Histopathological follow-up study of 66 cerebral arteriovenous malformations after therapeutic embolization with polyvinyl alcohol

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✓ Embolization with polyvinyl alcohol (PVA) is an accepted method of rendering complex arteriovenous malformations (AVM's) more amenable to surgery, but its effects on human vascular tissues have not been adequately documented. The authors reviewed the histopathology of 66 intracranial AVM's resected 1 to 76 days after embolization with PVA. The mean age of the patients was 36 years, and their AVM's were located in the cerebral hemispheres (92%), the cerebellum (6%), or the corpus callosum (2%). In 79% of cases, at least one vessel contained PVA particles; in most cases, the vessel was filled with sharp, angular PVA particles in a serpiginous pattern. Polyvinyl alcohol particles indented the endothelium in 69% of cases but were rarely found subendothelially. Clotted blood and fibroblasts were present among the particles, and abundant intraluminal mononuclear and polymorphonuclear inflammatory cells were found in all vessels containing PVA particles. Foreign-body giant cells appeared 2 to 14 days after embolization in the majority of cases. Patchy mural angionecrosis and necrotizing vasculitis were found in 39% of the cases. Recanalized lumina were seen in 18% of PVA-embolized vessels. Foreign materials resembling cotton fibers and other particulate substances, which were probably contaminants of the contrast solution or the embolic material, were found in 65% of the cases. These findings suggest a specific chain of events in the interaction between PVA and vessel wall components and may explain some important sequelae of embolization therapy.

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Address reprint requests to: Isabelle Germano, M.D., c/o The Editorial Office, Department of Neurological Surgery, 1360 Ninth Avenue, Suite 210, San Francisco, California 94122.

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Figures

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    Graph showing histological findings in cerebral arteriovenous malformations embolized with polyvinyl alcohol (PVA). The first column represents the percentage of cases in which PVA particles were found. The other columns represent the percentage of cases with PVA-embolized vessels showing a particular histological feature. In one case, PVA was found, but inadequate fixation prevented detailed histological analysis. PMN's/MN's = polymorphonuclear and mononuclear inflammatory cells. N = number of cases.

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    Graph showing histological changes over time between embolization and resection in 51 cases. Data points represent the percentage of cases showing a particular histological feature at a given time. Numbers in parentheses beneath the x axis represent the number of patients at a given time interval (N). PMN's/MN's = polymorphonuclear and mononuclear inflammatory cells.

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    Photomicrograph of cerebral arteriovenous malformation embolized by polyvinyl alcohol (PVA) showing sharp, angular PVA particles (asterisks) in a serpiginous pattern that fill the abnormal vessel and nearly occlude it. Clotted blood is present between the PVA emboli. A large mural thrombus is present in the bottom part of the vessel. The interval between embolization and surgery was 8 days. H & E, original magnification × 50.

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    Photomicrographs of a cerebral arteriovenous malformation embolized by polyvinyl alcohol (PVA) showing marked angionecrosis of the vessel wall adjacent to PVA. The interval between embolization and surgery for these specimens was 4 days. A: Intense inflammatory reaction surrounds PVA particles embolizing the vessel lumen. Larger, less serpiginous PVA particles (arrows) are found with smaller, sharper fragments in the same vessel. H & E, original magnification × 300. B: Sharp PVA spicule (arrow) indenting the necrotic endothelium. An inflammatory reaction is present in the thick necrotic vessel wall adjacent to the glial tissue (g). H & E, original magnification × 100.

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    Photomicrographs of a cerebral arteriovenous malformation resected 32 days after embolization with polyvinyl alcohol (PVA). Left: Numerous foreign-body giant cells (arrows) are seen surrounding the PVA emboli. H & E, original magnification × 300. Right: Specimen showing partial recanalization of the intraluminal PVA thrombi. Newly formed small channels (arrows) inside a well-organized thrombus are lined by endothelium. Several foreign-body giant cells are also present. H & E, original magnification × 500.

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    Photomicrographs of cerebral arteriovenous malformations embolized by polyvinyl alcohol (PVA). A: A sharp PVA particle indents the endothelium (arrow). The interval between embolization and surgery was 2 days. H & E, original magnification × 150. B: Specimen showing PVA particles incorporated into the vessel wall (curved arrows). The PVA emboli (asterisks) do not occlude the vessel lumen. The interval between embolization and surgery was 25 days. H & E, original magnification × 200.

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    Photomicrograph of a single arteriovenous malformation after embolization with polyvinyl alcohol (PVA) showing refractile needle-like foreign material in the lumina of PVA-embolized channels. Inset: Section showing another type of “fiber.” In both sections, multinucleated foreign-body giant cells surround unidentified foreign material. H & E, partially polarized, original magnification × 800.

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