Tag: hemorrhagic stroke

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Relationship of blood flow, angioarchitecture, and rupture in cerebral arteriovenous malformations

J Neurosurg 143:499–504, 2025

Patients with ruptured cerebral AVMs were more likely to have deep location, deep venous drainage, lower flow, smaller nidal volume, smaller arterial feeders, and fewer draining veins than unruptured AVMs. These findings highlight the complex interplay between angioarchitecture, hemodynamics, and rupture risk.

• Lower AVM flow, smaller nidus volume, deep location, deep venous drainage, smaller arterial feeders, and fewer draining veins are associated with ruptured AVMs compared to unruptured ones.

• Male sex and deep AVM location significantly increase the risk of hemorrhagic presentation.

• AVM size and flow are not independent predictors when other variables are considered.

• Fewer draining veins, but not venous stenosis, are linked to rupture, suggesting venous outflow restriction may play a role.

• Findings support previous smaller QMRA-based studies showing lower flow is associated with rupture, despite some conflicting literature.

• Prerupture flow data are lacking; rupture itself may alter measured hemodynamics.

• Further research is needed to clarify the role of hemodynamics and venous occlusion in AVM rupture risk.

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Transarterial Embolization of Dural Arteriovenous Fistulas: Conventional, Pressure Cooker, and Microballoon Catheter Embolization Techniques

Operative Neurosurgery 27:65–71, 2024

Dural fistulas are abnormal connections between dural arteries and intracranial veins treated mainly endovascularly in most settings. The aim was to examine a single-institution experience of microballoon catheter transarterial embolization (TAE) of dural arteriovenous fistulas (dAVFs) and compare it with other TAE techniques.

METHODS: We retrospectively identified all dAVFs treated at our institution between 2017 and 2022 with microballoon, conventional, and pressure cooker TAE. We studied occlusion and retreatment rates, treatment-related complications, and radiation doses.

RESULTS: During the study period, 66 patients underwent 75 TAE procedures to treat 68 dAVFs: 47 conventional TAE, 14 pressure cooker TAE, and 14 microballoon TAE. Median age of the study population was 63 years with 32% females. The most common dAVF location was the transverse sinus and 20% of dAVFs presented with hemorrhage. At 3-month follow-up, stable complete occlusion of the dAVF was seen in 72% (n = 34) after conventional TAE, 79% (n = 11) after pressure cooker TAE, and 86% (n = 12) after microballoon TAE. Retreatment was required in 19% (n = 9) after conventional TAE, 7% (n = 1) after pressure cooker TAE, and 7% (n = 1) after microballoon TAE. Treatment-related complications occurred in 17% (n =) after conventional TAE, 29% (n = 4) after pressure cooker TAE, and 7% (n = 1) after microballoon TAE.

CONCLUSION: In our experience, microballoon TAE of dAVFs resulted in better initial and 3-month angiographic outcomes and required less retreatment than conventional TAE. Microballoon TAE also resulted in fewer treatmentrelated complications than other techniques. In our experience, microballoon TAE is a reliable and safe endovascular technique to treat dAVFs.

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Surgical management of spontaneous intracerebral hemorrhage: insights from randomized controlled trials

Neurosurgical Review (2020) 43:999–1006

Spontaneous intracerebral hemorrhages (ICH) are a major cause of neurologic morbidity and mortality. The optimal management strategy of ICH remains controversial.

We examine the available randomized controlled trial (RCT) data regarding neurosurgical evacuation of ICHs. A systematic literature review on surgical evacuation of spontaneous ICHs was performed to identify pertinent RCT data published between 1980 and 2019.

We identified five RCTs that assessed the clinical impact of evacuation of spontaneous ICHs. Data from two high-quality RCTs randomizing 1033 and 601 patients with spontaneous ICHs (Surgical Trial in Intracerebral Hemorrhage (STICH) I and II) (1) failed to demonstrate a significant clinical benefit of routine open surgical evacuation of spontaneous cortical ICHs and (2) reinforced the high morbidity and mortality associated with ICH. These trials were nonetheless limited by high (> 20%) crossover from the medical to surgical arms. Data from three smaller RCTs on minimally invasive (stereotactic and endoscopic) surgical approaches randomizing 377, 242, and 100 patients with spontaneous ICHs suggest potential benefits relating to mortality and functional outcomes in patients with subcortical ICHs.

While these RCTs do not clearly define the role of surgical resection for ICHs, they provide insights into opportunities for patient advocacy, clinical trial design, and future research studies. Ongoing studies building upon the potential for minimally invasive approaches for ICH evacuation may expand the surgical indications for ICH.

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Cavernous angiomas: deconstructing a neurosurgical disease

J Neurosurg 131:1–13, 2019

Cavernous angioma (CA) is also known as cavernoma, cavernous hemangioma, and cerebral cavernous malformation (CCM) (National Library of Medicine Medical Subject heading unique ID D006392). In its sporadic form, CA occurs as a solitary hemorrhagic vascular lesion or as clustered lesions associated with a developmental venous anomaly. In its autosomal dominant familial form (Online Mendelian Inheritance in Man #116860), CA is caused by a heterozygous germ-line loss-of-function mutation in one of three genes—CCM1/KRIT1, CCM2/Malcavernin, and CCM3/PDCD10—causing multifocal lesions throughout the brain and spinal cord.

In this paper, the authors review the cardinal features of CA’s disease pathology and clinical radiological features. They summarize key aspects of CA’s natural history and broad elements of evidence-based management guidelines, including surgery. The authors also discuss evidence of similar genetic defects in sporadic and familial lesions, consequences of CCM gene loss in different tissues at various stages of development, and implications regarding the pathobiology of CAs.

The concept of CA with symptomatic hemorrhage (CASH) is presented as well as its relevance to clinical care and research in the field. Pathobiological mechanisms related to CA include inflammation and immune-mediated processes, angiogenesis and vascular permeability, microbiome driven factors, and lesional anticoagulant domains. These mechanisms have motivated the development of imaging and plasma biomarkers of relevant disease behavior and promising therapeutic targets.

The spectrum of discoveries about CA and their implications endorse CA as a paradigm for deconstructing a neurosurgical disease.

 

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