The effect of preoperative embolization and flow dynamics on resection of brain arteriovenous malformations

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OBJECTIVE

Preoperative embolization of brain arteriovenous malformations (AVMs) is performed to facilitate resection, although its impact on surgical performance has not been clearly defined. The authors tested for associations between embolization and surgical performance metrics.

METHODS

The authors analyzed AVM cases resected by one neurosurgeon from 2006 to 2017. They tested whether cases with and without embolization differed from one another with respect to patient and AVM characteristics using t-tests for continuous variables and Fisher’s exact tests for categorical variables. They used simple and multivariable regression models to test whether surgical outcomes (blood loss, resection time, surgical clip usage, and modified Rankin Scale [mRS] score) were associated with embolization. Additional regression analyses integrated the peak arterial afferent contrast normalized for the size of the region of interest (Cmax/ROI) into models as an additional predictor.

RESULTS

The authors included 319 patients, of whom 151 (47%) had preoperative embolization. Embolized AVMs tended to be larger (38% with diameter > 3 cm vs 19%, p = 0.001), less likely to have hemorrhaged (48% vs 63%, p = 0.013), or be diffuse (19% vs 29%, p = 0.045). Embolized AVMs were more likely to have both superficial and deep venous drainage and less likely to have exclusively deep drainage (32% vs 17% and 12% vs 23%, respectively; p = 0.002). In multivariable analysis, embolization was not a significant predictor of blood loss or mRS score changes, but did predict longer operating times (+29 minutes, 95% CI 2–56 minutes; p = 0.034) and increased clip usage (OR 2.61, 95% CI 1.45–4.71; p = 0.001). Cmax/ROI was not a significant predictor, although cases with large Cmax/ROI tended to have longer procedure times (+25 minutes per doubling of Cmax/ROI, 95% CI 0–50 minutes; p = 0.051).

CONCLUSIONS

In this series, preoperative embolization was associated with longer median resection times and had no association with intraoperative blood loss or mRS score changes.

ABBREVIATIONS AVM = arteriovenous malformation; Cmax = peak contrast density of the primary feeding artery; Cmax/ROI = Cmax normalized for the size of the ROI (i.e., the diameter of the artery); EVOH = ethylene vinyl alcohol copolymer; mRS = modified Rankin Scale; NBCA = N-butyl 2-cyanoacrylate; PI = proportional increase; PVA = polyvinyl alcohol; ROI = region of interest.

Article Information

Correspondence Grace F. Donzelli: UCSF Medical Center, San Francisco, CA. gracedonzelli@gmail.com.

INCLUDE WHEN CITING Published online May 17, 2019; DOI: 10.3171/2019.2.JNS182743.

Disclosures Dr. Hetts reports being a consultant for Cerenovus and MicroVention Terumo; ownership of Stryker; direct ownership of stock in ThrombX; and a research contract with Siemens.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Image created in iFlow from the pretreatment 2D angiogram of a surgical AVM patient. The primary feeding artery and draining vein were marked with a vessel-specific ROI, and the diameter of the ROI was adjusted in each patient. The time density curve was created by iFlow.

  • View in gallery

    We found that each doubling of Cmax/ROI was associated with increased blood loss in simple regression analysis, but not in multivariable analysis. Figure is available in color online only.

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