Associated Aneurysms in Infratentorial Arteriovenous Malformations: Role of Aneurysm Size and Comparison with Supratentorial Lesions

2016 ◽  
Vol 41 (5-6) ◽  
pp. 219-225 ◽  
Author(s):  
Klaus-Peter Stein ◽  
Isabel Wanke ◽  
Michael Forsting ◽  
Neriman Oezkan ◽  
Bernd-Otto Huetter ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Intracranial Hemorrhage ◽  
Arteriovenous Malformations ◽  
Posterior Inferior Cerebellar Artery ◽  
Aneurysm Rupture ◽  
Special Focus ◽  
Aneurysm Size ◽  
Common Location ◽  
Mean Size ◽  
The Mean

Background: The natural history and treatment of brain arteriovenous malformations (AVMs) is the object of ongoing debates and discussions. To capture the entirety of these complex lesions, associated vascular pathologies, such as associated aneurysms (AAs), have to be implemented in future risk stratification models, as they are believed to represent additional risk factors for intracranial hemorrhage. The present study aims to determine AA characteristics in posterior fossa AVMs and to compare with AAs accompanying supratentorial AVMs, with special focus on aneurysm size. Methods: Patients with cerebral AVMs, treated in our department between 1990 and 2013, were analyzed retrospectively. Only patients with flow-related AAs of the feeding arteries were evaluated. Thus, patients harboring intranidal, venous or remote aneurysms were excluded. Results: Of 485 patients with cerebral AVM, 76 patients harbored an AVM of the posterior fossa. Among those, 22 individuals exhibited a total of 35 AAs (n = 8 patients with multiple AAs). Most common location of AAs was the posterior inferior cerebellar artery (n = 20, 57%) and mean AA diameter was 7.9 mm (SD 5.5). In the subgroup of patients with a single AA, mean aneurysm size in posterior fossa AVMs was with 7.8 mm (SD 6.0; range 2-25 mm) significantly larger than the mean size of AAs with supratentorial AVMs (4.8 mm, SD 3.0; range 2-20 mm; p = 0.048). Intracranial hemorrhage was found in 18 of 22 patients (82%) with infratentorial AVMs, and of these, 11 patients suffered from aneurysm rupture. In 14 patients bearing a single AA, 8 (57%) had sustained hemorrhage from aneurysm rupture. The mean diameter of AAs was as supposed in the ruptured group with 9.8 mm (SD 6.9; range 4-25 mm) significantly larger than in the unruptured AA group exhibiting a mean of 5.0 mm (SD 3.3; range 2-10 mm; p = 0.038). Patients with posterior fossa AVMs and AAs were significantly older as compared to those patients with supratentorial lesions (57.1, SD 12.6 vs. 45.8 years, SD 15.9 years; p = 0.004), which was also evident in the subgroup of patients with single AAs (55.2, SD 11.7 vs. 45.8 years, SD 14.9 years; p = 0.038). Conclusions: AAs of posterior fossa AVMs are larger in diameter than aneurysms accompanying supratentorial AVMs. AA size influences risk for hemorrhage, which, together with the high number of hemorrhagic events in posterior fossa AVMs, justifies treating these pathologies. The higher age of patients with AVMs of the posterior fossa might be one reason for larger AAs in this cohort, when compared to patients with supratentorial AVMs and AAs.

Risk Assessment of Hemorrhage of Posterior Inferior Cerebellar Artery Aneurysms in Posterior Fossa Arteriovenous Malformations

2017 ◽  
Vol 14 (4) ◽  
pp. 359-366 ◽  
Author(s):  
Alice L Hung ◽  
Wuyang Yang ◽  
Maria Braileanu ◽  
Tomas Garzon-Muvdi ◽  
Justin M Caplan ◽  
...  
Keyword(s):  
Treatment Outcomes ◽  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Posterior Inferior Cerebellar Artery ◽  
Aneurysm Rupture ◽  
Acute Hydrocephalus ◽  
Increased Risk ◽  
Cerebellar Artery ◽  
Risk Of Rupture

Abstract BACKGROUND Posterior fossa arteriovenous malformations (AVMs) are associated with increased risk of rupture and severe consequences from such rupture. The hemorrhagic risk of prenidal aneurysms (anr) on the posterior inferior cerebellar artery (PICA) may exceed that of the AVM in posterior fossa AVMs fed by PICA (PICA-AVM). OBJECTIVE To characterize the relative risks of aneurysm and AVM hemorrhage in patients with posterior fossa AVMs. METHODS We retrospectively reviewed patients diagnosed with AVM. Patients with posterior fossa AVMs were divided into 3 groups: PICA-AVM with prenidal aneurysm (PICA-AVM-anr group), PICA-AVM without prenidal aneurysm (PICA-AVM group), and AVMs without PICA feeder with/without aneurysm (AVM-only group). Patient and lesion characteristics and treatment outcomes were compared. ANOVA and chi squared tests were used for statistical analyses. RESULTS Our cohort included 85 patients. Mean age was 45.3 ± 18.1 yr, with 43(50.6%) female patients. Fifty-one patients (60.0%) had hemorrhagic presentation, and 27 (31.8%) experienced acute hydrocephalus. Patients in the PICA-AVM-anr group (n = 11) were more likely to present with aneurysmal subarachnoid hemorrhage (SAH; P = .005) and less likely to have AVM rupture (P < .001). Ten (90.9%) patients presented with hemorrhage, 6 (60.0%) of which resulted from aneurysm rupture. Of these 6, 5 (83.3%) had acute hydrocephalus. No patients with AVM rupture had hydrocephalus. Eight (72.7%) received aneurysm treatment prior to AVM treatment. There were no significant differences in post-treatment outcomes dependent on treatment order. CONCLUSION In addition to relatively higher risk of AVM rupture from infratentorial location and prenidal aneurysm, a higher risk of aneurysm rupture rather than AVM rupture was observed in patients with PICA-AVM-anr complex.

Multimodality treatment of posterior fossa arteriovenous malformations

2008 ◽  
Vol 108 (6) ◽  
pp. 1152-1161 ◽  
Author(s):  
Michael E. Kelly ◽  
Raphael Guzman ◽  
John Sinclair ◽  
Teresa E. Bell-Stephens ◽  
Regina Bower ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Multimodality Treatment ◽  
Neurological Complications ◽  
Cure Rate ◽  
Complete Obliteration ◽  
The Mean ◽  
Risk Of Hemorrhage ◽  
Negative Predictor

Object Posterior fossa arteriovenous malformations (AVMs) are relatively uncommon and often difficult to treat. The authors present their experience with multimodality treatment of 76 posterior fossa AVMs, with an emphasis on Spetzler–Martin Grades III–V AVMs. Methods Seventy-six patients with posterior fossa AVMs treated with radiosurgery, surgery, and endovascular techniques were analyzed. Results Between 1982 and 2006, 36 patients with cerebellar AVMs, 33 with brainstem AVMs, and 7 with combined cerebellar–brainstem AVMs were treated. Natural history data were calculated for all 76 patients. The risk of hemorrhage from presentation until initial treatment was 8.4% per year, and it was 9.6% per year after treatment and before obliteration. Forty-eight patients had Grades III–V AVMs with a mean follow-up of 4.8 years (range 0.1–18.4 years, median 3.1 years). Fifty-two percent of patients with Grades III–V AVMs had complete obliteration at the last follow-up visit. Three (21.4%) of 14 patients were cured with a single radiosurgery treatment, and 4 (28.6%) of 14 with 1 or 2 radiosurgery treatments. Twenty-one (61.8%) of 34 patients were cured with multimodality treatment. The mean Glasgow Outcome Scale (GOS) score after treatment was 3.8. Multivariate analysis performed in the 48 patients with Grades III–V AVMs showed radiosurgery alone to be a negative predictor of cure (p = 0.0047). Radiosurgery treatment alone was not a positive predictor of excellent clinical outcome (GOS Score 5; p > 0.05). Nine (18.8%) of 48 patients had major neurological complications related to treatment. Conclusions Single-treatment radiosurgery has a low cure rate for posterior fossa Spetzler–Martin Grades III–V AVMs. Multimodality therapy nearly tripled this cure rate, with an acceptable risk of complications and excellent or good clinical outcomes in 81% of patients. Radiosurgery alone should be used for intrinsic brainstem AVMs, and multimodality treatment should be considered for all other posterior fossa AVMs.

Posterior fossa arteriovenous malformations

2009 ◽  
Vol 26 (5) ◽  
pp. E12 ◽  
Author(s):  
Omar M. Arnaout ◽  
Bradley A. Gross ◽  
Christopher S. Eddleman ◽  
Bernard R. Bendok ◽  
Christopher C. Getch ◽  
...  
Keyword(s):  
Natural History ◽  
Posterior Fossa ◽  
Intracranial Hemorrhage ◽  
Arteriovenous Malformations ◽  
Therapeutic Options ◽  
Aggressive Treatment

Arteriovenous malformations (AVMs) of the posterior fossa are complex neurovascular lesions that are less common than their supratentorial counterparts, accounting for < 15% of all AVMs. The majority of patients with these lesions present with intracranial hemorrhage, a factor that has been consistently shown to increase one's risk for subsequent bleeding. Studies have additionally shown a posterior fossa or deep AVM location to portend a more aggressive natural history. The authors reviewed the literature on posterior fossa AVMs, finding their annual rupture rates to be as high as 11.6%, an important factor that underscores the importance of aggressive treatment of lesions amenable to intervention as therapeutic options and results continue to improve.

scholarly journals What Size Cerebral Aneurysms Rupture? A Systematic Review and Meta-Analysis of Literature

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Maxim Mokin ◽  
Muhammad Waqas ◽  
Andrew Gong ◽  
Felix Chin ◽  
Hamid Rai ◽  
...  
Keyword(s):  
Systematic Review ◽  
Intracranial Aneurysms ◽  
Meta Analysis ◽  
Random Effect Model ◽  
Posterior Inferior Cerebellar Artery ◽  
Cerebral Aneurysms ◽  
Ruptured Aneurysms ◽  
Aneurysm Size ◽  
Ruptured Intracranial Aneurysm ◽  
Mean Size

Abstract INTRODUCTION Size of the cerebral aneurysms is given a considerable weightage in deciding on the management for cerebral aneurysms. Literature on the size of ruptured aneurysms is heterogenous and often contradictory. The purpose of this systematic review was to determine the size of ruptured aneurysms with respect to location. METHODS We conducted a systematic review of literature. The protocol was registered with PROSPERO. PubMed, Cochrane, CiNAHL, and EMBASE databases were reviewed All the studies reporting the mean size of consecutive patients with intracranial aneurysms were included. Studies that did not report mean with standard deviations or were restricted to the study of small or large aneurysms were excluded. Heterogeneity was assessed using I2 and random effect model was used to perform metanalysis of the data. Pooled mean and standard deviation were calculated for overall size and subgroup of aneurysms at a specific location. R statistical package was used for analysis. RESULTS A total of 64 studies with 10 873 intracranial aneurysms were included in the meta-analysis. Pooled mean ruptured intracranial aneurysm size in 64 studies was 6.99 ± 4.14 mm. Mean size for anterior communicating artery was reported by 9 studies, 1118 aneurysms with a pooled mean of 4.65 ± 2.12 mm. Posterior communicating artery aneurysm size was reported in 10 studies with pooled mean of 6.43 ± 2.41 mm. Nine studies reported mean size of middle cerebral artery. The pooled value was 8.90 ± 4.91 mm. Pooled mean size for posterior inferior cerebellar artery was 4.09 ± 1.63 mm. CONCLUSION Mean size of ruptured intracranial aneurysms reported by most studies is less than 7.0 mm and varies with the location of the aneurysm. Morphological and hemodynamic factors other than size may be more important in determining rupture risk.

scholarly journals Association between posterior fossa arteriovenous malformations and prenidal aneurysm rupture: potential impact on management

2014 ◽  
Vol 37 (3) ◽  
pp. E4 ◽  
Author(s):  
Evgueni Kouznetsov ◽  
Alain Weill ◽  
Jimmy S. Ghostine ◽  
Jean-Christophe Gentric ◽  
Jean Raymond ◽  
...  
Keyword(s):  
Posterior Fossa ◽  
Arteriovenous Malformations ◽  
Case Series ◽  
Aneurysm Rupture ◽  
Modified Rankin Scale ◽  
Feeding Artery ◽  
Potential Impact ◽  
Arterial Aneurysms ◽  
Lost To Follow Up

Object In patients with posterior fossa arteriovenous malformations (AVMs) who present with hemorrhage, feeding artery aneurysms are often the source of bleeding. The aim of this study was to evaluate the relative proportions of cases of infra- and supratentorial AVMs in which patients presented with prenidal aneurysm rupture. The management and outcome of 9 cases of posterior fossa AVMs associated with prenidal aneurysm rupture are presented. Methods The authors retrospectively reviewed 233 consecutive AVM cases involving patients treated at their institution between April 2001 and August 2012. Patients with a prenidal aneurysm as the cause of the hemorrhage were identified. The frequencies of prenidal aneurysm-related ruptures were compared in cases of supra- and infratentorial AVMs. Management and clinical outcome (modified Rankin Scale [mRS] score) of patients with posterior fossa AVMs treated for ruptured prenidal aneurysms were recorded. Results Of 233 AVMs, 25 (11%) were in the posterior fossa, and in 22 (88%) of these cases, the patients presented with hemorrhage, including 9 patients (41%) who presented with hemorrhage due to prenidal aneurysm rupture. Of 208 patients with supratentorial AVMs, 107 (51%) presented with hemorrhage, including 5 patients (4.7%) in whom the hemorrhage was associated with a prenidal aneurysm (p < 0.01). All 9 patients with posterior fossa AVMs and prenidal aneurysm rupture were treated with early embolization of the offending aneurysm. There was no early rebleeding or clinical complication related to this approach. At the end of follow-up (mean 46.8 months), 2 patients had an mRS score of 0, 1 had a score of 1, 3 had a score of 2, 2 patients were dead (mRS score of 6), and 1 patient was lost to follow-up. Conclusions Posterior fossa AVM hemorrhages are frequently associated with prenidal arterial aneurysms. Urgent endovascular treatment of the aneurysm was effective in this case series.

scholarly journals Endoscopic Incisional Technique for Histological Diagnosis of Gastric Subepithelial Lesions following EUS Evaluation

2018 ◽  
Vol 1 (1) ◽  
pp. 07-10
Author(s):  
Nico Pagano
Keyword(s):  
Diagnostic Yield ◽  
Gastrointestinal Stromal Tumour ◽  
Histological Diagnosis ◽  
Gastric Body ◽  
Tissue Samples ◽  
Common Location ◽  
Tissue Acquisition ◽  
Mean Size ◽  
The Mean ◽  
Subepithelial Lesions

Objective: Tissue acquisition is the gold standard for diagnosis and characterization of gastric subepithelial tumours (SETs). We present our experience with endoscopic incisional tissue acquisition (ITA) technique in hypoechoic SETs of the fourth layer at EUS examination. Methods: The ITA technique was performed in 32 patients. The mean size of the lesions was 19 mm, and the gastric body was the most common location. The mean procedure time was 19 minutes; a mean of 4 biopsies per lesion were taken. Results: Tissue samples were adequate for histological diagnosis in 30/32 cases (diagnostic yield 94%). The most frequent histological pattern was gastrointestinal stromal tumour in 20 cases. Surgical resection was performed in 12 cases, while the remaining patients were followed without additional therapy. Conclusion: Endoscopic ITA technique is a safe and effective sampling method for histological diagnosis of gastric SETs.

Embolization of Cerebral Arteriovenous Malformations to Enhance the Success of Subsequent Radiosurgery

1998 ◽  
Vol 4 (1_suppl) ◽  
pp. 121-126 ◽  
Author(s):  
S. Miyachi ◽  
T. Tanaka ◽  
T. Kobayashi ◽  
Y. Kida ◽  
M. Negoro ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Size Reduction ◽  
Diffuse Type ◽  
Cerebral Arteriovenous Malformations ◽  
Shunt Flow ◽  
Increased Risk ◽  
Mean Size ◽  
The Mean ◽  
Embolic Materials

We studied angiographic changes in embolized arteriovenous malformations (AVMs) by comparing pre- and postembolization angiograms and angiograms preceding radiosurgery. This study sought factors determining the usefulness of embolization as a pretreatment to enhance the success of subsequent radiosurgery. Thirty patients with cerebral AVMs treated in this manner over 4 years were studied. In these cases AVMs were embolized with cyanoacrylate and were treated with Gamma-knife radiosurgery. The mean size of the AVM nidus was reduced by a fraction of seven following embolization. The subsequent angiogram for planning radiosurgery showed further nidus reduction in 10 AVMs, no change in 12, and regrowth in 8. In all size-reduction cases the nidus was sufficiently packed, and 2 AVMs had thrombosed completely before radiosurgery. All the regrowing AVMs were of diffuse type; 6 were associated with already-developed leptomeningeal channels, and the remaining 3 were fed by newly sprouted meningeal feeders. Five AVMs disappeared following radiosurgery, all representing size-reduction or no-change cases. Analysis of cases with regrowth showed increased risk of that event with feeder occlusion of a multi-axially supplied AVM, lack of reduction of shunt flow, or remaining meningeal feeders. On the other hand, when embolization as pretreatment prior to radiosurgery succeeds in producing a small, compacted, plexiform nidus with slow shunt flow, it furthers the likelihood of successful radiosurgery, Nidus embolization and occlusion of fistulous and meningeal feeders are mandatory, while proximal feeder occlusion and use of embolic materials which risk recanalization should be avoided to prevent nidus regrowth.

scholarly journals Endovascular Treatment of Intracranial Ruptured Aneurysms Associated with Arteriovenous Malformations: A Clinical Analysis of 14 Hemorrhagic Cases

2011 ◽  
Vol 17 (1) ◽  
pp. 78-86 ◽  
Author(s):  
J.-L. Yu ◽  
S. Yang ◽  
Q. Luo ◽  
H.-L. Wang ◽  
B. Wang ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
Arteriovenous Malformations ◽  
Clinical Analysis ◽  
Therapeutic Strategies ◽  
Aneurysm Rupture ◽  
Unruptured Aneurysms ◽  
Ruptured Aneurysms ◽  
Aneurysm Treatment ◽  
Risk Of Rupture

This study investigated and summarized endovascular therapeutic strategies for intracranial ruptured aneurysms associated with arteriovenous malformations (AVMs). Between June 2005 and June 2009, we identified 16 aneurysms in 14 hemorrhagic cases of intracranial AVM using digital subtraction angiography (DSA). Of the 16 aneurysms, 14 were ruptured and two were unruptured. Aneurysms were classified as types I to IV, and were treated. Aneurysm treatment was followed by AVM treatment via various therapies, including embolization, gamma knife radiotherapy, or follow-up and observation to reduce the risk of aneurysm rupture or intracranial hemorrhage. Over a follow-up period ranging from six months to one year, none of the patients had aneurysm ruptures or intracranial hemorrhage. Most (13/14) patients had a Glasgow Outcome Scale (GOS) score of 5, and one patient had a score of 4. Sixteen aneurysms were treated successfully, as confirmed by DSA examination, and no AVMs re-grew. Clinical therapeutic strategies for intracranial ruptured aneurysms associated with AVMs should include aneurysm treatment first to reduce the risk of rupture and intracranial hemorrhage, eventually leading to a better prognosis.

Transvenous Embolization in Pediatric Plexiform Arteriovenous Malformations

Neurosurgery ◽  
2015 ◽  
Vol 78 (3) ◽  
pp. 458-465 ◽  
Author(s):  
George A.C. Mendes ◽  
Christina Iosif ◽  
Eduardo Pedrolo Silveira ◽  
Eduardo Waihrich ◽  
Suzana Saleme ◽  
...  
Keyword(s):  
Arteriovenous Malformations ◽  
Pediatric Population ◽  
Transvenous Embolization ◽  
Venous Infarction ◽  
Curative Therapy ◽  
Patient Demographics ◽  
Mean Size ◽  
The Mean ◽  
Transvenous Approach

Abstract BACKGROUND: Transvenous embolization is a developing concept for curative therapy of cerebral arteriovenous malformations (AVMs). The feasibility of this endovascular method has not been reported in children. OBJECTIVE: To report our experience treating pediatric AVMs with the transvenous approach (TVA). METHODS: A cohort of 7 pediatric patients (younger than 18 years of age) who underwent the TVA for cerebral AVMs between January 2012 and January 2014. The TVA was used alone or in conjunction with other arterial approaches in definitive embolization sessions. Patient demographics, AVM characteristics, clinical outcomes, and angiographic results were independently assessed. Pial arteriovenous fistulae and vein of Galen malformations were excluded. Control angiograms were obtained at 6 months, and curative treatment was determined by the anatomic obliteration of the nidus. RESULTS: All patients had anatomic exclusion of the AVM. The mean size was 2 ± 0.6 cm, and hemorrhage was the most common presentation (100%, n = 7). Most AVMs were deeply placed (71%, n = 5), and a proximal approach to the nidus was achieved in all cases. Transvenous embolization alone was performed in 3 patients (43%), whereas combined arterial and venous embolization was required in 4 patients (57%). The mean follow-up period was 20.2 ± 10.5 months. There were no hemorrhagic or thromboembolic events, and venous infarction was not documented. No recurrence was documented. CONCLUSION: This is the first report that demonstrates the feasibility of transvenous Onyx embolization of AVMs in the pediatric population. Such a technique may be considered in certain AVMs that meet anatomic criteria in which microsurgery and radiosurgery might not be indicated.

scholarly journals Neurosurgical management of cerebellar cavernous malformations

2006 ◽  
Vol 21 (1) ◽  
pp. 1-8 ◽  
Author(s):  
Jean G. de Oliveira ◽  
Aziz Rassi-Neto ◽  
Fernando A. P. Ferraz ◽  
Fernando M. Braga
Keyword(s):  
Posterior Fossa ◽  
Clinical Condition ◽  
Clinical Presentation ◽  
Complete Removal ◽  
Curative Treatment ◽  
Cavernous Malformations ◽  
Effective Option ◽  
Mean Size ◽  
The Mean

Object The aim of this study was to analyze cerebellar cavernous malformations (CMs) with respect to epide-miological, clinical, radiological, and therapeutic aspects. Methods Between 1984 and 2004, 100 patients were surgically treated for intracranial CMs at the Division of Neurosurgery of Federal University of São Paulo. The authors reviewed the records of 10 patients whose lesions were located in the cerebellum. There were four male and six female patients (ratio 1:1.5) whose ages ranged from 14 to 45 years (mean age 33 years). Clinical presentation was sudden or acute in all cases, and neuroimaging examinations performed in all patients demonstrated signs of bleeding. The mean size of the malformations was 4.6 cm, and in all but one patient the lesions were totally removed without complications. After a mean follow-up period of 70 months, all patients were considered to be in good or excellent clinical condition. Conclusions Cerebellar CMs should be analyzed separately from other posterior fossa CMs. These lesions can reach large sizes and cause massive hemorrhages, resulting in acute or sudden presentation. Surgery is a safe and effective option that provides a curative treatment when a complete removal is achieved.

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