Treatment of brain arteriovenous malformations with high-flow arteriovenous fistulas: risk and complications associated with endovascular embolization in multimodality treatment

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  • 1 Division of Interventional Neuroradiology, Department of Radiological Sciences, UCLA Medical Center and David Geffen School of Medicine and
  • | 2 Division of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California
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Object

High-flow fistulas associated with brain arteriovenous malformations (AVMs) pose a significant challenge to both stereotactic radiosurgery (SRS) and surgical treatment. The purpose of this study was to examine the outcomes of multimodality treatment of AVMs in association with a large arteriovenous fistula (AVF), with a special focus on endovascular embolization and its associated complications.

Methods

One hundred ninety-two patients harboring cerebral AVMs underwent endovascular treatment in the authors' department between 1997 and 2003. Of these, the authors selected 74 patients presenting with an AVM associated with high-flow AVF(s) for a retrospective analysis based on the findings of superselective angiography. After endovascular embolization, 32 patients underwent resection, 33 underwent either SRS or hypofractionated stereotactic radiotherapy (HSRT), and 3 underwent both surgery and SRS. Six patients underwent embolization only. Immediate and midterm treatment outcomes were analyzed.

Results

Fifty-seven (77%) of the 74 patients had AVMs that were Spetzler-Martin Grade III or higher. A complete resection was achieved in all 32 patients. Of patients who underwent SRS/HSRT, 13 patients (39.3%) had either complete or > 90% obliteration of the AVM, and 2 patients (6.1%) had incomplete obliteration. Fourteen patients (42.4%) with residual AVM underwent repeated radiotherapy (and remain under observation). Of the 3 patients who underwent both SRS and resection, resection was complete in 2 and incomplete in one. No follow-up was obtained in 6 patients (8.1%). An endovascular complication was observed in 4 patients (5.4%). Fistula embolization was safely performed in every patient, whereas every endovascular complication was associated with other procedures such as nidus embolization.

Conclusions

Endovascular occlusion of the fistulous component was successfully achieved in every patient; every endovascular complication in this series was related to other procedures such as nidus embolization. The importance of the fistula treatment should be emphasized to minimize the endovascular complications and to maximize the treatment effect when a multimodality therapy is used to treat brain AVMs with large AVF.

Abbreviations used in this paper:

AVF = arteriovenous fistula; AVM = AV malformation; GDC = Guglielmi detachable coil; GOS = Glasgow Outcome Scale; HSRT = hypofractionated stereotactic radiotherapy; NBCA = N-butyl cyanoacrylate; SRS = stereotactic radiosurgery.

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  • 1

    al-Rodhan NR, , Sundt TM Jr, , Piepgras DG, , Nichols DA, , Rufenacht D, & Stevens LN: Occlusive hyperemia: a theory for the hemodynamic complications following resection of intracerebral arteriovenous malformations. J Neurosurg 78:167175, 1993

    • Search Google Scholar
    • Export Citation
  • 2

    Chang SD, , Marcellus ML, , Marks MP, , Levy RP, , Do HM, & Steinberg GK: Multimodality treatment of giant intracranial arteriovenous malformations. Neurosurgery 53:113, 2003

    • Search Google Scholar
    • Export Citation
  • 3

    Colombo F, , Benedetti A, , Pozza F, , Marchetti C, & Chierego G: Linear accelerator radiosurgery of cerebral arteriovenous malformations. Neurosurgery 24:833840, 1989

    • Search Google Scholar
    • Export Citation
  • 4

    Drake CG: Cerebral arteriovenous malformations: considerations for and experience with surgical treatment in 166 cases. Clin Neurosurg 26:145208, 1979

    • Search Google Scholar
    • Export Citation
  • 5

    Duma CM, , Lunsford LD, , Kondziolka D, , Bissonette DJ, , Somaza S, & Flickinger JC: Radiosurgery for vascular malformations of the brain stem. Acta Neurochir Suppl (Wien) 58:9297, 1993

    • Search Google Scholar
    • Export Citation
  • 6

    Elisevich K, , Redekop G, , Munoz D, , Fisher B, , Wiese K, & Drake C: Neuropathology of intracranial arteriovenous malformations following conventional radiation therapy. Stereotact Funct Neurosurg 63:250254, 1994

    • Search Google Scholar
    • Export Citation
  • 7

    Friedlander RM: Clinical practice. Arteriovenous malformations of the brain. N Engl J Med 356:27042712, 2007

  • 8

    Friedman WA, , Bova FJ, , Bollampally S, & Bradshaw P: Analysis of factors predictive of success or complications in arteriovenous malformation radiosurgery. Neurosurgery 52:296298, 2003

    • Search Google Scholar
    • Export Citation
  • 9

    Gobin YP, , Laurent A, , Merienne L, , Schlienger M, , Aymard A, & Houdart E, et al.: Treatment of brain arteriovenous malformations by embolization and radiosurgery. J Neurosurg 85:1928, 1996

    • Search Google Scholar
    • Export Citation
  • 10

    Guo WY, , Wikholm G, , Karlsson B, , Lindquist C, , Svendsen P, & Ericson K: Combined embolization and gamma knife radiosurgery for cerebral arteriovenous malformations. Acta Radiol 34:600606, 1993

    • Search Google Scholar
    • Export Citation
  • 11

    Haw CS, , terBrugge K, , Willinsky R, & Tomlinson G: Complications of embolization of arteriovenous malformations of the brain. J Neurosurg 104:226232, 2006

    • Search Google Scholar
    • Export Citation
  • 12

    Houdart E, , Gobin YP, , Casasco A, , Aymard A, , Herbreteau D, & Merland JJ: A proposed angiographic classification of intracranial arteriovenous fistulae and malformations. Neuroradiology 35:381385, 1993

    • Search Google Scholar
    • Export Citation
  • 13

    Jahan R, , Solberg TD, , Lee D, , Medin P, , Tateshima S, & De Salles A, et al.: An arteriovenous malformation model for stereotactic radiosurgery research. Neurosurgery 61:152159, 2007

    • Search Google Scholar
    • Export Citation
  • 14

    Jennett B, & Bond M: Assessment of outcome after severe brain damage. Lancet 1:480484, 1975

  • 15

    Kondziolka D, , Lunsford LD, , Kanal E, & Talagala L: Stereotactic magnetic resonance angiography for targeting in arteriovenous malformation radiosurgery. Neurosurgery 35:585591, 1994

    • Search Google Scholar
    • Export Citation
  • 16

    Lasjaunias P, , Manelfe C, & Chiu M: Angiographic architecture of intracranial vascular malformations and fistulas—pretherapeutic aspects. Neurosurg Rev 9:253263, 1986

    • Search Google Scholar
    • Export Citation
  • 17

    Lawton MT, , Hamilton MG, & Spetzler RF: Multimodality treatment of deep arteriovenous malformations: thalamus, basal ganglia, and brain stem. Neurosurgery 37:2936, 1995

    • Search Google Scholar
    • Export Citation
  • 18

    Luessenhop AJ, & Rosa L: Cerebral arteriovenous malformations. Indications for and results of surgery, and the role of intravascular techniques. J Neurosurg 60:1422, 1984

    • Search Google Scholar
    • Export Citation
  • 19

    Meder JF, , Oppenheim C, , Blustajn J, , Nataf F, , Merienne L, & Lefkoupolos D, et al.: Cerebral arteriovenous malformations: the value of radiologic parameters in predicting response to radiosurgery. AJNR Am J Neuroradiol 18:14731483, 1997

    • Search Google Scholar
    • Export Citation
  • 20

    Miyawaki L, , Dowd C, , Wara W, , Goldsmith B, , Albright N, & Gutin P, et al.: Five year results of LINAC radiosurgery for arteriovenous malformations: outcome for large AVMS. Int J Radiat Oncol Biol Phys 44:10891106, 1999

    • Search Google Scholar
    • Export Citation
  • 21

    Nakstad PH, & Nornes H: Superselective angiography, embolisation and surgery in treatment of arteriovenous malformations of the brain. Neuroradiology 36:410413, 1994

    • Search Google Scholar
    • Export Citation
  • 22

    Ogilvy CS, , Stieg PE, , Awad I, , Brown RD Jr, , Kondziolka D, & Rosenwasser R, et al.: AHA Scientific Statement: recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Stroke 32:14581471, 2001

    • Search Google Scholar
    • Export Citation
  • 23

    Ogilvy CS, , Stieg PE, , Awad I, , Brown RD Jr, , Kondziolka D, & Rosenwasser R, et al.: Recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Circulation 103:26442657, 2001

    • Search Google Scholar
    • Export Citation
  • 24

    Petereit D, , Mehta M, , Turski P, , Levin A, , Strother C, & Mistretta C, et al.: Treatment of arteriovenous malformations with stereotactic radiosurgery employing both magnetic resonance angiography and standard angiography as a database. Int J Radiat Oncol Biol Phys 25:309313, 1993

    • Search Google Scholar
    • Export Citation
  • 25

    Richling B, , Killer M, , Al-Schameri AR, , Ritter L, , Agic R, & Krenn M: Therapy of brain arteriovenous malformations: multimodality treatment from a balanced standpoint. Neurosurgery 59:5 Suppl 3 S148S157, 2006

    • Search Google Scholar
    • Export Citation
  • 26

    Schneider BF, , Eberhard DA, & Steiner LE: Histopathology of arteriovenous malformations after gamma knife radiosurgery. J Neurosurg 87:352357, 1997

    • Search Google Scholar
    • Export Citation
  • 27

    Spetzler RF, & Martin NA: A proposed grading system for arteriovenous malformations. J Neurosurg 65:476483, 1986

  • 28

    Spetzler RF, , Martin NA, , Carter LP, , Flom RA, , Raudzens PA, & Wilkinson E: Surgical management of large AVM's by staged embolization and operative excision. J Neurosurg 67:1728, 1987

    • Search Google Scholar
    • Export Citation
  • 29

    Stefani MA, , Porter PJ, , terBrugge KG, , Montanera W, , Willinsky RA, & Wallace MC: Large and deep brain arteriovenous malformations are associated with risk of future hemorrhage. Stroke 33:12201224, 2002

    • Search Google Scholar
    • Export Citation
  • 30

    Taylor CL, , Dutton K, , Rappard G, , Pride GL, , Replogle R, & Purdy PD, et al.: Complications of preoperative embolization of cerebral arteriovenous malformations. J Neurosurg 100:810812, 2004

    • Search Google Scholar
    • Export Citation
  • 31

    Valavanis A, & Yaşargil MG: The endovascular treatment of brain arteriovenous malformations. Adv Tech Stand Neurosurg 24:131214, 1998

  • 32

    Vinuela F, , Dion JE, , Duckwiler G, , Martin NA, , Lylyk P, & Fox A, et al.: Combined endovascular embolization and surgery in the management of cerebral arteriovenous malformations: experience with 101 cases. J Neurosurg 75:856864, 1991

    • Search Google Scholar
    • Export Citation
  • 33

    Vinuela F, , Fox AJ, , Debrun G, & Pelz D: Preembolization superselective angiography: role in the treatment of brain arteriovenous malformations with isobutyl-2 cyanoacrylate. AJNR Am J Neuroradiol 5:765769, 1984

    • Search Google Scholar
    • Export Citation
  • 34

    Wallace RC, , Flom RA, , Khayata MH, , Dean BL, , McKenzie J, & Rand JC, et al.: The safety and effectiveness of brain arteriovenous malformation embolization using acrylic and particles: the experiences of a single institution. Neurosurgery 37:606608, 1995

    • Search Google Scholar
    • Export Citation
  • 35

    Wedderburn CJ, , van Beijnum J, , Bhattacharya JJ, , Counsell CE, , Papanastassiou V, & Ritchie V, et al.: Outcome after interventional or conservative management of unruptured brain arteriovenous malformations: a prospective, population-based cohort study. Lancet Neurol 7:223230, 2008

    • Search Google Scholar
    • Export Citation
  • 36

    Willinsky R, , Lasjaunias P, , Terbrugge K, & Pruvost P: Brain arteriovenous malformations: analysis of the angio-architecture in relationship to hemorrhage (based on 152 patients explored and/or treated at the hopital de Bicêtre between 1981 and 1986). J Neuroradiol 15:225237, 1988

    • Search Google Scholar
    • Export Citation
  • 37

    Wilson CB, & Hieshima G: Occlusive hyperemia: a new way to think about an old problem. J Neurosurg 78:165166, 1993

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