Embolized cerebral arteriovenous malformations: a multivariate analysis of 101 excised specimens

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OBJECTIVE

Endovascular approaches have evolved from a technique practiced at very few centers to a widely available option in the management of arteriovenous malformations (AVMs) of the central nervous system. Embolization can be employed as definitive therapy or as an adjunct to surgical excision. A wide variety of embolic agents have been successfully developed and used in the clinical setting. In addition to facilitating vascular occlusion, embolic agents induce a number of reactive and destructive changes in vessel walls and the surrounding tissue. However, studies examining the pathological changes induced by different embolic agents and varying times of exposure are scarce. The goal of the present study was to compare embolic agents and time of exposure on the pathology in excised specimens.

METHODS

The records of the Department of Pathology at the London Health Sciences Centre were searched for embolized AVMs for the 35-year period 1980–2015. All cases were reevaluated for clinical and technical variables and standardized histopathological findings. Cases were grouped by embolic agent, volume of agent used, and time to excision.

RESULTS

A total of 101 specimens were identified. Embolic agents were invariably associated with a range of pathological findings, some of which may affect the integrity of vessel walls or the reestablishment of flow, thrombosis, acute and chronic inflammatory changes, angionecrosis, extravasation, and recanalization. The type of embolic agent did not predict differences in the incidence or severity of histopathological changes. Larger volumes of embolic agent were associated with a greater proportion of vessels containing embolic material. AVMs excised early (< 1 week postembolization) contained more acute vasculitis, while those excised later (≥ 1 week postembolization) were more likely to exhibit recanalization and foreign body giant cell infiltrates.

CONCLUSIONS

Embolic agents induce a predictable range and temporal progression of pathological changes in cerebral AVMs. The embolic agents studied are indistinguishable in terms of the range and frequency of pathological reactions induced. Greater volumes of embolic agent are associated with more abundant agent within the lesion, but the proportion of vessels and vascular cross-sectional areas containing agent is small. Several changes are significantly associated with time postembolization. Acute vasculitis is a more common finding in the 1st week, while recanalization and foreign body–type granulomatous inflammation are more common at 1 week and beyond.

ABBREVIATIONS AVM = arteriovenous malformation; FBGC = foreign body giant cell; IBCA = isobutyl 2-cyanoacrylate; NBCA = N-butyl 2-cyanoacrylate; PVA = polyvinyl alcohol.

Article Information

Correspondence Robert Hammond: London Health Sciences Centre, London, ON, Canada. rhammond@uwo.ca.

INCLUDE WHEN CITING Published online March 15, 2019; DOI: 10.3171/2018.12.JNS182244.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Examples of AVM-related pathology. a: Extraluminal embolic material, IBCA (arrowhead), and tantalum (arrow). b: Intraluminal PVA foam (arrow) and denatured collagen (Avitene, arrowhead). c: Acute necrotizing vasculitis with the vessel wall (VW) infiltrated by neutrophils and lumen embolized with IBCA and tantalum. d: Angionecrosis (arrow). e: FBGC reaction (arrow) to embolic agents (IBCA and tantalum). f: Recanalization of the original vessel by multiple small-caliber channels (asterisks). H & E. Bar = 100 µm (a–c and e); 200 µm (d and f). Figure is available in color online only.

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