The safety profile and angioarchitectural changes after acute targeted embolization of ruptured arteriovenous malformations

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  • 1 Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto;
  • | 2 Division of Neuroradiology, Department of Medical Imaging, and
  • | 3 Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto; and
  • | 4 Krembil Neuroscience Center, University Health Network, Toronto, Ontario, Canada
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OBJECTIVE

The aim of this study was to 1) compare the safety and efficacy of acute targeted embolization of angiographic weak points in ruptured brain arteriovenous malformations (bAVMs) versus delayed treatment, and 2) explore the angioarchitectural changes that follow this intervention.

METHODS

The authors conducted a retrospective analysis of a prospectively acquired database of ruptured bAVMs. Three hundred sixteen patients with ruptured bAVMs who presented to the hospital within 48 hours of ictus were included in the analysis. The first analysis compared clinical and functional outcomes of acutely embolized patients to those with delayed management paradigms. The second analysis compared these outcomes of patients with acute embolization to those with angiographic targets who did not undergo acute embolization. Finally, a subset of 20 patients with immediate postembolization angiograms and follow-up angiograms within 6 weeks of treatment were studied to determine the angioarchitectural changes after acute targeted embolization. Kaplan-Meier curves for survival between the groups were devised. Multivariate logistical regression analysis was conducted.

RESULTS

There were three deaths (0.9%) and an overall rerupture rate of 4.8% per year. There was no statistical difference in demographic variables, mortality, and rerupture rate between patients with acute embolization and those with delayed management. Patients with acute embolization were more likely to present functionally worse (46.9% vs 69.8%, modified Rankin Scale score 0–2, p = 0.018) and to require an adjuvant therapy (71.9% vs 26.4%, p < 0.001). When comparing acutely embolized patients to those nonacutely embolized angiographic targets, there was a significant protective effect of acute targeted therapy on rerupture rate (annual risk 1.2% vs 4.3%, p = 0.025) and no difference in treatment complications. Differences in the survival curves for rerupture were statistically significant. Multivariate analyses significantly predicted lower rerupture in acute targeted treatment and higher rerupture in those with associated aneurysms, deep venous anatomy, and higher Spetzler-Martin grade. All patients with acute embolization experienced complete obliteration of the angiographic weak point with various degrees of resolution of the nidus; however, some had spontaneous recurrence of their bAVM, while others had spontaneous resolution over time. No patients developed new angiographic weak points.

CONCLUSIONS

This study demonstrates that acute targeted embolization of angiographic weak points, particularly aneurysms, is technically safe and protective in the early phase of recovery from ruptured bAVMs. Serial follow-up imaging is necessary to monitor the evolution of the nidus after targeted and definitive treatments. Larger prospective studies are needed to validate these findings.

ABBREVIATIONS

AVM = arteriovenous malformation; bAVM = brain AVM; CTA = CT angiography; DSA = digital subtraction angiography; ICH = intracerebral hemorrhage; IVH = intraventricular hemorrhage; mRS = modified Rankin Scale; NBCA = n-butyl cyanoacrylate; SAH = subarachnoid hemorrhage.

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Contributor Notes

Correspondence Vitor Mendes Pereira: University of Toronto, Toronto Western Hospital, Toronto, ON, Canada. vitor.pereira@uhn.ca.

INCLUDE WHEN CITING Published online May 7, 2021; DOI: 10.3171/2020.9.JNS201558.

Disclosures Dr. Krings reports being a consultant to Penumbra, Stryker, and Medtronic; having direct stock ownership in Marblehead; and receiving royalties from Thieme.

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