Endovascular treatment of head and neck arteriovenous malformations.

INTRODUCTION: Head and neck arteriovenous malformations (H&N AVM) are associated with considerable clinical and psychosocial burden and present a significant treatment challenge. We evaluated the presentation, response to treatment, and outcome of patients with H&N AVMs treated by endovascular means at our institution. METHODS: Patients with H&N AVMs treated by endovascular means from 1984 to 2012 were evaluated retrospectively. These included AVMs involving the scalp, orbit, maxillofacial, and upper neck localizations. Patient's clinical files, radiological images, catheter angiograms, and surgical reports were reviewed. RESULTS: Eighty-nine patients with H&N AVMs (46 females, 43 males; 48 small, 41 large) received endovascular therapy. The goals of treatment were curative (n = 30), palliative (n = 34), or presurgical (n = 25). The total number of endovascular treatment sessions was 244 (average of 1.5 per patient). The goal of treatment was met in 92.1 % of cases. Eventual cure was achieved in 42 patients accounting for 58.4 % (52/89) of all patients who underwent treatment for any goal. Twenty-eight of these patients were cured by embolization alone (28/89, 31.4 %) of which 18 were single-hole AVFs. Twenty-four were cured by planned surgical excision after presurgical embolization (24/89, 27 %). Seven patients (7/89, 7.2 %) suffered transient and two (2/89, 2.2 %) permanent endovascular treatment complications. CONCLUSION: Endovascular treatment is effective for H&N AVMs and relatively safe. It is particularly effective for symptom palliation and presurgical aid. Embolization is curative mostly in small lesions and single-hole fistulas. In patients with large non-curable H&N AVMs, endovascular therapy is often the only palliative option.

Cement embolization of a segmental artery after percutaneous vertebroplasty: a potentially catastrophic vascular complication.

Serious complications related to percutaneous vertebral augmentation procedures, vertebroplasty and kyphoplasty, are rare and most often result from local cement leakage or venous embolization. We describe an adult patient who underwent multi-level, thoracic percutaneous vertebral augmentation procedures for painful osteoporotic compression fractures. The patient's percutaneous vertebroplasty performed at the T9 level was complicated by the asymptomatic, direct embolization of the right T9 segmental artery with penetration of cement into the radicular artery beneath the pedicle. We review the literature regarding the unusual occurrence of direct arterial cement embolization during vertebral augmentation procedures, discuss possible pathomechanisms, and alert clinicians to this potentially catastrophic vascular complication.

Transvenous embolization of intracranial dural arteriovenous shunts through occluded venous segments: experience in 51 Patients.

BACKGROUND AND PURPOSE: DAVFs with cortical venous reflux carry a high risk of morbidity and mortality. Endovascular treatment options include transarterial embolization with a liquid embolic agent or transvenous access with occlusion of the involved venous segment, which may prove difficult if the venous access route is thrombosed. The aim of this article is to describe the technique and results of the transvenous approach via thrombosed venous segments for occlusion of DAVFs. MATERIALS AND METHODS: Our study was a retrospective analysis of 51 patients treated with a transvenous approach through an occluded sinus that was reopened by gentle rotational advancement of a 0.035-inch guidewire, which opened a path for a subsequently inserted microcatheter. RESULTS: Of 607 patients with DAVFs, the transvenous reopening technique was attempted in 62 patients in 65 sessions and was successful in 51 patients and 53 sessions. Immediate occlusion was seen in 42 patients; on follow-up, occlusion was seen in 49 patients, whereas 2 patients had reduced flow without cortical venous reflux. No permanent procedure-related morbidity was noted. CONCLUSIONS: The reopening technique to gain access to isolated venous pouches or the cavernous sinus for the treatment of DAVFs is a safe and effective treatment, which should be considered if transarterial approaches fail or are anticipated to result only in an incomplete anatomic cure.

Management and clinical outcome of posterior fossa arteriovenous malformations: report on a single-centre 15-year experience.

OBJECTIVES: Posterior fossa brain arteriovenous malformations (PFbAVMs) are rare lesions. Management is complicated by eloquence of adjacent neurological structures, multimodality treatment is often necessary, and obliteration is not always possible. We describe a 15-year experience in the management of posterior fossa brain AVMs with a focus on clinical outcome. METHODS: From 1989 to 2004, prospectively collected information on 106 patients with diagnosis of a PFbAVMs was obtained. Clinical and angioarchitectural characteristics, management options and complications are described and reviewed to evaluate their impact on final outcome as measured by the Modified Rankin Score (mRS). RESULTS: Ninety-eight patients were followed for an average of 3.3 years (1-14.6). The male-to-female ratio was 1:1. Ninety-five out of 98 patients (96.9%) were symptomatic at presentation, with 61 (62.2%) intracranial haemorrhages. Sixty-two patients were treated (46 cerebellar, 16 brainstem). Ten haemorrhages occurred in follow-up (4.1%/year). The mRS was obtained in 62 patients and was classified as low (good, mRSor=3). Haemorrhage was the only predictor of poor mRS at presentation (p = 0.0229). A poor clinical outcome was correlated with the presence of AA (p = 0.0276), a poor initial mRS (p<0.0001) and the number of treatments needed (p = 0.0434). Patients were significantly more likely to improve than to deteriorate over time (p = 0.0201). CONCLUSION: The final clinical outcome in PFbAVMs relates directly with the presence of associated aneurysms, number of treatments needed to obliterate the AVM and mRS at presentation. Despite the fact that patients tend to improve after brain AVM haemorrhage, the relationship of MRS at presentation and final outcome suggests that an expedited, more definitive treatment is probably a better choice, especially in patients with good grades after the initial bleeding.

Intrasellar rupture of a paraclinoid aneurysm with subarachnoid hemorrhage: usefulness of MR imaging in diagnosis.

Characterization of paraclinoid aneurysms may be difficult because of the complexity of anatomic structures involved, and differentiation between intradural and extradural lesions is crucial. We report a case of a patient with a unique presentation of a paraclinoid aneurysm with intrasellar hemorrhage in which the presence of intrasellar blood and the relationship of the paraclinoid aneurysmal neck and sac to the dural rings were elegantly demonstrated on MR imaging and were critical in choosing the target lesion for treatment.

Endovascular treatment of intracranial aneurysms with matrix coils: immediate posttreatment results, clinical outcome and follow-up.

INTRODUCTION: Endovascular aneurysm repair with coils has become a safe and effective alternative to surgical clipping. Efforts have been made to create coils that will facilitate aneurysm healing and reduce recurrence. The purpose of this study was to review the safety and durability of our aneurysm treatment using Matrix coils. METHODS: A total of 39 aneurysms in 38 patients, aged 30 to 77 years, were treated using Matrix coils in 42 procedures. Two procedures were unsuccessful, and 12 were done using only Matrix coils. Aneurysm volume, packing density and percentage length of Matrix coils were calculated. The treatment results, procedural complication rate and clinical outcome were analyzed. Follow-up examinations were available for 34 procedures with a mean follow-up of 4.9 months (maximum 13.5 months). RESULTS: Angiographic results were similar to those following the use of platinum coils, with complete occlusion or a residual neck in 82.5% of procedures. Six procedures (14%) were complicated with platelet aggregation. Recanalization occurred in 32% of the patients. Nine patients (26%) had major recanalization and were retreated. One patient had a re-bleed 5 months after the treatment resulting in severe disability. The mean packing density of 39.2% in the recanalized aneurysms was similar to that in the nonrecanalized group. CONCLUSION: In our series, treatment with Matrix coils had a complication rate similar to that reported with platinum coils. However, we had a higher percentage of major recanalizations requiring retreatment. We believe that the absorption of the polymer contributes to the failure of formation of a stable scar within the aneurysm.

Focal Lesion in Splenium of Corpus Callosum on FLAIR MRI: Common Findings in Aged Patients.

Focal high signal intensity in the splenium of the corpus callosum on fluid-attenuated inversion-recovery (FLAIR) images is generally considered an abnormal MR finding. The aim of this study was to determine the frequency of this finding in elderly patients and review the differentiation from other diseases with the similar findings. FLAIR images of 132 patients with suspect CNS disease were retrospectively reviewed. The changes in the splenium of corpus callosum, deep white matter lesions, periventricular matter lesions, infarcts, atrophy and age were analyzed, as well as history. Among the initial 132 patients, focal high signal intensity in the splenium was associated with aging, white matter changes, atrophy, and cognitive disorders. Focal high signal intensity in the splenium of the corpus callosum on FLAIR image is a common finding in elderly patients, especially in aged patients with cognitive disorders. The pathologic alterations were commonly described by the term of "leukoaraiosis". Knowledge of this finding and differentiation from other lesions focusing on the splenium of corpus callosum may help avoid unnecessary invasive diagnostic and therapeutic intervention.

Cerebral arteriovenous fistulas induced by dural arteriovenous shunts.

Dural arteriovenous shunts and pial arteriovenous fistulas are uncommonly associated. Their etiology, pathogenesis, and natural history are still unclear and are likely different. We present three cases of high-flow dural arteriovenous shunts associated with pial arteriovenous fistulas and discuss their pathogenesis, anatomic association, and angioarchitecture. We propose that venous steal effect in the dural sinus secondary to the high-flow dural arteriovenous shunt induced the pial arteriovenous fistulas. Treatment of the high-flow dural arteriovenous shunts and the induced pial arteriovenous fistulas are discussed.

Coexistence of Mandibular Arteriovenous Malformation and Cerebellar Arteriovenous Malformation. An Example of Cerebrofacial Arteriovenous Metameric Syndrome Type III.

SUMMARY: We describe a patient with cerebellar and mandibular arteriovenous malformations who initially presented with oral haemorrhage and then subsequently had a cerebellar haemorrhage. This is the second reported case of cerebrofacial arteriovenous metameric syndrome type III (CAMS III) in the literature and we discuss the role of homeobox genes in craniofacial development and angiogenesis.

Angiographic and clinical characteristics of patients with cerebral arteriovenous malformations associated with hereditary hemorrhagic telangiectasia.

BACKGROUND AND PURPOSE: Cerebral arteriovenous malformations (AVMs) are occasionally associated with hereditary hemorrhagic telangiectasia (HHT), which is characterized by the presence of multiple mucocutaneous telangiectasia, epistaxis, and familial inheritance. We analyzed the angiographic and clinical characteristics of patients with cerebral AVMs related to HHT. METHODS: Among 638 patients with cerebral AVMs, we identified 14 patients with HHT. The AVMs were classified as those with nidi of 1 cm or less (micro AVMs), those with nidi between 1 and 3 cm (small AVMs), and those of the fistulous type (arteriovenous fistulas [AVFs]). RESULTS: A total of 28 AVMs were found; seven of 14 patients had multiple AVMs. The 28 AVMs were categorized as 12 micro AVMs, eight small AVMs, and eight AVFs. All except one micro AVM were asymptomatic, whereas all small AVMs were symptomatic. Three of eight AVFs were asymptomatic. All 28 AVMs were located on the cortex. All micro AVMs and AVFs had single feeders and single draining veins, whereas the small AVMs had multiple feeders in all lesions and single draining veins in six of eight lesions. CONCLUSION: Multiple, cortical, micro AVMs or AVFs harboring single feeding arteries and single draining veins should raise clinical suspicion of HHT-related AVMs.

Selected interventional procedures for pediatric head and neck vascular lesions.

Although vascular malformations are commonly seen in children, they are lesions managed best by an experienced multidisciplinary team. Recognizing, investigating, and diagnosing the type of vascular malformation is critical to determining treatment modality and pathway. Generic identification-despite Mulligan's excellent classification-or confusing vascular malformations with hemangiomas are both inappropriate because treatment is quite different for these separate groups of diseases. Additionally, an understanding of the recognition and classification of vascular malformations is essential for effective family counseling and management of these childhood lesions.

The natural history and management of intracranial dural arteriovenous fistulae. Part 1: benign lesions.

SUMMARY: The recently proposed classification scheme of Borden, Wu, and Shucart (Borden(*)) should have the ability to identify those intracranial dural arteriovenous fistulae (ICDAVF) which will continue to behave in a benign fashion. We examine for the first time the natural history of benign ICDAVF, including the predictive ability of this grading scale, and the implications for lesion management. A cohort of 55 Borden(*) grade I lesions was selected from a heterogeneous series of 102 consecutive lCDAVF seen at one institution between 1984 and 1995. Data were collected prospectively from 1991. Grade 1 lesions were those whose nidus drained directly into a dural venous sinus (DVS) or meningeal vein. The absence of retrograde leptomeningeal venous drainage (RLVD) was an important feature. Intracranial haemorrhage (ICH), non haemorrhagic neurological deficit (NHND), and death were considered aggressive features. There were 23 cavernous sinus, 2 foramen magnum, 1 middle cranial fossa, and 29 transverse sinus lesions. One patient received obliterative surgical treatment. Thirty-two lesions were observed only, and 22 patients developed symptoms or signs requiring palliative embolisation. Two minor complications occurred following embolisation: transient pulmonary aedema (1), and an asymptomatic pericallosal artery embolus (1). Follow-up was available on 48 (89%) patients for a total of 133 patient years (mean 33 months). This included 26 of the 32 patients observed and all 22 of the patients embolised. Aggressive interval behavior was seen in only one patient. Symptom improvement or resolution was observed in the majority of patients, whether observed only [21/26 (81%) j, or whether they required embolisation for symptom palliation [19/22 (86%)). Overall, 53 of the 54 (98%) of ICDAVF behaved in a benign fashion in the follow-up period. The predictable benign natural history of patients identified as Borden(*) grade I at presentation mandates a conservative approach to these ICDAVF. In some patients, when symptom severity demands, palliative embolisation is an effective and safe therapy.

The natural history and management of intracranial dural arteriovenous fistulae. Part 2: aggressive lesions.

SUMMARY: The natural history of aggressive intracranial dural arteriovenous fistulae (ICDAVF) is unknown. Despite this, the recently proposed classification scheme of Borden et al (Borden(*)) has the potential to predict aggressive lesion behavior after presentation for any lesion, but has so far been untested. In addition, they discuss a new but logical treatment strategy for aggressive ICDAVF based on the elimination of retrograde leptomeningeal venous drainage (RLVD). Our similar philosophy and substantial experience with these lesions, provides a unique opportunity to test these hypotheses. A cohort of 46 Borden(*) grade II and III ICDAVF was selected from a series of 102 ICDAVF seen at a single institution between 1984 and 1995. Patients with these lesions, presumed to have an aggressive course were all offered treatment. Conservative therapy was chosen by 14 (30%) patients, 22 (47%) had surgery, and 20 (43%) had embolisation either as sole treatment or prior to surgery. During the follow-up period (249 lesion months) for the conservatively treated group, Jour (29%) patients died. Excluding presentation, these patients were observed to have interval rates of intracranial hemorrhage (ICH), non haemorrhagic neurological deficit (NHND), and mortality, of 19.2%, 10.9%, and 19.3% / lesion year respectively. The 11 patients who had embolisation alone were followed for a total of 344 months after treatment. All nine patients who had lesion obliteration, or subtotal obliteration with elimination of RLVD, as confirmed by angiography, experienced improvement or complete clinical recovery. Two patients had subtotal obliteration without elimination of RLVD. One died from interval ICH and the other experienced a delayed NHND. Twenty-five surgical operations were performed on 23 ICDAVF in 22 patients. Resection of the ICDAVF was performed in 9 patients, and 16 patients were treated with surgical disconnection alone. Complications occurred in 3/9 (33%) patients who had their lesions resected and none of the disconnected group. Failure to achieve angiographic obliteration of RLVD in 2 patients treated with resection was associated with an adverse outcome in both cases (death, and interval NHND). All 16 (100%) of the disconnected group were shown to have undergone angiographic obliteration with excellent clinical outcome. Untreated, Borden(*) grade II and III ICDAVF have a poor natural history. Also, persistence of RLVD after inadequate treatment results in adverse outcomes. Embolisation usually improves the safety of surgical access and may lead to obliteration on its own in some cases. For the aggressive ICDAVF, surgery is required in most cases, and our data confirm that surgical disconnection alone results in cure of all Borden(*) grade III ICDAVF, and in grade II lesions, ifnot cure, conversion to a benign grade I lesion.