Natural History and Histopathology of Expanding Cysts and Hematomas After Stereotactic Radiosurgery for Arteriovenous Malformations of the Brain: A Case Series.

BACKGROUND: We reviewed the clinical course and histopathologic findings for cases involving the formation of expanding cysts and/or hematomas after gamma knife surgery (GKS) for arteriovenous malformations (AVMs). METHODS: We report a single-center retrospective review of 18 patients who presented with cyst and/or hematoma expansion after GKS for AVMs between 1993 and 2023. Expanding cysts and hematomas were defined as well-demarcated cavities filled with fluid or well-marginated heterogenous hematomas presenting with expansion proximal to or in the location of the original AVM, respectively. Patient demographics, AVM characteristics, history of interventions and surgeries, and imaging and histopathologic features of expanding cysts and hematomas were collected for analysis. RESULTS: Among 1072 AVM patients treated using GKS, 18 presented with expanding cysts or hematomas during a total follow-up period of 16,757 patient-years (0.11 case/100 persons/patient-year). The time to cyst or hematoma identification was 4-13 years after initial GKS, with a mean duration of 8.6 years. Among the patients examined, 7 (38.9%) presented mainly with hematoma, 10 (55.6%) presented mainly with cysts, and 1 presented with approximately equal components of both. Among the 18 patients, 13 (72.2%) underwent craniotomy to treat cyst or hematoma expansion. All the specimens had similar histopathologic characteristics, including organizing hematoma with fresh and old hemorrhage, fibrinoid necrosis of the vessels, gliosis of normal brain tissue, infiltration of hemosiderin-laden histiocytes, and extravascular protein leakage. CONCLUSIONS: Our findings suggest that the formation of these 2 complications can be attributed to a common mechanism involving radiation-induced vascular damage in brain tissue adjacent to the AVM and subsequent chronic inflammation and capillary dilatation.

Recurrent Intraventricular Haemorrhage in Cerebral Proliferative Angiopathy - A Case Report and Review of the Literature.

Cerebral proliferative angiopathy (CPA) is an entity distinct from that of classical arteriovenous malformations. As such, few reports have considered the long-term follow-up of patients with hemorrhage in CPA. Accordingly, herein the authors present a case of recurrent hemorrhage in CPA with 32 years of follow-up and in so doing summarize the literature of hemorrhagic cases in CPA. A 19-year-old presented with focal awareness seizures and diagnostic work-up revealed a left hemispheric vascular lesion. The patient presented again with intracranial hemorrhage at ages 28, 43 and 51. Angioarchitectural workup revealed intermingled brain parenchyma between vascular spaces, absence of dominant feeders and a clear nidus consistent with CPA. The size and diffuse nature of the lesion deemed it inoperable. Given our case and review of the literature it is apparent that CPA has a high risk of re-hemorrhage in the rare event that hemorrhage does occur.

Frameless versus frame-based stereotactic radiosurgery for intracranial arteriovenous malformations: A propensity-matched analysis.

Objective: The frameless linear accelerator (LINAC) based stereotactic radiosurgery (SRS) has been evolving with a reduction in patient discomfort. However, there was limited evidence comparing frame-based and frameless SRS for intracranial arteriovenous malformations (AVM). We aimed to compare the treatment outcomes between frame-based and frameless LINAC SRS. Materials and Methods: This retrospective cohort compared the outcomes of frame-based LINAC SRS (1998-2009) with frameless LINAC SRS (2010-2020). The primary outcome was the obliteration rate. The other outcomes included the neurological, radiological, and functional outcomes after SRS. A matched cohort was identified by propensity scores for further comparisons. Results: A total of 65 patients were included with a mean follow-up time of 13.2 years (158.5 months). There were 40 patients in the frame-based group and 25 patients in the frameless group. The overall obliteration rate was comparable (Frame-based 82.5% vs Frameless 80.0%, p = 0.310) and not significantly different over time (log-rank p = 0.536). The crude post-SRS hemorrhage rate was 1.5% and the incidence was 0.3 per 100 person-years. There were 67.7% of patients with AVM obliteration without new persistent neurological deficits at the last visit and 56.9% of patients with AVM obliteration without any deficits (transient or persistent) during the entire follow-up period. Four patients (8.0%) developed late onset persistent adverse radiation effects (more than 96 months after SRS) among 50 patients with more than 8-year surveillance. In the propensity-matched cohort of 42 patients, there was no significant difference in AVM obliteration (Frame-based vs Frameless, log-rank p = 0.984). Conclusion: Frameless and frame-based LINAC SRS have comparable efficacy in intracranial AVM obliteration. A longer follow-up duration may further characterize the rate of late adverse radiation effects in frameless SRS.

Primary and secondary non-traumatic intra-cerebral haemorrhage: MRI findings.

Intracranial haemorrhage (ICH) accounts for 10-30% of strokes, being the form with the worst prognosis. The causes of cerebral haemorrhage can be both primary, mainly hypertensive and amyloid angiopathy, and secondary, such as tumours or vascular lesions. Identifying the aetiology of bleeding is essential since it determines the treatment to be performed and the patient's prognosis. The main objective of this review is to review the main magnetic resonance imaging (MRI) findings of the primary and secondary causes of ICH, focusing on those radiological signs that help guide bleeding due to primary angiopathy or secondary to an underlying lesion. The indications for MRI in the event of non-traumatic intracranial haemorrhage will also be reviewed.

Sphenoidal meningoencephalocele associated with CSF fistula and arteriovenous malformation Spetzler-Martin V: A case report / Meningoencefalocele esfenoidal asociado a fístula de líquido cefalorraquídeo y malformación arteriovenosa Spetzler-Martin V: reporte de caso

Cerebral Arteriovenous malformations (AVMs) are presumed congenital anomalies of the blood vessels, which can increase intracranial pressure by uncertain mechanisms. We report the rare case of a 55-year-old male patient who complained about CSF rhinorrhea. Persisting CSF leakage prompted CT, which evidenced a bone defect in the right middle cranial fossa with protruding brain tissue. The diagnosis of a sphenoidal meningoencephalocele was made. Neuroimaging evidenced an AVM Spetzler Martin V. The lesion was targeted via an endonasal approach with resection of the herniated brain tissue and closure of the bony and dural defects. The postoperative course was uneventful without recurrence of the CSF fistula. Documentation of these cases is essential to come up with standardized therapeutical protocols and follow-up. Nevertheless, conservative management of the AVM and surgical repair of the bone defects is an appropriate approach in the first instance, depending on the morphology and characterization of the AVM (AU)

Las malformaciones arteriovenosas (MAV) son consideradas anomalías congénitas de los vasos sanguíneos; estas pueden aumentar la presión intracraneal a través de mecanismos inciertos. Reportamos el caso de un hombre de 55 años con presencia de rinolicuorrea de larga data. Se realizó la toma de una TC de cráneo, evidenciando un defecto óseo en la fosa craneal media derecha con protrusión de tejido cerebral, diagnosticando un meningoencefalocele esfenoidal. Las imágenes complementarias evidenciaron una MAV Spetzler-Martin V. La lesión fue tratada con un abordaje endonasal resecando el tejido cerebral herniado con cierre de los defectos dural y óseo. En el postoperatorio no hubo recurrencia de rinolicuorrea. La documentación de estos casos es esencial para generar protocolos estandarizados de tratamiento y seguimiento. En nuestra experiencia el manejo conservador de la MAV y el reparo quirúrgico de los defectos es un abordaje adecuado, teniendo en cuenta la morfología y caracterización de la MAV (AU)

Sphenoidal meningoencephalocele associated with CSF fistula and arteriovenous malformation Spetzler-Martin V: A case report.

Cerebral Arteriovenous malformations (AVMs) are presumed congenital anomalies of the blood vessels, which can increase intracranial pressure by uncertain mechanisms. We report the rare case of a 55-year-old male patient who complained about CSF rhinorrhea. Persisting CSF leakage prompted CT, which evidenced a bone defect in the right middle cranial fossa with protruding brain tissue. The diagnosis of a sphenoidal meningoencephalocele was made. Neuroimaging evidenced an AVM Spetzler Martin V. The lesion was targeted via an endonasal approach with resection of the herniated brain tissue and closure of the bony and dural defects. The postoperative course was uneventful without recurrence of the CSF fistula. Documentation of these cases is essential to come up with standardized therapeutical protocols and follow-up. Nevertheless, conservative management of the AVM and surgical repair of the bone defects is an appropriate approach in the first instance, depending on the morphology and characterization of the AVM.

Economic analysis of n-butyl cyanoacrylate compared with ethylene vinyl alcohol copolymer liquid embolic embolization of brain arteriovenous malformations (bAVMs) from a US hospital perspective.

BACKGROUND: In US hospitals, the liquid embolic systems (LESs) n-butyl cyanoacrylate (n-BCA) and ethylene vinyl alcohol copolymer (EVOH) are used for brain arteriovenous malformation (bAVM) embolization to achieve presurgical devascularization. The aim of this study was to perform an economic analysis comparing four techniques for bAVM embolization based on LES, ancillary device, and angiography suite time costs. METHODS: An economic model was developed comparing the embolization costs for n-BCA, EVOH with the plug and push technique, EVOH with detachable-tip microcatheters, and EVOH with balloon microcatheters. Per procedure costs were calculated for bAVMs with one to four pedicles. Annual cohort analyses were performed to evaluate the potential impact for low and high-volume centers. Sensitivity analyses were performed to determine cost drivers. RESULTS: The analyses showed that the n-BCA technique was the least costly of the four techniques. Total per procedure costs for one to four embolized pedicles ranged from $5941 to $10,074 for the n-BCA technique, $8428 to $30,345 for the EVOH balloon microcatheter technique, $12,711 to $47,477 for the EVOH plug and push technique, and $13,900 to $52,233 for the EVOH detachable-tip microcatheter technique. Cohort analyses costs for 52 annual cases ranged from $308,953 to $523,838 with the n-BCA technique and from $722,816 to $2,716,096 with the EVOH detachable-tip microcatheter technique. CONCLUSIONS: Procedure costs associated with n-BCA are lower than those with each of the three EVOH techniques examined. Future cost analyses should compare the costs of new LES products once available.

Preoperative flow analysis of arteriovenous malformations and obliteration response after stereotactic radiosurgery.

OBJECTIVE: Morphological and angioarchitectural features of cerebral arteriovenous malformations (AVMs) have been widely described and associated with outcomes; however, few studies have conducted a quantitative analysis of AVM flow. The authors examined brain AVM flow and transit time on angiograms using direct visual analysis and a computer-based method and correlated these factors with the obliteration response after Gamma Knife radiosurgery. METHODS: A retrospective analysis was conducted at a single institution using a prospective registry of patients managed from January 2013 to December 2019: 71 patients were analyzed using a visual method of flow determination and 38 were analyzed using a computer-based method. After comparison and validation of the two methods, obliteration response was correlated to flow analysis, demographic, angioarchitectural, and dosimetric data. RESULTS: The mean AVM volume was 3.84 cm3 (range 0.64-19.8 cm3), 32 AVMs (45%) were in critical functional locations, and the mean margin radiosurgical dose was 18.8 Gy (range 16-22 Gy). Twenty-seven AVMs (38%) were classified as high flow, 37 (52%) as moderate flow, and 7 (10%) as low flow. Complete obliteration was achieved in 44 patients (62%) at the time of the study; the mean time to obliteration was 28 months for low-flow, 34 months for moderate-flow, and 47 months for high-flow AVMs. Univariate and multivariate analyses of factors predicting obliteration included AVM nidus volume, age, and flow. Adverse radiation effects were identified in 5 patients (7%), and 67 patients (94%) remained free of any functional deterioration during follow-up. CONCLUSIONS: AVM flow analysis and categorization in terms of transit time are useful predictors of the probability of and the time to obliteration. The authors believe that a more quantitative understanding of flow can help to guide stereotactic radiosurgery treatment and set accurate outcome expectations.

Passive smoking may be associated with bleeding of cerebral arteriovenous malformation in non-smoking women: a retrospective analysis / O tabagismo passivo pode estar associado com o sangramento de malformação arteriovenosa cerebral em mulheres não fumantes: uma análise retrospectiva

ABSTRACT Background Smoking has been considered to be a risk factor for cardiovascular disease, cancer, depression and other diseases in previous reports, and active smoking is considered to be a risk factor for hemorrhagic stroke. In addition, a retrospective study showed that male smokers were at increased risk of bleeding from arteriovenous malformation (AVM), compared with non-smokers. However, the effect of passive smoking on rupturing of cerebral AVM in non-smoking women has not been addressed. Objective This study aimed to assess the impact of tobacco exposure on AVM bleeding risk in non-smoking women. Methods A total of 393 non-smoking women diagnosed with AVM were included. They were divided into a bleeding group (205 women) and a non-bleeding group (188 women). We conducted univariate and multivariate analysis on these two groups. In univariate analysis, risk factors that might be related to AVM bleeding were analyzed. In multivariate analysis, the relationship between passive smoking and AVM rupture was analyzed by correcting confounding factors. Results Multivariate analysis showed that the proportion of passive smoking was statistically different between the bleeding group and the non-bleeding group (OR = 1.609; CI = 1.031-2.509; p = 0.036). Conclusion Passive smoking may increase the risk of AVM bleeding in non-smoking women. This increased risk may be related to the inflammatory response, vascular wall damage, hemodynamic disorders, changes in atherosclerosis and changes in gene expression caused by passive smoking.

RESUMO Antecedentes O tabagismo tem sido considerado fator de risco para doenças cardiovasculares, câncer, depressão e outras doenças em relatos anteriores, e o tabagismo ativo é considerado fator de risco para acidente vascular cerebral hemorrágico. Além disso, um estudo retrospectivo mostrou que os fumantes do sexo masculino apresentavam risco aumentado de sangramento por malformação arteriovenosa (MAV), em comparação com os não fumantes. No entanto, o efeito do tabagismo passivo na ruptura da MAV cerebral em mulheres não fumantes não foi abordado. Objetivo: Este estudo teve como objetivo avaliar o impacto da exposição ao tabaco no risco de sangramento de MAV em mulheres não fumantes. Métodos Foram incluídas 393 mulheres não fumantes diagnosticadas com MAV. Elas foram divididas em um grupo com sangramento (205 mulheres) e um grupo sem sangramento (188 mulheres). Realizamos análise univariada e multivariada nesses dois grupos. Na análise univariada, foram analisados ​​os fatores de risco que podem estar relacionados ao sangramento de MAV. Na análise multivariada, a relação entre tabagismo passivo e ruptura de MAV foi analisada por meio da correção de fatores de confusão. Resultados A análise multivariada mostrou que a proporção de tabagismo passivo foi estatisticamente diferente entre o grupo com sangramento e o grupo sem sangramento (OR = 1,609; IC = 1,031-2,509; p = 0,036). Conclusão O tabagismo passivo pode aumentar o risco de sangramento de MAV em mulheres não fumantes. Esse risco aumentado pode estar relacionado à resposta inflamatória, danos na parede vascular, distúrbios hemodinâmicos, alterações na aterosclerose e alterações na expressão gênica causadas pelo tabagismo passivo.

Safety and Effectiveness of First-line Endovascular Management of Low-Grade Brain Arteriovenous Malformations : Single Center Experience in 145 Patients.

PURPOSE: Spetzler-Martin grade (SMG) I-II (low-grade) brain arteriovenous malformations (BAVMs) are often considered safe for microsurgical resection; however, the role of endovascular treatment (EVT) remains to be clarified in this indication, especially for unruptured BAVMs. The purpose of our study was to assess the safety and effectiveness of endovascular treatment as the first-line treatment for low-grade BAVMs. METHODS: From our local database, we retrospectively retrieved patients with low-grade BAVMs, either ruptured or unruptured, treated by embolization as first-line treatment in our department between January 2005 and January 2020. The primary endpoint was the total obliteration rate of BAVMs, and secondary endpoints were hemorrhagic complications and final clinical outcome, assessed through shift of the modified Rankin scale, and mortality rate secondary to BAVM embolization. RESULTS: A total of 145 patients meeting inclusion criteria and treated by EVT as first-line therapy were included in the study (82 ruptured and 63 unruptured BAVMs). Overall, complete exclusion of BAVMs was achieved in 110 patients (75.9%); 58 patients (70.7%) with ruptured and 52 (82.5%) unruptured BAVMs, including 37.9% BAVMs excluded by EVT alone (35.5% among ruptured and 44.4% among unruptured BAVMs) and 38% by combined treatment (EVT and surgery or EVT and SRS). There was no BAVM volume cut-off predictive for total obliteration by embolization alone. Early minor hemorrhagic complications were reported in 14 patients (9.6%) and early major hemorrhagic complications were reported in 5 patients (3.4%). No late hemorrhagic complications (0%) occurred; mortality rate was 0.7% (1/145 patients). Improved/unchanged mRS was reported in 137 patients (94.5%). CONCLUSION: Endovascular treatment alone or associated with others exclusion techniques, might be safe and effective for complete exclusion of low-grade brain arteriovenous malformations regardless of the volume.

Perioperative Complications of Transvenous Embolization of Ruptured Intracranial Arteriovenous Malformations.

Purpose: To investigate the perioperative complications of transvenous embolization of ruptured intracranial arteriovenous malformations. Materials and Methods: A total of 27 patients with ruptured intracranial arteriovenous malformations underwent transvenous embolization were enrolled from November 2016 to May 2020 in our prospective database. Perioperative complications and angiographic characteristics were analyzed retrospectively. Results: Complete disappearance of the nidus occured in 22 (88%) of 25 patients with technically feasible AVMs immediately after embolization. Two cases were partially treated by transarterial embolization due to the failure of microcatheter placement into the draining vein. Seven (25.9%, 7/27) patients had perioperative complications, including three cases of intraoperative hemorrhage, three cases of postoperative hemorrhage and one case of ischemic infarction. No significant differences in complication rates between patients with nidus ≥3 cm and <3 cm (P = 0.659), eloquent area and non-eloquent (P = 0.137), deep location and superficial (P = 0.637), deep venous drainage and cortical vein (P = 1.0), the number of venous drainage (P = 0.49), the angle of draining vein entering venous sinus <90° and ≥90° (P = 1.0), aneurysms (P = 0.058) and the time between hemorrhage and TVE (P = 1.0) were found. Three of these patients received ventriculostomy, two of which received lumbar drainage treatments at the same time, and four patients just received conservative management. Good outcomes (mRS ≤ 2) at the 1-month evaluation were achieved in 5 of the patients who had complications, but poor outcome (mRS = 5) at the 1-month evaluation was in 1 patient, and 1 lethal complication occurred. Conclusion: The most common complication of AVMs with transvenous endovascular embolization is cerebral hemorrhage. The prevention of complications may improve the efficacy of AVM embolization, but the current quality of evidence is low and limited in guiding policy development and improving the TVE for AVMs. It is, therefore, necessary to develop clinical research programs in this field.

Extracranial Arteriovenous Malformations Rupture in Pregnancy.

Arteriovenous malformations are congenital vascular malformations with a high flow rate. They are made up of a complex vessel system that forms a nidus by connecting feeding arteries to draining veins. Arteriovenous malformations can be fatal due to progressive symptoms and infiltrative disease. The head and neck are the most affected areas by extracranial arteriovenous malformations, followed by the limbs. Hormonal changes during pregnancy lead to the expansion of arteriovenous malformations, which may lead to aggressive progression. We present a case of a patient who had a very rare presentation of ruptured forehead arteriovenous malformations during her fifth pregnancy. A combination of radiological embolization followed by surgical excision was used to treat the condition.

Comparing hematoma characteristics in primary intracerebral hemorrhage versus intracerebral hemorrhage caused by structural vascular lesions.

Intracerebral hemorrhage (ICH) caused by structural vascular lesions is associated with better outcomes than primary ICH, but this relationship is poorly understood. We tested the hypothesis that ICH from a vascular lesion has more benign hematoma characteristics compared to primary ICH. We performed a retrospective study using data from our medical center. The SMASH-U criteria were used to adjudicate the etiology of ICH. The co-primary outcomes were admission parenchymal hematoma volume and hematoma expansion at 24 h. Linear and logistic regression analyses were performed to test associations. A total of 231 patients were included of whom 42 (18%) had a vascular lesion. Compared to primary ICH patients, those with structural vascular lesions were younger (49 vs. 68 years, p < 0.001), less likely to have hypertension (29% vs. 74%, p < 0.001), had lower mean admission systolic blood pressure (140 ± 23 vs. 164 ± 35, p < 0.001), less frequently had IVH (26% vs. 44%, p = 0.03), and had mostly lobar or infratentorial hemorrhages. The median admission hematoma volume was smaller with vascular lesions (5.9 vs. 9.7 mL, p = 0.01). In regression models, ICH from a vascular lesion was associated with smaller admission hematoma volume (beta, -0.67, 95% CI, -1.29 to -0.05, p = 0.03), but no association with hematoma expansion was detected when assessed as a continuous (OR, 0.93; 95% CI, -4.46 to 6.30, p = 0.73) or dichotomous exposure (OR, 1.86; 95% CI, 0.40 to 8.51, p = 0.42). In a single-center cohort, patients with ICH from vascular lesions had smaller hematoma volumes than patients with primary ICH.

Correlation between angioarchitectural characteristics of brain arteriovenous malformations and clinical presentation of 183 patients / Impacto das características angioarquiteturais das malformações arteriovenosas cerebrais na apresentaçáo clínica: análise de 183 pacientes

ABSTRACT Background: The correlation between angioarchitecture and clinical presentation of brain arteriovenous malformation (bAVM) remains a subject of debate. Objective: The main purpose of the present study was to assess the correlation between angioarchitectural characteristics of bAVM and clinical presentation. Methods: A retrospective review of all consecutive patients presenting a bAVM who underwent a cerebral angiography at Beneficencia Portuguesa Hospital in São Paulo between January 2006 and October 2016 was carried out. Patients were divided in five groups: group 1 - hemorrhage; group 2 - seizure; group 3 - headache; group 4 - progressive neurological deficits (PND); group 5 - incidental). Results: A total of 183 patients were included, with group 1 comprising 56 cases, group 2 49 cases, group 3 41 cases, group 4 28 cases, and group 5 9 cases. Regarding hemorrhage presentation, a statistical correlation was observed with female gender (P < 0.02), Spetzler-Martin 3B (P < .0015), and lesions with low flow (P < 0.04). A positive association was found between group 2 and age less than 36 years (P < 0.001), male sex (P < 0.018), presence of superficial lesions not classified as SM 3B (P < 0.002), presence of venous ectasia (p <0.03), and arterial steal phenomenon (P < 0.03). Group 4 was associated with older age (P < 0.01). Conclusions: Angioarchitectural characteristics can be correlated with some clinical presentations as well as with some clinical data, making it possible to create predictive models to differentiate clinical presentations.

RESUMO Antecedentes: A correlação entre a angioarquitetura e a apresentação clínica da Malformação Arteriovenosa do cérebro (MAVc) permanece um assunto de debate. Objetivos: Correlacionar as características angioarquiteturais das MAVc com a apresentação clínica. Métodos: Estudou-se pacientes consecutivos atendidos no Hospital Beneficência Portuguesa-SP, entre 2006 a 2016. Após análise geral, criaram-se cinco grupos de acordo com a apresentação clínica: 1- Hemorragia; 2 - Epilepsia; 3 - Cefaléia; 4 - Déficit Neurológico Progressivo (DNP) e 5 - Incidental. Características epidemiológicas (clínica e topografia) e angioarquiteturais (Classificação de Spetzler-Martin Modificada - SMM; Fluxo intranidal; Aneurismas arteriais, intranidais e venosos; Ectasia venosa; Congestão venosa; "Roubo" arterial; Vascularização dural; Drenagem Venosa Profunda) foram analisadas. Resultados: 183 pacientes foram incluídos e analisados globalmente. Após essa etapa, foram divididos nos grupos: 1 - 56 casos (30,6%); 2 - 49 casos (26,7%); 3 - 41 casos (22,4%); 4 - 28 casos (15,3%) e 5 - 9 casos (4,9%). Principais achados foram referentes a apresentação hemorrágica, na qual observamos correlação estatística positiva com o sexo feminino (P<0,02), lesões classificadas como SMM 3B (P<0,0015) e baixo fluxo (P<0,04). Relacionado à epilepsia, encontramos significância estatística que possibilitou a correlação com pacientes com idade inferior a 36 anos (P<0,001), sexo masculino (P<0,018), lesões superficiais (P<0,002), presença de ectasia venosa (P<0,003) e "roubo" arterial (P<0,01). Pacientes com DNP se apresentam com idade superior aos demais (P<0,01). Conclusões: Após análise multivariada, foi possível separar as MAV em grupos de acordo com as características angioarquiteturais, comprovando que algumas dessas características estão fortemente relacionadas a determinada manifestação.

Fulminant Guillain-Barré syndrome developed after surgical treatment of intracranial hemorrhage due to arteriovenous malformation: a case report.

Guillain-Barré syndrome (GBS) is a rare autoimmune disorder. GBS after surgical treatment of intracranial hemorrhage due to arteriovenous malformation (AVM) is even rarer. We present a 62-year-old man diagnosed with intracranial AVM and cerebral hemorrhage. He developed GBS after the operation for AVM and cerebral hemorrhage. Following surgical excision of AVM and cerebral hematoma, the patient developed generalized weakness, with subsequent quadriplegia and life-threatening dyspnea. The diagnosis was confirmed to be the acute motor-sensory axonal neuropathy subtype of GBS after cerebrospinal fluid analysis and antibody tests. The patient responded poorly to immunoglobulin and steroid therapy. His family abandoned further management and signed out of the hospital against medical advice. Despite being rare, GBS can occur after intracranial hemorrhage and surgery. Clinicians should rule out GBS when patients show no improvement or develop new neurologic.

Single-center experience with endovascular treatment of cerebral arteriovenous malformations with intent to cure in pediatric patients.

PURPOSE: This study aimed to report the incidence of technical complications and immediate complete angiographic occlusion, identify associated factors with failure of complete occlusion and identify predictors of technical complications in a single-center experience of pediatric arteriovenous malformations (AVM) treated with endovascular treatment with intent to cure. METHODS: Patients between 1 and 18 years of age undergoing endovascular embolization between 2011 and 2020 were included. RESULTS: A total of 120 embolizations were performed in 69 patients. The most frequent clinical presentation was intracerebral hemorrhage (76.8%). Immediate obliteration of the malformations was achieved in 40 (58%) cases. The technical complication rate was 15%. AVM nidus size between 3 and 6 cm (OR: 3.91; 95% CI 1.1-13.85; p = 0.035) and the presence of multiple feeders (OR: 5.08; 95% CI 1.41-18.28; p = 0.074) were predictive of failure of immediate complete occlusion. The location of the temporal lobe (OR: 7.83; p = 0.048), deep venous drainage (OR: 4.67; p = 0.112), and the presence of an intranidal aneurysm (OR: 3.58; p = 0.134) were predictors of technical complications. CONCLUSIONS: Embolization of pediatric AVMs with intent to cure shows a high rate of technical complications and acceptable immediate occlusion rates. Nidus size and the presence of multiple feeders were predictive of failure of complete occlusion, while temporal lobe location, deep venous drainage, and the presence of an intranidal aneurysm were predictors of technical complications. Further studies are needed to determine the best therapeutic approach in the pediatric population.

Application of susceptibility-weighted imaging in intracranial dural arteriovenous fistula / 国际脑血管病杂志

Objective:To investigate the application value of susceptibility-weighted imaging (SWI) in the diagnosis of intracranial dural arteriovenous fistula (DAVF).Methods:Patients with DAVF confirmed by digital subtraction angiography (DSA) in Weihai Municipal Hospital from January 2014 to January 2021 were retrospectively included. All patients underwent conventional T 1-weighted imaging (T 1WI), T 2-weighted imaging (T 2WI) and SWI, and some patients also underwent 3D time-of-flight magnetic resonance angiography (3D-TOF-MRA). Results:A total of 36 patients with DAVF were enrolled, 29 of them received 3D-TOF-MRA. The fistula location of 24 patients (24/36, 66.7%) underwent SWI and 26 patients (26/29, 89.7%) underwent 3D-TOF-MRA were correctly judged, and the difference was statistically significant (Fisher's Exact Test, P=0.039). SWI showed that the proportion of patients with thickened supply arteries (7/36, 19.4%) was significantly lower than that on 3D-TOF-MRA (14/29, 48.3%; χ2=6.105, P=0.013). T 2WI, 3D-TOF-MRA and SWI showed no cerebral venous abnormalities in all 7 patients with DAVF without cortical venous reflux; in 29 patients with DAVF with cortical venous reflux revealed by DSA, SWI and T 2WI showed all patients (100%) and 26 patients (89.7%) had superficial venous dilatation respectively, but there was no significant difference ( χ2=0.693, P=0.405). SWI showed medullary vein dilation in 17 patients (47.2%), and only 2 patients (5.6%) had medullary vein thickening on T 2WI, and the difference was statistically significant ( P<0.001). The proportion of patients with venous cerebral infarction on T 2WI was significantly higher than that on SWI (22.2% vs. 0%; Fisher’s Exact Test P=0.005), and the proportion of patients with intracerebral hemorrhage on SWI was significantly higher than that on T 2WI (61.1% vs. 25.0%; χ2=9.574, P=0.004). Conclusion:SWI is helpful to evaluate the abnormal drainage vein of DAVF and the secondary changes in brain, especially intracerebral hemorrhage.

Treatment of cerebral arteriovenous malformations in children / 国际脑血管病杂志

Brain arteriovenous malformation (bAVM) is a common cerebrovascular disease in clinical practice. Compared with adults, children with bAVM are more prone to rupture and bleeding, and have a higher mortality and disability. Therefore, it is very important to accurately evaluate the bleeding risk of children with bAVM and reasonably select intervention measures to improve the prognosis. The treatment methods of children with bAVM mainly include conservative treatment, microsurgical treatment, endovascular embolization, stereotactic radiosurgery, and multimodal combined treatment. At present, the treatment indications and specific treatment options for children with bAVM are controversial.

Magnetic resonance imaging detected radiation-induced changes in patients with proton radiation-treated arteriovenous malformations.

BACKGROUND: Treatment of intracranial arteriovenous malformations (AVMs) includes surgery, radiation therapy, endovascular occlusion, or a combination. Proton radiation therapy enables very focused radiation, minimizing dose to the surrounding brain. PURPOSE: To evaluate the presence of radiation-induced changes on post-treatment MRI in patients with AVMs treated with proton radiation and to compare these with development of symptoms and nidus obliteration. MATERIAL AND METHODS: Retrospective review of pre- and post-treatment digital subtraction angiography and MRI and medical records in 30 patients with AVMs treated with proton radiation. Patients were treated with two or five fractions; total radiation dose was 20-35 physical Gy. Vasogenic edema (minimal, perinidal, or severe), contrast enhancement (minimal or annular), cavitation and nidus obliteration (total, partial, or none) were assessed. RESULTS: 26 of 30 patients (87%) developed MRI changes. Vasogenic edema was seen in 25 of 30 (83%), abnormal contrast enhancement in 18 of 26 (69%) and cavitation in 5 of 30 (17%). Time from treatment to appearance of MRI changes varied between 5 and 25 months (median 7, mean 10). Seven patients developed new or deteriorating symptoms that required treatment with corticosteroids; all these patients had extensive MRI changes (severe vasogenic edema and annular contrast enhancement). Not all patients with extensive MRI changes developed symptoms. We found no relation between MRI changes and nidus obliteration. CONCLUSION: Radiation-induced MRI changes are seen in a majority of patients after proton radiation treatment of AVMs. Extensive MRI changes are associated with new or deteriorating symptoms.