Tag: Cerebral arteriovenous malformation

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Seizure Outcomes in Patients With Surgically Treated Cerebral Arteriovenous Malformations

ICG and AVM

Neurosurgery 77:762–768, 2015

Epilepsy is the second most common symptom in cerebral arteriovenous malformation (AVM) patients. The consecutive reduction of life quality is a clinically underrated problem because treatment usually focuses on the prevention of intracerebral hemorrhage.

OBJECTIVE: To evaluate postoperative seizure outcome with the aim of more accurate counseling for postoperative seizure outcome.

METHODS: From 1985 to 2012, 293 patients with an AVM were surgically treated by J.S. One hundred twenty-six patients with preoperative seizures or epilepsy could be identified; 103 of 126 had a follow-up of at least 12 months and were included in the analysis. The different epilepsy subtypes were categorized (sporadic seizures, chronic epilepsy, drug-resistant epilepsy [DRE]). Preoperative workup and surgical technique were evaluated. Seizure outcome was analyzed by using International League Against Epilepsy classification.

RESULTS: Sporadic seizures were identified in 41% of patients (chronic epilepsy and DRE were identified in 36% and 23%, respectively). Detailed preoperative epileptological workup was done in 13%. Seizure freedom was achieved in 77% (79% at 5 years, 84% at 10 years). Outcome was significantly poorer in DRE cases. More extensive resection was performed in 11 cases with longstanding symptoms (.24 months) and resulted in better seizure outcome as well as the short duration of preoperative seizure history.

CONCLUSION: Patients presenting with AVM-associated epilepsy have a favorable seizure outcome after surgical treatment. Long-standing epilepsy and the progress into DRE markedly deteriorate the chances to obtain seizure freedom and should be considered an early factor in establishing the indication for AVM removal.

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Results for a Series of 697 Arteriovenous Malformations Treated by Gamma Knife

AVM frontal

Neurosurgery 75:568–583, 2014

Stereotactic radiosurgery (RS) is an effective tool in treating brain arteriovenous malformations (AVMs). Careful study of AVM angiographic characteristics may improve results.

OBJECTIVE: To report the long-term outcomes of Gamma Knife RS (GKRS) in brain AVMs, focusing on how the angioarchitectural and hemodynamic parameters of AVMs affect the post-RS results.

METHODS: This was a retrospective, longitudinal study of 697 consecutive GKRS treatments of brain AVMs in 662 patients performed at a single center between 1993 and 2005. The mean age of the patients was 37 years; the median AVM volume was 3.6 cm3; and the mean follow-up was 11 years. Forty-five percent of patients presented with intracranial hemorrhage; 44% underwent embolization; and 7% had multiple RSs. AVM characteristics in the RS-planning angiograms were analyzed, and their relationship to the post-RS obliteration rate was determined by univariate and multivariate analyses.

RESULTS: The obliteration rate after a single RS was 69.3%; after multiple RS, it was 75%. Positive predictors of obliteration included compact nidus (odds ratio = 3.16; 95% confidence interval, 1.92-5.22), undilated feeders (odds ratio = 0.36; 95% confidence interval, 0.23-0.57), smaller AVM volume (odds ratio = 0.95; 95% confidence interval, 0.92-0.99), and higher marginal dose (odds ratio = 1.16; 95% confidence interval, 1.06-1.27). Improvement or clinical stability was observed in 89.3% of patients; postprocedural bleeding was noted in 6.1%; and clinical worsening attributable to RS was seen in 3.8%. The annual risk of hemorrhage in the 4 years after RS was 1.2%.

CONCLUSION: GKRS yielded a good long-term clinical outcome in most patients. Certain angiographic features of brain AVMs such as a well-defined nidus and undilated feeder arteries contribute to AVM occlusion by RS. GKRS can be regarded as the treatment of choice for AVMs <6 cm3, even after bleeding.

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Evaluation of Serial Intraoperative Surgical Microscope-Integrated Intraoperative Near-Infrared Indocyanine Green Videoangiography in Patients With Cerebral Arteriovenous Malformations

Neurosurgery 70[ONS Suppl 1]:ons34–ons43, 2012 DOI: 10.1227/NEU.0b013e31822d9749 

With the use of indocyanine green (ICG) as a novel fluorescent dye, fluorescence angiography has recently reemerged as a viable option.

OBJECTIVE: To show the result of ICG videoangiography in cases of cerebral arteriovenous malformations.

METHODS: Twenty-seven ICG videoangiography procedures were performed in 11 patients with cerebral arteriovenous malformations. Intraoperative digital subtraction angiography (DSA) was performed 27 times in these patients. The timing of intraoperative DSA was before dissection, after clipping of feeders, and after dissection of the nidus.

RESULTS: The procedures were performed in 4.7 ± 1.4 minutes (mean ± SD; n = 27 minutes), whereas intraoperative digital subtraction angiography was performed for a mean of 16.6 ± 3.8 minutes (n = 27 minutes). In predissection studies, feeders were visualized by ICG in 3 of 9 cases. The nidus was visualized in all 9 cases, and drainers were visualized in 8. Intraoperative DSA visualized the feeders, nidus, and drainers in all 9 cases. After clipping of feeders, ICG videoangiography showed flow reduction of the nidus in 7 of 7 cases. Intraoperative DSA also showed that finding in 9 of 9 cases. After total dissection of the nidus, all cases disclosed that the drainers were without ICG filling. Intraoperative DSA also showed that result in all of the cases. Unexpected residual nidus was not visualized in our series with either method.

CONCLUSION: We found that ICG videoangiography is helpful for resecting cerebral arteriovenous malformation. It is especially effective in visualizing the nidus and superficial drainers, as well as changes in flow after clipping or coagulating of feeders.

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