation bed due to multiple or inaccessible pedicles and neural deficits due to paradoxical embolisation of normal brain. Analysis of preliminary calibrated leak balloon angiograms supported by temporary balloon occlusion of other pedicles yields insights into the dynamics of blood flow to anterior malformations. Strategies have been devised using temporary balloon occlusion to improve filling of malformation bed and reduce paradoxical embolisation of eloquent brain.

Valved latex balloons and water-soluble contrast opacified polymer. Simple detachable balloon system.

Latex balloons of different shapes, sizes and volume, incorporating a simple valve mechanism, were produced cheaply. These balloons are ethylene oxide sterilized and are available on 'the shelf' for use at any time. A contrast soluble polymer consisting of 2 hydroxy-ethyl-methacrylate, a cross linker, Iopamidol and water-soluble free radical curing system has been developed. The polymer sets in 10 minutes and there is no 'dead volume' problem. The balloons and polymer were evaluated in dog arteries, including histologic studies and have been subsequently used in 7 patients without any complications.

Embolization of small vessels with a double-lumen microballoon catheter. Part I: Design and construction.

Existing coaxial balloon catheters cannot be passed through the smaller catheters used for superselective angiography; nor can they be used by themselves for selective catheterization, as the balloons are easily damaged. The authors describe the principles and construction of double-lumen catheters ranging from 0.45 to 0.85 mm in outer diameter, which may be passed through 4.1-6.0 F catheters to engage smaller vessels. Double-lumen catheters with an outer diameter of 0.45-0.56 mm permit injection of ethanol or a mixture of isobutyl-2-cyanoacrylate, iophendylate, and tantalum powder. The 0.85-mm size is best suited for low-viscosity silicone rubber opacified with tantalum.

Embolization of small vessels with a double-lumen microballoon catheter. Part II: Laboratory, animal, and histological studies. Work in progress.

A double-lumen microballoon catheter system measuring 0.5-0.85 mm in outer diameter (1.3-2.8 F) was fabricated for passage through standard 4.1 and 5 F catheters. By arresting circulation with the balloon, embolization with low-viscosity silicone rubber, ethanol, or isobutyl-2-cyanoacrylate can proceed in a methodical, unhurried manner, permitting precise control of tissue penetration and preventing paradoxical embolization of other vessels. Problems such as gluing the catheter in situ with cyanoacrylate did not occur. The catheter may also be inserted during surgery to control embolization at a remote site, which did result in the catheter being glued in situ in one case.

Treatment of caroticocavernous fistulae with detachable balloons introduced by percutaneous catheterization.

Five patients with caroticocavernous fistula were treated by new, interventional angiographic techniques. In four patients, latex balloons filled with a silicone polymer were introduced into the cavernous sinus via the transfemoral route and detached; this resulted in complete obliteration of the caroticocavernous fistula and preservation of the internal carotid artery flow in two of the four patients. In the fifth patient, stainless steel coils were introduced into the cavernous sinus via the superior ophthalmic vein which had previously been surgically exposed. These percutaneous, angiographic techniques of intervention should be considered the initial treatment of choice for caroticocavernous fistulae.

Myelography with metrizamide--an analysis of the complications encountered in cervical, thoracic and lumbar myelography.

Detailed analysis of complications in 363 patients undergoing myelography with metrizamide is presented. Patients have been separated into three groups: those who had lumbar myelograms via lumbar puncture; patients who had cervical myelograms via lumbar route and patients who had cervical myelograms via cervical puncture (lateral C1/C2. approach). Analysis has revealed that the incidence of minor complications like headaches, nausea, and vomiting is higher than that associated with myodil myelography. Nevertheless, it is concluded that because of lack of long term disability of arachnoiditis, and because of greater diagnostic accuracy, metrizamide represents the best contrast medium for myelography currently available.

Some pitfalls in the diagnosis of pituitary tumours: the importance of carotid angiography.

Headache and the radiological finding of an abnormal pituitary fossa are a frequent mode of presentation in patients with pituitary tumours. The case histories and radiological findings of 4 patients who presented with the above features, and in whom the major abnormalities of the pituitary fossa were due mainly to variations in the cavernous portions of the carotid artery, are described. The role of carotid angiography in the investigation of a patient with an abnormal pituitary fossa is stressed.