Delayed coil migration into oropharynx following endovascular coiling of a traumatic carotid cavernous fistula

Acta Neurochirurgica (2022) 164:1287–1292

Carotid-cavernous fistulas (CCFs) are abnormal vascular shunts between the carotid artery and the cavernous sinus.

A 37-year-old male presented with a traumatic CCF and basal skull fracture extending through the medial wall of the cavernous sinus and sphenoid sinus. The CCF was treated with endovascular coiling.

Three months after this procedure, he was found to have coil migration through the traumatic sphenoid defect into the pharynx. He underwent urgent endonasal endoscopic surgery to disconnect and remove the extruded coil.

Post-operative coil migration is a rare but serious complication following endovascular treatment of traumatic CCF.

Recurrence and risk factors of posterior communicating artery aneurysms after endovascular treatment

Acta Neurochirurgica (2021) 163:2319–2326

Endovascular treatment (EVT) of posterior communicating artery aneurysms (PcomA) is challenging because of posterior communicating artery (Pcom) architecture. Additionally, these aneurysms have a high risk of recanalization compared with those located elsewhere.

Methods The radiographic findings of 171 patients treated with EVT at two institutions were retrospectively reviewed. Univariate and multivariate analyses were performed, and subgroup analyses were performed based on Pcom characteristics.

Results Recanalization of PcomAs occurred in 53 patients (30.9%). Seven patients (4.0%) were retreated (six endovascularly and one with microsurgical clipping). The mean follow-up duration was 27.7 months (range: 3.5–78.6). The maximum diameter (odds ratio [OR] 1.23, P = .006, 95% CI 1.07–1.44), a Raymond–Roy classification of grade II or III (OR 2.26, P = .03, 95% CI 1.08–4.82), and the presence of reinforcement (balloon or/and stent, OR 0.44, P = .03, 95% CI 0.20–0.91) were associated with recanalization using multivariate logistic regression. Significant differences were found in maximum aneurysm diameter (P = .03) between normal- and fetal-type Pcoms on analysis of variance.

Conclusions The recanalization rate of PcomAs after EVT was 30.9%; the retreatment rate was 4.0%. Maximum diameter, Raymond–Roy classification, and presence of reinforcement were significantly associated with recanalization but not associated with fetal-type Pcom. Aneurysm size was larger in patients with a fetal-type Pcom than in those with a normal Pcom. Pcom size was not related to recanalization rate.

Neuroform Atlas Stent for Treatment of Middle Cerebral Artery Aneurysms

Neurosurgery 89:102–108, 2021

Heterogeneous effect of endovascular aneurysm therapy has been observed across different anatomic locations. There is a paucity of data for stent-assisted coiling of middle cerebral artery (MCA) aneurysms.

OBJECTIVE: To present the results of the MCA aneurysmgroup from the Neuroform Atlas (Stryker Neurovascular) investigational device exemption (IDE) trial.

METHODS: The Atlas IDE trial is a prospective, multicenter, single-arm, open-label study of wide-neck aneurysms (neck ≥ 4 mm or dome-to-neck ratio < 2) in the anterior circulation treated with the Neuroform Atlas Stent and approved coils. Follow-up was obtained immediately postprocedure and 2, 6, and 12 mo postoperatively.We herein describe safety and efficacy outcomes, and functional independence of the subjects with aneurysms from all segments of MCA.

RESULTS: A total of 35 patients were included (27 MCA bifurcation, 5 M1, 3 M2). The mean aneurysm size was 6.0 ± 1.8 mm, and the mean neck was 4.4 ± 1.2 mm. Technical procedural success was achieved in all patients. A total of 26 patients had follow-up digital subtraction angiography available at 12mo, with 80.8% (21/26) having complete aneurysm occlusion. Twelve-month safety data were collected for 91.4% (32/35), 8.5% (3/35) had primary safety endpoint, all 3 major ischemic strokes. Mortality occurred in 2 patients beyond 30 d unrelated to procedure (1 gallbladder cancer and 1 fentanyl intoxication). At 1 yr, modified Rankin Score was 0 to 2 in 84.4% (27/32), 3 in 9.4%, and 3 patientswere missing. Approximately 5.7% (2/35) of patients were retreated at 12 mo.

CONCLUSION: Stent-assisted coiling with the Neuroform Atlas Stent is a viable alternative to clipping for selected MCA aneurysms. Complete aneurysm occlusion rates have improved compared to historical data. Proper case selection can lead to acceptable endovascular results.

Predictors of Complications, Functional Outcome, and Morbidity in a Large Cohort TreatedWith Flow Diversion

Neurosurgery DOI:10.1093/neuros/nyz508

A dramatic improvement in obliteration rates of large, wide-necked aneurysms has been observed after the FDA approved the Pipeline Embolization Device (PED) in 2011.

OBJECTIVE: To assess the predictors of complications, morbidity, and unfavorable outcomes in a large cohort of patients with aneurysms treated with PED.

METHODS: A retrospective chart review of a prospectively maintained database for subjects treated with flow diversion from 2010 to 2019.

RESULTS: A total of 598 aneurysms were treated during a period extending from 2010 to 2019 (84.28% females, mean age 55.5 yr, average aneurysm size 8.49 mm). Morbidity occurred at a rate of 5.8% and mortality at a rate of 2.2%. Ischemic stroke occurred at a rate of 3%, delayed aneurysmal rupture (DAR) at 1.2%, and distal intraparenchymal hemorrhage (DIPH) at 1.5%. On multivariate analysis, the predictor of stroke was aneurysm size>15 mm. Predictors of DAR were previous subarachnoid hemorrhage (SAH), increasing aneurysm size, and posterior circulation aneurysm. Predictors of DIPH were using more than 1 PED and baseline P2Y12 value. Predictors of in-stent stenosis were the increasing year of treatment and balloon angioplasty, whereas increasing age and previous treatment were negatively associated with in-stent stenosis. Predictors of morbidity were posterior circulation aneurysms, increasing aneurysm size, and hypertension, and incidental aneurysm diagnosis was protective for morbidity.

CONCLUSION: Flow diversion is a safe and effective treatment option for aneurysms. A better understanding of predictive factors of complications, morbidity, and functional outcomes is of high importance for a more accurate risk assessment.

Flow diversion treatment of complex bifurcation aneurysms beyond the circle of Willis: complications, aneurysm sac occlusion, reabsorption, recurrence, and jailed branch modification at follow-up

J Neurosurg 131:1751–1762, 2019

The purpose of this study is to present the authors’ medium-term results, with special emphasis on complications, occlusion rate of the aneurysm sac (digital subtraction angiography [DSA] and MRI), and the fate of cortical branches and perforating arteries covered (“jailed”) by the flow diverter (FD) stent.

METHODS Between January 2010 and September 2017, 29 patients (14 female) with 30 aneurysms were treated with an FD stent. Twenty-one aneurysms were at the middle cerebral artery bifurcation, 8 were in the anterior communicating artery region, and 1 was a pericallosal artery bifurcation. Thirty-five cortical branches were covered. A single FD stent was used in all patients. Symptomatic and asymptomatic periprocedural and delayed complications were reported. DSA and MRI controls were analyzed to evaluate modification of the aneurysm sac and jailed branches.

RESULTS Permanent morbidity was 3.4% (1/29), due to a jailed branch occlusion, with a modified Rankin Scale (mRS) score of 2 at the last follow-up. Mortality and permanent complication with poor prognosis (mRS score > 2) rates were 0%. The mean follow-up time for DSA and MRI (mean ± SD) was 21 ± 14.5 months (range 3–66 months) and 19 ± 16 months (range 3–41 months), respectively. The mean time to aneurysm sac occlusion (available for 24 patients), including stable remodeling, was 11.8 ± 6 months (median 13, range 3–27 months). The overall occlusion rate was 82.1% (23/28), and it was 91.7% (22/24) in the group of patients with at least 2 DSA control sequences. One recanalization occurred at 41 months posttreatment. At the time of publication, at the latest follow-up, 7 (20%) of 35 covered branches were occluded, 18 (51.4%) showed a decreased caliber, and the remaining 10 (28.5%) were unchanged. MRI T2-weighted sequences showed complete sac reabsorption in 7/29 aneurysms (24.1%), and the remaining lesions were either smaller (55.2%) or unchanged (17.2%). MRI revealed asymptomatic and symptomatic ischemic events in perforator territories in 7/28 (25%) and 4/28 (14.3%) patients, respectively, which were reversible within 24 hours.

CONCLUSIONS Flow diversion of bifurcation aneurysms is feasible, with low rates of permanent morbidity and mortality and high occlusion rates; however, recurrence may occur. Caliber reduction and asymptomatic occlusion of covered cortical branches as well as silent perforator stroke are common. Ischemic complications may occur with no identified predictable factors. MRI controls should be required in all patients to evaluate silent ischemic lesions and aneurysm sac reabsorption over time.

Surgical or endovascular management of ruptured intracranial aneurysms: an agreement study

J Neurosurg 131:25–31, 2019

Ruptured intracranial aneurysms (RIAs) can be managed surgically or endovascularly. In this study, the authors aimed to measure the interobserver agreement in selecting the best management option for various patients with an RIA.

METHODS The authors constructed an electronic portfolio of 42 cases of RIA in which an angiographic image along with a brief clinical vignette for each patient were displayed. Undisclosed to the responders was that the RIAs had been categorized as International Subarachnoid Aneurysm Trial (ISAT) (small, anterior-circulation, non–middle cerebral artery location, n = 18) and non-ISAT (n = 22) aneurysms; the non-ISAT group also included 2 basilar apex aneurysms for which a high number of endovascular choices was expected. The portfolio was sent to 132 clinicians who manage pa- tients with RIAs and circulated to members of an American surgical association. Judges were asked to choose between surgical and endovascular management, to indicate their level of confidence in the choice of treatment on a quantitative 0–10 scale, and to determine whether they would include the patient in a randomized trial in which both treatments are compared. Eleven clinicians were asked to respond twice at least 1 month apart. Responses were analyzed using kappa statistics.

RESULTS Eighty-five clinicians (58 cerebrovascular surgeons, 21 interventional neuroradiologists, and 6 interventional neurologists) answered the questionnaire. Overall, endovascular management was chosen more frequently (n = 2136 [59.8%] of 3570 answers). The proportions of decisions to clip were significantly higher for non-ISAT (50.8%) than for ISAT (26.2%) aneurysms (p = 0.0003). Interjudge agreement was only fair (kappa 0.210, 95% CI 0.158–0.276) for all cases and judges, despite high confidence levels (mean score > 8 for all cases). Agreement was no better within sub- groups of clinicians with the same specialty, years of experience, or location of practice or across capability groups (ability to clip or coil, or both). When agreement was defined as > 80% of responders choosing the same option, agreement occurred for only 7 of 40 cases, all of which were ISAT aneurysms, for which coiling was preferred.

CONCLUSIONS Agreement between clinicians regarding the best management option was infrequent but centered around coiling for some ISAT aneurysms. Surgical clipping was chosen more frequently for non-ISAT aneurysms than for ISAT aneurysms. Patients with such an aneurysm might be candidates for inclusion in randomized trials.

Aneurysm wall enhancement on magnetic resonance imaging as a risk factor for progression of unruptured vertebrobasilar dissecting aneurysms after reconstructive endovascular treatment

J Neurosurg 128:747–755, 2018

The recurrence rate of vertebrobasilar dissecting aneurysms (VBDAs) after reconstructive endovascular treatment (EVT) is relatively high. The aneurysm wall enhancement on high-resolution MRI (HRMRI) reportedly predicts an unsteady state of an intracranial aneurysm. The authors used HRMRI to investigate the relationship between wall enhancement on HRMRI and progression of VBDAs after reconstructive EVT.

METHODS From January 2012 to December 2015, patients with an unruptured VBDA who underwent reconstructive EVT were enrolled in this study. Preoperative enhanced HRMRI was performed to evaluate radiological characteristics. The relationships between aneurysm wall enhancement and various potential risk factors were statistically analyzed. Follow-up angiographic examination was performed with digital subtraction angiography and conventional HRMRI. Cox regression analysis was performed to identify predictors of VBDA progression after reconstructive EVT.

RESULTS Eighty-two patients (12 women and 70 men, mean age 53.48 ± 9.23 years) with 83 VBDAs were evaluated in the current study. The average maximum diameter of the VBDAs was 11.30 ± 7.90 mm. Wall enhancement occurred in 43 VBDAs (51.81%). Among all 83 VBDAs, 62 (74.70%) were treated by stent-assisted coil embolization and 21 (25.30%) by stenting alone. The mean duration of imaging follow-up among all 82 patients was 10.55 months (range 6–45 months), and 15 aneurysms (18.07%) exhibited progression. The statistical analysis indicated no significant differences in age, sex, risk factors (high blood pressure, smoking, diabetes mellitus, and a high cholesterol level), VBDA stage, or VBDA size between enhanced and unenhanced VBDAs. Univariate Cox regression analysis showed that both the maximum diameter of the VBDAs and wall enhancement were associated with recurrence (p < 0.05). Multivariate Cox proportional hazard regression analysis showed that the maximum diameter of the VBDAs and wall enhancement on HRMRI were independent risk factors for aneurysm progression (p < 0.05).

CONCLUSIONS Aneurysm size and wall enhancement on HRMRI can predict the progression of VBDAs after reconstructive EVT.

Validation of a System to Predict Recanalization After Endovascular Treatment of Intracranial Aneurysms


Neurosurgery 77:168–174, 2015

With increasing use of endovascular techniques in the treatment of ruptured and unruptured aneurysms, the issue of obliteration efficacy has become increasingly important. We have previously reported the Aneurysm Recanalization Stratification Scale, which uses accessible predictors including aneurysm-specific factors (size, rupture, and intraluminal thrombosis) and treatment-related features (treatment modality and immediate angiographic result) to predict retreatment risk after endovascular therapy.

OBJECTIVE: To assess the external validity of the Aneurysm Recanalization Stratification Scale.

METHODS: External validity was assessed in independent cohorts from 4 centers in the United States and Canada where endovascular and open neurovascular procedures are performed, and in a multicenter cohort of 1543 patients. Probability of retreatment stratified by risk score was derived for each center and the combined multicenter cohort.

RESULTS: Despite moderate variability in retreatment rate among centers (29.5%, 9.9%, 9.6%, 26.3%, 19.7%, and 18.3%), the Aneurysm Recanalization Stratification Scale demonstrated good predictive value with C-statistics of 0.799, 0.943, 0.780, 0.695, 0.755, and 0.719 for each center and the combined cohort, respectively. Probability of retreatment stratified by risk score for the combined cohort is as follows: -2, 4.9%; -1, 5.7%; 0, 5.8%; 1, 13.1%; 2, 19.2%; 3, 34.9%; 4, 32.7%; 5, 73.2%; 6, 89.5%; and 7, 100.0%.

CONCLUSION: Surgical decision-making and patient-centered informed consent require comprehensive and accessible information on treatment efficacy. The Aneurysm Recanalization Stratification Scale is a valid prognostic index. This is the first comprehensive model that has been developed to quantitatively predict retreatment risk following endovascular therapy.

Stratification of Recanalization for Patients With Endovascular Treatment of Intracranial Aneurysms

Recanalization for Patients With Endovascular Treatment of Intracranial Aneurysms

Neurosurgery 76:390–395, 2015

With the increasing use of endovascular techniques in the treatment of both ruptured and unruptured intracranial aneurysms, the issue of obliteration efficacy has become increasingly important.

OBJECTIVE: To systematically develop a comprehensive model for predicting retreatment with various types of endovascular treatment.

METHODS: We retrospectively reviewed medical records that were prospectively collected for 305 patients who received endovascular treatment for intracranial aneurysms from 2007 to 2013. Multivariable logistic regression was performed on candidate predictors identified by univariable screening analysis to detect independent predictors of retreatment. A composite risk score was constructed based on the proportional contribution of independent predictors in the multivariable model.

RESULTS: Size (.10 mm), aneurysm rupture, stent assistance, and posttreatment degree of aneurysm occlusion were independently associated with retreatment, whereas intraluminal thrombosis and flow diversion demonstrated a trend toward retreatment. The Aneurysm Recanalization Stratification Scale was constructed by assigning the following weights to statistically and clinically significant predictors: aneurysm-specific factors: size (.10 mm), 2 points; rupture, 2 points; presence of thrombus, 2 points. Treatment-related factors were stent assistance, 21 point; flow diversion, 22 points; Raymond Roy occlusion class 2, 1 point; Raymond Roy occlusion class 3, 2 points. This scale demonstrated good discrimination with a C-statistic of 0.799.

CONCLUSION: Surgical decision making and patient-centered informed consent require comprehensive and accessible information on treatment efficacy. We constructed the Aneurysm Recanalization Stratification Scale to enhance this decisionmaking process. This is the first comprehensive model that has been developed to quantitatively predict the risk of retreatment after endovascular therapy.

Combined endovascular and surgical treatment of fusiform aneurysms of the basilar artery

Combined endovascular and surgical treatment of fusiform aneurysms of the basilar artery- technical note

Acta Neurochir (2014) 156:53–61

To present the combined treatment of fusiform basilar artery aneurysms consisting of a surgical posterior fossa decompressive craniectomy and ventriculoperitoneal (VP) shunt operation at the same sitting, before the endovascular procedure with telescopic stenting of the aneurysmatic vessel segment in four cases.

Methods Combined treatment involving surgical procedure consisting of ventriculoperitoneal shunt placement for hydrocephalus and an occipital bone craniectomy and C1 vertebrae posterior laminectomy to decompress the posterior fossa in the same session. After surgery, the patients were loaded with acetylsalicylic acid and clopidogrel, and then the endovascular treatment was performed.

Results All of the procedures were performed successfully without technical difficulty. The patients tolerated the procedures well and all cases showed remodelling with the overlapping stent technique. The patients were discharged home with baseline neurological situation and computed tomography (CT) angiography was performed at the 3rd month.

Conclusion This technique is a safer endovascular approach to treating symptomatic fusiform basilar artery aneurysms by protecting patients from both the haemorrhagic complications of anticoagulant therapy and thrombotic complications due to the interruption of anticoagulant therapy, while treating the hydrocephalus and compression by surgical means.

Hypoglossal canal dural arteriovenous fistula

Hypoglossal canal dural arteriovenous fistula

J Neurosurg 119:955–960, 2013

The purpose of this study was to evaluate the incidence, radiographic findings, relationship between presenting symptoms for treatment and drainage pattern, and treatment outcomes of hypoglossal canal dural arteriovenous fistula (HC-dAVF).

Methods. During a 16-year period, 238 patients underwent endovascular treatment for cranial dAVF at a single center. The incidence, radiographic findings, relationship between presenting symptoms for treatment and drainage pattern, and treatment outcomes of HC-dAVF were retrospectively evaluated.

Results. The incidence of HC-dAVF was 4.2% (n = 10). Initial symptoms were tinnitus with headache (n = 6), tinnitus only (n = 1), ocular symptoms (n = 1), otalgia (n = 1), and congestive myelopathy (n = 1). Presenting symptoms requiring treatment included ocular symptoms (n = 4), hypoglossal nerve palsy (n = 4), aggravation of myelopathy (n = 1), and aggravation of tinnitus with headache (n = 1). While the affected HC was widened in 4 of 10 patients, hypersignal intensity on source images was conspicuous in all 7 patients who underwent MR angiography (MRA). All ocular symptoms and congestive myelopathy were associated with predominant drainage to superior ophthalmic or perimedullary veins due to antegrade drainage restriction. All patients who underwent transvenous coil embolization (n = 8) or transarterial N-butyl cyanoacrylate (NBCA) embolization (n = 1) improved without recurrence. One patient who underwent transarterial particle embolization had a recurrence 12 months posttreatment and was retreated with transvenous embolization.

Conclusions. The incidence of HC-dAVF was 4.2% of all cranial dAVF patients who underwent endovascular treatment. Source images of MRA helped to accurately diagnose HC-dAVF. More aggressive symptoms may develop as a result of a change in the predominant drainage route due to the development of venous stenosis or obstruction over time. Transvenous coil embolization appears to be the first treatment of choice.

Factors predicting retreatment and residual aneurysms at 1 year after endovascular coiling for ruptured cerebral aneurysms: Prospective Registry of Subarachnoid Aneurysms Treatment (PRESAT) in Japan

Neuroradiology (2012) 54:597–606. DOI 10.1007/s00234-011-0945-0

Endovascular treatment of cerebral aneurysms includes follow-up imaging to identify aneurysms that may need retreatment. The aim of this study was to determine predictors of incomplete aneurysm occlusion at 1 year after endovascular coiling for ruptured cerebral aneurysms.
Methods In 129 patients of the Prospective Registry of Subarachnoid Aneurysms Treatment cohort, ruptured aneurysms were coiled within 14 days of onset and both initial post-coiling and 1-year follow-up digital subtraction angiography or magnetic resonance angiography were obtained. Factors predicting 1-year incomplete aneurysm occlusion (retreatment within 1-year or residual aneurysms at 1 year) were determined using multivariate logistic regression analyses.
Results One-year incomplete aneurysm occlusion was identified in 59 patients, including ten patients who were retreated within 1-year post-coiling. Dome size ≥7.5 mm (P=0.007, odds ratio (OR)=5.00, 95% confidence interval (CI)=1.55– 16.15), pre-treatment aneurysm re-rupture (P=0.023, OR= 3.50, 95% CI=1.19–10.31), non-small size/small neck aneurysm (dome size, ≥10 mm or neck size, ≥4 mm; P= 0.022, OR=3.26, 95% CI=1.19–8.96), and residual aneurysms on immediate post-coiling angiograms (P=0.017, OR= 1.43, 95% CI=1.07–1.93) significantly predicted incomplete aneurysm occlusion at 1-year post-coiling.
Conclusions In addition to the characteristics of aneurysm and initially incomplete aneurysm occlusion, this study showed pre-treatment aneurysm re-rupture to be a predictor that favors closer imaging follow-ups for coiled aneurysms.

Management of Residual and Recurrent Aneurysms After Initial Endovascular Treatment

Neurosurgery 70:537–554, 2012 DOI: 10.1227/NEU.0b013e3182350da5

Coil instability possibly translating into higher delayed rebleeding rates remains a concern in the endovascular management of cerebral aneurysms.

OBJECTIVE: To report on 127 patients with endovascular aneurysmal remnants who underwent re-treatment over an 18 year period.

METHODS: Patients presenting with aneurysm residuals .20% of the original lesion, unstable neck remnants, aneurysmal regrowth, or new aneurysmal daughter sacs were treated by an individualized approach, using both endovascular and surgical techniques.

RESULTS: Seventy-five aneurysmal remnants (59.1%) were treated by further re-embolization. Standard coil embolization was used in 65 cases, stent-protected coiling in 9 cases, and balloon remodeled coiling in 1 case, respectively. Fifty-two (40.9%) aneurysmal remnants were treated surgically. Standard microsurgical clipping was used in 44 patients, parent artery occlusion or trapping under bypass protection in 5 cases, deliberate clipping of the basilar artery trunk in 2 cases, and aneurysm wrapping in one case, respectively. Mechanisms of aneurysm recurrence were coil compaction in 93 cases and regrowth in 34 cases. A single reembolization was sufficient to occlude 78.7% of recurrences from coil compaction, but only 14.3% of recurrences from aneurysm regrowth.

CONCLUSION: The individualized approach resulted in complete occlusion of 114 aneurysms (89.7%), with neck remnants and residual aneurysms detectable in 11 (8.7%) and 2 (1.6%) cases, respectively. Treatment morbidity was 11.9%, without significant differences between surgical (15.6%) and endovascular (9.3%) patients (P = .09). Recurrences from coil compaction were safely treated by re-embolization, whereas recurrences from aneurysmal regrowth may best be managed surgically when technically feasible.

Management, risk factors and outcome of cranial dural arteriovenous fistulae: a single-center experience

Acta Neurochir (2011) 153:1273–1281. DOI 10.1007/s00701-011-0981-x

The role of endovascular interventions in managing dural arteriovenous fistulas (DAVFs) is increasing. Furthermore, in patients with aggressive DAVFs, different surgical interventions are required for complete obliteration or disconnection. Our objective was to evaluate the management of patients with intracranial DAVFs treated in our institution to identify the parameters that may help guide the long-term management of these lesions.

Methods The hospital records of 53 patients with intracranial DAVFs were reviewed. We then conducted a systematic telephone interview to obtain long-term follow-up information.

Results The main presenting symptoms were tinnitus and headache. Nineteen (35%) patients presented with intracranial bleeding, 84% of patients scored between 0 and 2 using a modified Rankin Scale at the last follow-up visit. Twentyfour patients were treated surgically. Overall postoperative complications occurred in seven (29%) surgically treated patients, but only two patients permanently worsened. For patients with Borden type II and III fistulas, the annual incidence of hemorrhage was 30%. Two patients had late recurrences of surgically and endovascularly occluded DAVFs. Long-term follow-up showed that compared with spinal DAVFs, only 50% of intracranial DAVFs showed complete remission of symptoms, 41% partial remission, 6% no remission and 4% deterioration of symptoms that led to treatment of the DAVF.

Conclusion In general, intracranial DAVFs can be successfully surgically managed by simple venous disconnection in many cases. However, half of the patients do not show complete remission of symptoms. Age and the occurrence of perioperative complication were the most important determinants of outcome.

Onyx embolization for the treatment of brain arteriovenous malformations

Acta Neurochir (2011) 153:869–878. DOI 10.1007/s00701-010-0848-6

Onyx has emerged in recent years for the endovascular treatment of brain arteriovenous malformations (AVMs). However, the role of Onyx embolization is still under discussion. We report our initial experiences in the treatment of brain AVMs with Onyx embolization.

Methods Between January 2004 and December 2007, 86 patients with brain AVMs were embolized with Onyx. Clinical presentation included intracerebral hemorrhage in 32 patients, seizures in 25 patients, headaches in 20 patients, neurologic deficits in 3 patients, and in 6 patients the AVM was an incidental finding. According to the Spetzler–Martin scale, three AVMs were grade I, 13 were grade II, 45 were grade III, 19 were grade IV, and 6 were grade V. Seventy-four AVMs were located in eloquent regions.

Results Initial complete obliteration after final embolization was achieved in 16 patients (18.6%), with an average of 80.5% (range, 30–100%) volume reduction. Partial embolization was followed by surgery in 18 patients, whereas 17 AVMs were cured. In 48 patients treated by embolization and radiosurgery, four patients were lost to follow-up. Three-year follow-up angiography was performed on 30 patients and showed complete obliteration after radiosurgery in 23 patients. The remaining 14 patients are awaiting 3-year postradiosurgery results. Embolization-related permanent morbidity was 3.5%, whereas mortality was 1.2%.

Conclusions Although Onyx allows moderate obliteration rates, combined management, such as adjunctive embolization with microsurgery or radiosurgery, may be effective for selected large AVMs.

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