Reflections on the management of cerebral arteriovenous malformations.

BACKGROUND: The authors report their personal experience in the management of cerebral arteriovenous malformations (AVMs), using the three techniques now available: surgical resection, endovascular embolization, and radiosurgery. They review the recent literature on this topic and present their current management algorithm based on this experience. METHODS: A series of 90 patients treated for cerebral AVMs is reported (68% Grade I-III and 32% Grade IV-V, Spetzler scale). The three methods of treatment were used, either individually or in combination, based on the size and the location of the malformation. The first intervention was surgical resection in 26% of cases, endovascular embolization in 57%, and radiosurgery in 17%. Surgery and embolization were followed by another technique in some cases and eventually single modality treatment was used in 58% of cases (surgical resection 21%, endovascular embolization 20%, radiosurgery 17%) and multimodality treatment in 42% (embolization + resection, 21%; embolization + radiosurgery, 17%; resection + radiosurgery, 4%). Embolization was used as reductive therapy in 38% of the overall series (65% of all embolized patients), and was followed by surgery in 56% of cases or by radiosurgery in 44%. Angiography was used to assess the cure rates. RESULTS: The following cure rates were obtained, when each technique was used as a first treatment: surgical resection, 82%; embolization, 6%; and radiosurgery, 83% (2-year angiographic follow-up). After combined treatment, embolization and resection resulted in a 100% cure rate, embolization and radiosurgery produced a 90% cure rate. The clinical outcome was evaluated in terms of deterioration attributable to treatment. Seventy-one percent of patients had no complication, minor complications were observed in 18%, and severe complications in 11%. Treatment mortality was 3%. All deaths were attributable to hemorrhage during the embolization procedure. CONCLUSIONS: In this management algorithm, AVMs submitted directly to surgery or to radiosurgery were considered "good risk" malformations, and the outcome for these cases was good in terms of clinical result and cure rate. AVMs submitted first to endovascular embolization were considered "poor risk" malformations, including a majority of Spetzler Grade IV-V lesions. Not surprisingly, the majority of severe complications occured in this group during embolization. Thus, the major risk of the treatment of AVMs has now shifted from surgery to endovascular techniques. Endovascular embolization as sole treatment gave a low rate of complete occlusion, but proved to be very useful as a reductive therapy, in preparation for further surgery or radiosurgery. Partial embolization permitted high rates of complete cure in difficult AVMs. Embolization should be used to the maximum extent possible as a reductive technique, despite the risks of the procedure. Because of its risks however, this technique of reductive embolization should be used only if absolutely necessary to allow the complete cure of the malformation. Thus, the use of embolization should be considered very cautiously in small malformations as well as in very large and complex AVMs in which partial embolization will not be sufficient to allow complete cure with either endovascular or surgical techniques.

[Involuntary motor activity or alien hand syndrome following ischemic lesion sparing medial frontal cortex]. / Activité motrice involontaire ou "alien hand syndrome" à l'issue d'une lésion ischémique respectant le cortex frontal médian.

We report a case of a left alien hand syndrome without grasp reflex, inter-manual conflict or sensory impairement after an infarction involving the striatum, premotor lateral cortex and colossal fibers but sparing medical premotor cortex. According to the location of the lesion, the mechanism underlying this clinical feature might mainly involve cortico-putamino-thalamo-cortical loop which links extrapyramidal system to medial premotor cortex.

[Painful ophthalmoplegia disclosing dural fistula of the anterior cranial fossa]. / Ophtalmoplégie douloureuse révélatrice d'une fistule durale de l'étage antérieur.

We report the case of a 54-year-old man without previous medical history who presented with sudden vertical diplopia and frontal headache. Clinical examination and Lancaster's test were consistent with superior rectus muscle palsy. Brain CT scan, MRI and CSF examination were normal. Cerebral angiography revealed a dural arteriovenous fistula at the base of the anterior cranial fossa with bilateral arterial supply from small branches of the ophthalmic artery. The causal relationship, the pathophysiology and the therapeutic approaches are discussed.

[Therapeutic risk in multidisciplinary approach of cerebral arteriovenous malformations]. / Le risque thérapeutique dans l'approche multidisciplinaire des malformations artério-veineuses cérébrales.

PATIENTS AND TECHNIQUES: A series of 67 patients treated for cerebral AVMs using a multidisciplinary approach is reported, paying special attention to the complications due to treatment. The malformations were classified according to the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: resection alone (25% of cases), embolization plus resection (24%), embolization alone (21%), and radiosurgery, (30%) either alone or after embolization or surgery. The following eradication rates were obtained: 80% overall, 91% after resection (with or without embolization), 13% after embolization alone, 87% after radiosurgery. CLINICAL OUTCOME: The outcome was evaluated in terms of deterioration due to treatment. Treatment-related deterioration occurred in 28% of cases and consisted of a minor deterioration (19%), a neurological deficit (4%), or death (4%). As far as the mode of treatment is concerned, surgical resection was followed by deterioration in 20% of all operated cases (minor 17%, deficit 3%). Radiosurgery was followed by a minor deterioration in 10% of irradiated cases. Embolization resulted in complication in 25% of all embolized cases (minor 12.5%, neurological deficit 5%, or death 7.5%). The mechanism of the complication was: resection on manipulation of a functional area and the haemorrhage for cases treated by surgery, radionecrosis for radiosurgery, ischemia and haemorrhage (50% each) for embolization. In 4 out of the 5 cases of haemorrhage due to embolization, an occlusion of the main venous drainage could be demonstrated. DISCUSSION: The haemodynamic disturbances relating to AVMs and to their treatment are reviewed in the literature. The main haemodynamic mechanisms at the origin of a complication after treatment of cerebral AVMs are the normal perfusion pressure breakthrough syndrome, venous drainage defects (venous overload or occlusive hyperemia), and retrograde thrombosis of the feeding arteries. CONCLUSIONS: Improved treatment of cerebral AVMs has been achieved through the multidisciplinary approach, and especially through the endovascular embolization technique. Such an improvement is especially visible in the field of high-grade malformations, which are the most difficult and the most dangerous to treat. As a consequence, the risk of the treatment has naturally shifted from surgical resection towards endovascular embolization which is the first procedure to be performed in difficult cases. Careful consultation between the various specialists is necessary in this pathology, particularly as some of these AVMs are a good indication for each of the three available methods of treatment.

Complications after multidisciplinary treatment of cerebral arteriovenous malformations.

PATIENTS AND TECHNIQUES: A series of 67 patients treated for cerebral AVMs with a multidisciplinary approach is reported, with special attention for the complications due to treatment. The malformations were classified after the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: resection alone (25% of cases), embolization plus resection (24%), embolization alone (21%), and radiosurgery (30%), either alone or after embolization or surgery. The following eradication rates were obtained: overall 80%, after resection (with or without embolization) 91%, after embolization alone 13%, after radiosurgery 87%. CLINICAL OUTCOME: The outcome was evaluated in terms of deterioration due to treatment. A deterioration after treatment occurred in 19 patients (28%), and was a minor deterioration (19%), a neurological deficit (4%), or death (4%). As far as the mode of treatment is concerned, surgical resection was responsible for deterioration (minor) in 17% of all cases operated upon. Radiosurgery was followed by a minor deterioration in 10% of irradiated cases. Embolization gave a complication in 25% of all embolized cases (minor or neurological deficit, or death). The mechanism of the complications was: resection or manipulation of an eloquent area during surgery, radionecrosis after radiosurgery, ischaemia and haemorrhage (50% each) following embolization. In most cases of haemorrhage due to embolization, occlusion of the main venous drainage could be demonstrated. DISCUSSION: The haemodynamic disturbances to AVMs and to their treatment are reviewed in the literature. The main haemodynamic mechanisms admitted at the beginning of a complication after treatment of cerebral AVMs are the normal perfusion pressure breakthrough syndrome, the disturbances of the venous drainage (venous overload or occlusive hyperaemia), and the retrograde thrombosis of the feeding arteries. CONCLUSIONS: According the authors' experience, the emphasis of treatment for cerebral AVMs has now shifted from surgical resection to endovascular embolization. One of the explanations is that endovascular techniques are now employed in the most difficult cases (high grade AVMs). As severe complications of endovascular embolization may also occur for low-grade malformations, the question arises whether surgery or radiosurgery should not be used first for this low-grade group even if embolization is feasible.

Multidisciplinary treatment of cerebral arteriovenous malformations.

A series of 67 patients treated for cerebral AVM with a multidisciplinary approach is reported. The malformations were classified after the Spetzler Grading Scale, with 67% low-grade and 33% high-grade AVMs. Three modes of treatment were used: surgical resection, endovascular embolization, and radiosurgery (linear accelerator technique). The actual treatment was: surgical resection alone (25% of cases), embolization plus resection (25% of cases), embolization alone (21%) and radiosurgery (30%) either alone (12%), or after incomplete embolization (15%) or after incomplete resection (3%). The clinical outcome was evaluated in terms of deterioration due to treatment. The treatment was responsible for a deterioration in 28% of all patients, either minor deterioration (19%) neurological deficit (4%), or death (4%). All complications of surgical resection (17% of all operated cases) and of radiosurgery (10% of irradiated cases) remained minor. None was haemodynamic-related. After endovascular embolization, a deterioration occurred in 25% of all embolized cases (minor 13%, neurological deficit 5% and death 8%). These complications occurring after embolization were haemodynamic related: ischaemia and haemorrhage (50% for each mechanism). Haemorrhage occurred either during or some days after the embolization procedure. The angiographic eradication rate was: 80% overall, 91% after resection (with or without previous embolization), 87% after radiosurgery (alone or after other techniques), and 10% after embolization alone. The discussion reviews in the literature the general evolution of the management of cerebral AVMs, with successive application of first surgical resection, the embolization and lastly radiosurgery.(ABSTRACT TRUNCATED AT 250 WORDS)

CT-guided needle biopsy of intracranial tumours: results in 118 consecutive patients.

The purpose of this paper is to evaluate the efficacy and safety of CT-guided needle biopsies and to determine the optimal indications for this technique. The case histories of 118 patients who underwent a CT-guided biopsy for brain lesions during a six-year period, from November 1986 to September 1992, were reviewed. During a preliminary CT-scan, the entry site was determined and localized using a radio opaque marker and the safest route to the lesion was chosen. One hundred and thirty four procedures were performed in 118 patients. A positive diagnosis of tumour was obtained in 106 patients (89.8%). Repeat procedures were required in 18 patients. High-grade gliomas were the more common lesions (55.1%). Morbidity and mortality was assessed over the 30-day period after the procedure. Nine patients died during this time. Eight patients from day 3 to day 30 in the expected course of their disease and one within 48 first hours from neurological deterioration following the procedure. We found that CT-scan guided biopsies are a safe and accurate way to obtain brain tissue specimens for pathological diagnosis in selected cases. For superficial and large tumours it is a simple, fast and effective procedure.

Dural arteriovenous fistula of the posterior fossa draining into the spinal medullary veins--an unusual cause of myelopathy: case report.

In a 31-year-old male patient suffering from progressive myelopathy, a right carotid angiography disclosed an intracranial tentorial arteriovenous fistula (AVF) draining intrathecally into the spinal medullary veins. An embolization via the afferent meningohypophyseal artery was not technically feasible, and a microsurgical excision of the AVF was accomplished via a suboccipital approach, resulting in the angiographic cure of the fistula and progressive relief of the myelopathy. Fourteen reported cases of intracranial dural AVF draining intrathecally are reviewed. In most patients, authors encountered diagnostic difficulties similar to those noted in this case. Surgical and/or endovascular therapeutic methods have provided disappointing results, likely attributable to a prolonged course of spinal cord dysfunction. Pathophysiologically, a mechanism of venous congestion of the cord seems to be involved, as acknowledged by several magnetic resonance and angiographic studies. In patients who appear to have a clinical and myelographic picture of "vascular" myelopathy and who exhibit negative spinal angiography, a four-vessel cerebral angiography should be undertaken, aiming at the recognition of an intracranial AVF.

Prognostic value of the Spetzler's grading system in a series of cerebral AVMs treated by a combined management.

The prognostic value of the Spetzler's grading system is studied in a series of 52 AVMs treated by a combined management, using one or several of the 3 available techniques: surgical resection, endovascular embolization, radiosurgery. The symptoms at the time of treatment were haemorrhage 50%, seizures 31%, headache and deficit 19%. Three grade groups were considered: I and II (31%), III (33%), IV and V (36%). Overall, AVMs were managed as follows: resection alone 25%, embolization plus resection 23%, embolization alone 23%, radiosurgery with various combinations 29%. According to the grade groups, the most frequently used technique was resection alone for grade I-II AVMs (44%), radiosurgery for grade III AVMs (41%) and embolization alone for grade IV-V AVMs (42%). The clinical outcome was evaluated in terms of deterioration due to treatment. The best results were obtained in grade I-II AVMs (81% with no deterioration) then in grade III AVMs (65%) and in grade IV-V (58%). However, when we consider the outcome in terms of favourable results (no or only minor deterioration) we obtained a similar outcome for grade I-II and grade III AVMs (94% each), and only 79% for grade IV-V malformations. The angiographic outcome showed a better eradication rate in grade III AVMs (88% complete eradication), than in grade I-II AVMs (75%) and in grade IV-V (47%). Our conclusion is that the Spetzler's grading system in this series was well correlated with both the clinical and the angiographic outcome. However, we found no real difference between grade I-II and grade III AVMs. So, in terms of prognostic value, the grade I, II, and III AVMs could be considered together as low-grade malformations, with a better prognosis than the high-grade malformations (grade IV and V).

The combined management of cerebral arteriovenous malformations. Experience with 100 cases and review of the literature.

A series of 100 patients treated for a cerebral arteriovenous malformation (AVM) is presented. Patients were admitted between 1985 and April 1992. Two groups are considered: the first group including 52 patients treated before the availability of radiosurgery (1985-1988), and the second group including 48 patients treated after the availability of radiosurgery (1989-1992). AVM's were classified in five grades according to the Spetzler's Grading System. Three techniques of treatment were used: surgical resection, intravascular embolization (with cyanoacrylate), and radiosurgery (linear accelerator). These three techniques were used either alone or in association, giving four types of management: surgical resection alone, embolization and resection, embolization alone, and radiosurgery (alone, or after embolization, or after surgical resection). From 1989 on, the availability of radiosurgery was responsible for the decrease of the "embolization and resection" group, which until then was predominantly used as well for low-grade (I, II, III) as for high-grade AVM's (IV, V). Overall, for the low-grade AVM's, the treatment of choice was surgical resection (79% of cases), with pre-operative embolization in one-half of these cases; the other low-grade AVM's were irradiated, with various combinations. For the high-grade AVM's, the treatment of choice was intravascular embolization (95% of cases), either alone, or followed by resection (45%) or radiosurgery (9%). Results were evaluated in terms of deterioration following treatment, in five groups: no deterioration (59%), minor deterioration (20%), long-lasting deficit (10%), major deterioration (5%), and death (6%). Overall, results improved after 1989: favourable outcome (no deterioration and minor deterioration) increased from 67% to 90%. Results were not related to the patients' age. More favourable results were obtained for low-grade AVM's (93%) than for high-grade AVM's (60%). For the low-grade AVM's the evolution from 1989 on (favourable outcomes increasing from 89% to 96%) occurred with the lowering of the mortality rate. For the high-grade AVM's, the evolution from 1989 onwards (favourable outcome increasing from 46% to 78%) occurred with the decrease of the cases with deficits. The angiographic results were strongly related to the management: 95% of complete eradication after surgical resection and 5% only after embolization alone. Concerning the results in irradiated cases, the follow-up is not long enough. The review of the neurosurgical literature since 1972 demonstrates progressive modifications in the therapeutic attitude as regards AVM's. The surgical management which was predominantly used at the beginning gave way progressively to a combined management, with a combination of embolization, surgery, and lately radiosurgery.(ABSTRACT TRUNCATED AT 400 WORDS)

[The neurosurgeon's role in the treatment of cerebral arteriovenous malformations. A study of a series of 100 cases and review of the literature]. / La place du neurochirurgien dans le traitement des malformations artério-veineuses cérébrales. Etude d'une série de 100 cas et revue de la littérature.

The Neurosurgeons's place in the management of cerebral A.V.M.'s is discussed in the light of a personal experience and of the review of the neurosurgical literature. A personal series of 100 treated patients is presented. Patients were admitted between 1985 and April 1992. Two groups are considered: the first group including 52 patients treated before the availability of radiosurgery (1985-1988), and the second group including 48 patients treated afterwards (1989-1992). A.V.M.'s were classified in five grades according to the Spetlzer's Grading System. Three techniques of treatment were used: Surgical Resection, Intravascular Embolization (cyanoacrylate) and Radiosurgery (linear accelerator). These three techniques were used either alone or in association, giving four types of management: surgical resection alone, embolization and resection, embolization alone, and radiosurgery (alone, or after embolization or after surgical resection). From 1989 on, the availability of radiosurgery was responsible for the diminution of the "embolization and resection" group, which until then was predominantly used, for the low-grade A.V.M.'s (I.II.III) and for the high grade A.V.M.'s (IV.V) as well. Overall, for the low grade A.V.M.'s, the treatment of choice was the surgical resection (79% of cases), with a preoperative embolization in one half of these cases; the other A.V.M.'s were irradiated, with various combinations. For the high-grade A.V.M.'s, the treatment of choice was the intravascular embolization (95% of cases), either alone, or followed by exeresis (45%) or radiosurgery (9%). Results were evaluated in terms of deterioration due to treatment, in five groups: no deterioration (59%), minor deterioration (20%), long-lasting deficit (10%), major deterioration (5%) and death (6%). Overall, results improved after 1989: favourable outcome (no deterioration and minor deterioration) increased from 67% to 90%. Results were not related to the patient's age. More favourable results were obtained for low grade A.V.M.'s (93%) than for high grade A.V.M.'s (60%). For the low grade A.V.M.S. the evolution form 1989 on (favourable outcome increasing from 89% to 96%) occurred with the suppression of death cases. For the high grade A.V.M.'s, the evolution from 1989 on (favourable outcome increasing from 46% to 78%), occurred with the decreasing of the deficit cases. The angiographic eradication was strongly related to the management: 95% of complete eradication after surgical resection and 5% only after embolization alone. Concerning the results in irradiated cases, the follow-up is not long enough. The review of the neurosurgical literature since 1972 demonstrates progressive modifications in the therapeutic attitude as regards A.V.M.'s. The surgical management which was predominantly used at the beginning gave progressively way to a combined management, with a combination of embolization, surgery, and lately radiosurgery.(ABSTRACT TRUNCATED AT 400 WORDS)

Dural fistulae of the cavernous sinus treated by embolization. Ten cases.

We report ten cases of dural fistulae of the cavernous sinus treated by the endovascular route. The fistulae were fed by the internal and external carotid arteries. All patients presented with ophthalmic symptoms and/or headache and/or intracranial murmur. Embolization was decided on the ground of all in visual acuity, exophthalmos, ophthalmoplegia or sudden exacerbation of clinical symptoms. It was performed after selective catheterization of external carotid feeders with non-resorbable particles. The shunt was totally occluded in 7 cases, and local signs were improved in all patients: the intracranial murmur disappeared in 2 out of 4 cases and headache was relieved in 2 out of 3 cases. No permanent complication was observed. Among the various possible treatments of these dural fistulae, embolization of branches of the external carotid artery is a simple, effective and safe method, provided its principles and indications are respected.

[Dural fistula of the lateral sinus. Apropos of 2 recent cases]. / Fistule durale du sinus latéral. A propos de deux observations récentes.

On the basis of two recent cases of dural fistula of the lateral sinus, the authors review the literature relating to this type of arteriovenous fistulae. The development of selective arteriographic techniques has allowed better knowing them, ensurgin the diagnosis and also treating them with embolization techniques. The role of the ENT specialist is no less important: during the clinical stage, it for him to recognize the pulsatile character of a tinnitus and to demonstrate it in order to establish the diagnosis.

[Treatment of osteoid osteoma with percutaneous resection under computerized tomography control. Apropos of 5 cases]. / Traitement de l'ostéome ostéoïde par résection percutanée sous contrôle tomodensitométrique. A propos de 5 cas.

Osteoid osteoma is a benign tumor requiring a surgical resection. An original technique is reported: the nidus was first located by computed tomography and then reached and resected through a small percutaneous approach. A special device, similar to those of knee arthroscopy or percutaneous discotomy has been designed. Five patients have been thus treated successfully (1 femoral neck, 1 trochanter, 1 femur, 2 tibias). Recent progress in radiology for management of bone tumors (scintigraphy, angiography) have given greater accuracy in the preoperative diagnosis of osteoid osteoma. It is thus possible to dispense with an histological proof in case of destruction of the nidus. However a new device is now designed to achieve true "en bloc" resection of the nidus.

[Chiasmal radionecrosis after irradiation of the sella turcica using a conventional dosage. Contribution of magnetic resonance imaging]. / Radionécrose chiasmatique après irradiation de la selle turcique à doses conventionnelles. Apport de l'imagerie par résonance magnétique.

A 47 year-old man developed rapid visual loss, visual field defects and memory disturbances after radiotherapy with conventional doses for a pituitary metastasis from a renal carcinoma. CT and MRI did not show recurrent tumour, pituitary apoplexy or empty sella. Eventually, T2-weighted MRI images showed abnormal high signals in the optic chiasm, the left mesial temporal lobe and the right inferior frontal lobe, supporting the diagnosis of delayed radionecrosis. The role of chemotherapy associated with radiotherapy is discussed.

Apparently isolated, spontaneous haematomas of the brain stem. Seven cases explored by CT and MRI.

The authors present seven cases of apparently isolated spontaneous haematomas of the brain stem detected by computerized tomography (CT). Magnetic resonance imaging (MRI) was performed in all patients, and in three of these on two occasions at different stages of the lesion. Changes in MRI signal according to the moment this examination was carried out (acute, subacute or chronic stage) are described. In two of three patients operated upon the haematoma was found to be due to an occult vascular malformation.

[Tumors of the pineal region: MRI aspects. Apropos of 20 cases]. / Tumeurs de la région pinéale: aspects IRM. A propos de vingt observations.

MR imaging (0,5 T) was performed in twenty patients with a tumor of the pineal region (17 pathological correlations). To establish the place of this technique, MR imaging data are studied. There is a great variety of tumor types, but the signal of the tumor is usually non specific. The main indication of MR imaging appears to be the evaluation of the extension of the tumor before surgery.