Search Results (36)

Background: Awake craniotomy (AC) surgeries are less common in the pediatric population in comparison to their adult counterparts. Nonetheless, they can be considered for selected cases whereby speech preservation is paramount during maximal safe resection of intracranial lesions. We describe a case of AC for the excision of a brain arteriovenous malformation (bAVM) with language mapping in a pediatric patient. Methods: A previously well 16-year-old male presented with a spontaneous left frontal intracranial hemorrhage. Neuroimaging confirmed the cause to be a left antero-temporal bAVM centered in the insula. A decision was made for AC bAVM excision with language mapping for speech preservation. Results: As part of the pre-operative preparation, the patient and his caregivers were reviewed by a multidisciplinary team. For the conduct of the AC, the asleep–awake–asleep technique was used with processed EEG to guide anesthesia management. Additional modifications to make the patient comfortable included the avoidance of rigid cranial skull pins, urinary catheterization and central line insertion at the start of the surgery. Conclusions: Our experience concurs with the evidence that AC in children is a feasible option for select individuals. To our knowledge, this is the first detailed case description of a pediatric patient undergoing AC with language mapping for a bAVM. Emphases include a strong rapport between the patient and the managing multidisciplinary team, flexibility to adjust conventional workflows and limitations of neuroimaging adjuncts. Full article

Background and Objectives: Pediatric cerebral arteriovenous malformations (AVMs) are associated with significant morbidity and mortality. The aim of this study was to assess the long-term outcomes of surgical excision and stereotactic radiosurgery (SRS) of cerebral AVMs in pediatric patients. Materials and Methods: A single-center retrospective analysis was conducted using data obtained from a single medical center between January 2012 and July 2022. The Modified Rankin Scale (mRS) at admission and discharge and the Spetzler–Martin (SM) scores were analyzed. Results: Among 45 patients (mean age 11.8 years), 19 patients (42.2%) received surgical resection, with good outcomes (mRS 0–2) in 16 patients and complete obliteration in all patients. In total, 26 patients (57.8%) were managed with SRS. After 36.3 months on average, complete obliteration in 19 of 26 patients (69.2%) was confirmed. Among the 7 SRS patients without complete obliteration, 6 had residual cerebral AVMs at the last follow-up, and 1 had recurrence. All patients receiving SRS had favorable outcomes (mRS 0–1) and no apparent radiosurgery-related complications. Conclusions: In our study, the surgical resection or SRS was selected based on individual patient conditions, and the overall outcomes were satisfactory. Both surgical resection and SRS proved to be effective treatment options. Microsurgical resection demonstrated a high rate of obliteration and remains a favorable therapeutic choice with acceptable risks for pediatric AVMs. Full article

Hemorrhagic neurovascular diseases, with high mortality and poor outcomes, urge novel biomarker discovery and therapeutic targets. Micro-ribonucleic acids (miRNAs) are potent post-transcriptional regulators of gene expression. They have been studied in association with disease states and implicated in mechanistic gene interactions in various pathologies. Their presence and stability in circulating fluids also suggest a role as biomarkers. This review summarizes the current state of knowledge about miRNAs in the context of cerebral cavernous malformations (CCMs), a disease involving cerebrovascular dysmorphism and hemorrhage, with known genetic underpinnings. We also review common and distinct miRNAs of CCM compared to other diseases with brain vascular dysmorphism and hemorrhage. A systematic search, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline, queried all peer-reviewed articles published in English as of January 2025 and reported miRNAs associated with four hemorrhagic neurovascular diseases: CCM, arteriovenous malformations, moyamoya disease, and intracerebral hemorrhage. The PubMed systematic search retrieved 154 articles that met the inclusion criteria, reporting a total of 267 unique miRNAs identified in the literature on these four hemorrhagic neurovascular diseases. Of these 267 miRNAs, 164 were identified in preclinical studies, while 159 were identified in human subjects. Seventeen miRNAs were common to CCM and other hemorrhagic diseases. Common and unique disease-associated miRNAs in this systematic review motivate novel mechanistic hypotheses and have potential applications in diagnostic, predictive, prognostic, and therapeutic contexts of use. Much of current research can be considered hypothesis-generating, reflecting association rather than causation. Future areas of mechanistic investigation are proposed alongside approaches to analytic and clinical validations of contexts of use for biomarkers. Full article

Background: Arteriovenous malformations (AVMs) are high-risk cerebrovascular anomalies that can lead to devastating complications, especially when associated with intracranial aneurysms. Their coexistence poses unique challenges in diagnosis and management due to heightened hemodynamic stress and rupture risks. This case presents a 35-year-old woman with a giant unruptured left frontal AVM and a bilobed posterior communicating artery (PComA) aneurysm, highlighting the critical role of advanced imaging, meticulous surgical planning, and individualized care in addressing complex cerebrovascular conditions. Methods: The patient presented with a generalized tonic–clonic seizure, her first-ever neurological event. Advanced imaging, including digital subtraction angiography and 3D rotational imaging, revealed a 3–4 cm AVM supplied by the left middle and anterior cerebral arteries, with venous drainage into the superior sagittal sinus. Additionally, an unruptured bilobed PComA aneurysm was identified. Given the AVM’s large size, high-flow dynamics, and significant rupture risk, surgical resection was prioritized. The aneurysm, being stable and anatomically distinct, was managed conservatively. Microsurgical techniques were employed to ensure complete AVM resection while preserving critical vascular and neurological structures. Results: Postoperative angiography confirmed the complete removal of the AVM without residual nidus or abnormal vascular connections. The patient recovered without complications, achieving seizure freedom and preserved neurological function. At the three-month follow-up, imaging showed a stable resection cavity and a hemodynamically stable aneurysm. Conclusions: This case demonstrates the power of multidisciplinary care and advanced neurosurgical techniques in achieving curative outcomes for complex cerebrovascular anomalies. It underscores the importance of risk-prioritized strategies and highlights emerging directions for the field, including AI-integrated imaging, hybrid treatment approaches, and long-term studies on hemodynamic stability post-resection. This case contributes valuable insights into optimizing outcomes for patients with coexisting AVMs and aneurysms, offering hope for those facing similarly challenging diagnoses. Full article

Background/Objectives: Cerebral arteriovenous malformations (AVMs) are rare but complex vascular anomalies, particularly challenging when located in eloquent regions such as the corpus callosum and post-central gyrus. This report aims to highlight the management and outcomes of a 41-year-old female patient with a hemorrhagic AVM in these critical areas, emphasizing the importance of early surgical intervention and advanced imaging techniques. Methods: The patient presented with a right-sided tonic–clonic seizure and expressive aphasia, prompting imaging that revealed a complex AVM with deep venous drainage and arterial supply from the anterior cerebral artery. A multidisciplinary team performed microsurgical resection via a left parasagittal fronto-parietal craniotomy. The surgical approach prioritized hematoma evacuation followed by a stepwise dissection of the AVM nidus under intraoperative monitoring. Results: Complete resection of the AVM was confirmed through postoperative angiographic and CT imaging. The patient showed stable recovery over 15 months, with no recurrence or new neurological deficits. This case demonstrates the critical role of advanced imaging, intraoperative strategies, and a multidisciplinary approach in achieving successful outcomes. Conclusions: Microsurgical resection remains the gold standard for AVMs in eloquent and deep-seated brain regions. Early diagnosis and tailored surgical interventions are crucial for managing these high-risk cases. This case underscores the importance of integrating advanced imaging, strategic surgical planning, and intraoperative monitoring to minimize complications and optimize long-term recovery. Full article

Introduction: Cerebral arteriovenous malformations (CAVMs) are rare, with an estimated prevalence of 0.01%. Symptoms typically present in adults under 40, often beginning with hemorrhage in 61% of cases. The annual risk of hemorrhage is between 2–4%, with a mortality rate of 10%, and 50% of survivors may experience permanent neurological deficits. Embolization can induce changes in the angioarchitecture of the affected vessels. Our case uniquely demonstrates a morphological alteration in the carotid artery (CA) and its primary branches, associated with the presence of a CAVM. Detailed Case Presentation: A 52-year-old patient presented to the Emergency Department with weakness, shortness of breath, dizziness, nausea, and vomiting that began earlier that morning. Clinical and radiological evaluations suggested acute bleeding from a ruptured CAVM. The patient was admitted for digital subtraction angiography (DSA) and potential embolization. DSA confirmed the presence of a CAVM, supplied by the middle meningeal and occipital arteries, with distortion of the left CA angioarchitecture. Selective catheterization and embolization using Onyx 18 were successfully performed. After receiving supportive treatment, the patient was discharged in good condition. A follow-up CT scan three months later showed complete resolution of the brain pathologies. A repeat angiogram revealed no recanalization of the CAVM, with normalization of the CA and its branches. The patient is currently asymptomatic. Conclusions: Detection of pathological changes in the head and neck arteries linked to CAVM can predict rupture risk and complicate endovascular access. Identifying these changes early warrants consideration of interventions to prevent hemorrhage, though alternative access routes or strategies may be needed for safe, effective treatment. Full article

Background/Objectives: Indocyanine green video angiography, integrated into the operative microscope, is frequently used in cerebrovascular surgery. This technology is often preferred, for cost or availability, to Doppler or intraoperative DSA (digital subtraction angiography). With the same assumption it was possible, in our preliminary experience, to partially vicariate the aforementioned devices using the SPY mode of the Stryker endoscope; it allowed the visualization of fluorescence in high definition. Methods: A retrospective analysis was conducted on a series of five patients suffering from cerebral aneurysm or AVM (arteriovenous malformation) who underwent, during the last year, surgical treatment with the aid of the microscope supported by the Stryker endoscope in the SPY mode for the visualization of the fluorescence emitted by indocyanine green. Results: All aneurysms were completely excluded from the cerebrovascular circulation in the absence of residues in the collar and occlusion of adjacent vessels; the complete removal of the nidus in all the AVMs was achieved with no residues. Conclusions: The intraoperative use of indocyanine green was a safe, rapid, and effective technique within a preliminary case study of “regular—not giant” aneurysms and superficially located AVM. The endoscopic technique in the SPY mode has allowed to partially vicariate the use of Doppler, intraoperative angiography, and integrated microscope video angiography. For these purposes, we propose, in selected cases, the support of the endoscope in the SPY mode during the microsurgical procedure in order to visualize the green fluorescence of indocyanine. Full article

Background/Objectives: Arteriovenous malformations (AVMs) are complex vascular anomalies that can present with significant complications, including intracranial hemorrhage. This report presents the case of a 36-year-old female with Prothrombin G20210A mutation-associated thrombophilia, highlighting its potential impact on AVM pathophysiology and management. Methods: The patient presented with a right paramedian intraparenchymal frontal hematoma, left hemiparesis, and seizures. Cerebral angiography identified a ruptured right parasagittal frontal AVM classified as Spetzler–Martin Grade II. A right interhemispheric frontal craniotomy was performed, enabling microsurgical resection of the AVM. Intraoperative findings included evacuation of a subcortical hematoma and excision of a 20 mm AVM nidus with arterial feeders from the A4 segment of the anterior cerebral artery and a single venous drainage into the superior sagittal sinus. Results: Postoperative recovery was favorable, with significant neurological improvement. The patient demonstrated resolution of hemiparesis and a marked reduction in seizure activity. The hypercoagulable state associated with Prothrombin G20210A mutation was identified as a contributing factor in the thrombosis of the AVM’s draining vein, potentially leading to increased venous pressure, rupture, and hemorrhage. Conclusions: This case underscores the importance of recognizing thrombophilia in patients with AVMs for optimal surgical planning and complication management. Despite the challenges posed by the hypercoagulable condition, microsurgical resection proved to be a viable and effective treatment option. Further research is warranted to elucidate the relationship between thrombophilic disorders and AVMs to enhance patient management strategies and outcomes. Full article

Background/Objectives: Endovascular embolization is an effective treatment option for cerebral arteriovenous malformation (AVM) and dural arteriovenous fistulas (DAVFs). The objective of this study was to assess the safety and efficacy of Menox^TM in patients with cranial dural arteriovenous fistulas. Methods: From January 2021 to January 2023, 19 patients with intracranial DAVFs underwent embolization procedures. All patients were treated by embolization with Menox^TM or/and in combination with other embolization products such as Onyx (Covidien, Irvine, California), PHIL (MicroVention, Tustin, California), and Squid (Balt Extrusion, Montmorency, France). Treatment approaches were selected depending on the anatomical location of the fistula. Patients were monitored and followed-up for 12 months. Results: The patients’ mean age was 56.26 ± 16.49 years. Of these 19 patients, 58% (n = 11) were treated with the Menox^TM liquid embolizing agent (LEA) alone or in combination with different LEAs, while n = 7 were treated with other LEAs and 1 patient was treated solely with coils. Complete occlusion of DAVFs with Menox^TM and other agents was evident in 68.4% (n = 13/19) of patients. Complete occlusion (100%) was observed in the sinus rectus, transverse sinus, and diploic veins of the orbital roof, while complete occlusion was observed in 50% of falcotentorial patients and 60% of superior sagittal sinus patients. The lowest rate of complete fistula obliteration was observed in the dural carotid cavernous fistula (CCF) group (25%). An intra-procedural adverse event occurred in one patient. No other post-procedural adverse events were noted. Furthermore, in patients treated with Menox^TM, total occlusion was achieved in 72.7% (n = 8) of patients, whereas the non-Menox^TM group had 62.5% (n = 5) of patients with 100% occlusion and 37.5% (n = 3) of patients with subtotal occlusion. Conclusions: Outcomes using Menox^TM alone and in combination with other agents were effective, and it is safe for the treatment of dural arteriovenous fistulas. Full article

Stereotactic radiosurgery (SRS) is an effective treatment strategy for cerebral arteriovenous malformations (AVMs). Aggressive treatment achieving complete obliteration is necessary to prevent further intracranial hemorrhage and neurological deficits. However, SRS treatment of large AVMs (>10 cm³) is challenging. To prevent toxicity in the normal brain tissue, it is imperative to reduce the radiation dose as the lesion volume increases; however, this also reduces the rate of obliteration. In this study, we review the various radiosurgical approaches for treating large AVMs and their outcomes, and suggest ways to improve treatment outcomes during SRS for large AVMs. Full article

Arterial spin labeling (ASL) has emerged as a promising noninvasive tool for the evaluation of both pediatric and adult arteriovenous malformations (AVMs). This paper reviews the advantages and challenges associated with the use of ASL in AVM assessment. An assessment of the diagnostic workup of AVMs and their variants in both adult and pediatric populations is proposed. Evaluation after treatments, whether endovascular or microsurgical, was similarly examined. ASL, with its endogenous tracer and favorable safety profile, offers functional assessment and arterial feeder identification. ASL has demonstrated strong performance in identifying feeder arteries and detecting arteriovenous shunting, although some studies report inferior performance compared with digital subtraction angiography (DSA) in delineating venous drainage. Challenges include uncertainties in sensitivity for specific AVM features. Detecting AVMs in challenging locations, such as the apical cranial convexity, is further complicated, demanding careful consideration due to the risk of underestimating total blood flow. Navigating these challenges, ASL provides a noninvasive avenue with undeniable merits, but a balanced approach considering its limitations is crucial. Larger-scale prospective studies are needed to comprehensively evaluate the diagnostic performance of ASL in AVM assessment. Full article

Vein of Galen aneurysmal malformation is a relatively rare disease in which failure of the median prosencephalic vein of Markowski to involute early in gestation leads to a grossly dilated deep cerebral vein with multiple arterial feeders, causing a large arteriovenous shunt which leads to high-output cardiac failure. We describe a case of a term neonate who presented to a tertiary neonatal centre on day one of life with history, symptoms, and signs consistent with perinatal asphyxia; however, in the context of worsening multi-organ dysfunction and cardiomegaly, the infant was found to have a severe vein of Galen aneurysmal dilatation leading to high-output cardiac failure. The patient was transferred to a tertiary paediatric hospital and underwent a total of four coiling procedures to embolise the multiple feeder arteries supplying the aneurysmal malformation. This case highlights the difficulties in diagnosing this relatively uncommon condition, particularly in the context of a possible perinatal insult. Full article

This study conducts an in-depth analysis of the management of a complex arteriovenous malformation (AVM) in a 44-year-old individual, who initially manifested with acute left hemiparesis and progressively declined into a comatose state. Diagnostic neuroimaging identified a substantial right fronto-temporal intraparenchymal hematoma via a CT scan. Cerebral angiography further elucidated a choroidal AVM originating from the anterior choroidal artery, accompanied by intranidal aneurysms. The elected treatment strategy was the surgical excision of the AVM. The procedure achieved complete removal of the intracranial AVM, situated in a neurologically sensitive region, leading to notable neurological recovery. This study thoroughly explores and critically evaluates a wide spectrum of treatment approaches for intracranial arteriovenous malformations, including novel endovascular therapies. Despite extensive discourse on AVM in contemporary literature, this report is among the few documenting the treatment of a choroidal AVM via a microsurgical technique, and highlights various therapeutic options. Full article

A cerebral arteriovenous malformation (AVM) is a tangle of abnormal blood vessels that irregularly connects arteries and veins. Stereotactic radiosurgery (SRS) has been shown to be an effective treatment for AVM patients, but the factors associated with AVM obliteration remains a matter of debate. In this study, we aimed to develop a model that can predict whether patients with AVM will be cured 36 months after intervention by means of SRS and identify the most important predictors that explain the probability of being cured. A machine learning (ML) approach was applied using decision tree (DT) and logistic regression (LR) techniques on historical data (sociodemographic, clinical, treatment, angioarchitecture, and radiosurgery procedure) of 202 patients with AVM who underwent SRS at the Instituto de Radiocirugía del Perú (IRP) between 2005 and 2018. The LR model obtained the best results for predicting AVM cure with an accuracy of 0.92, sensitivity of 0.93, specificity of 0.89, and an area under the curve (AUC) of 0.98, which shows that ML models are suitable for predicting the prognosis of medical conditions such as AVM and can be a support tool for medical decision-making. In addition, several factors were identified that could explain whether patients with AVM would be cured at 36 months with the highest likelihood: the location of the AVM, the occupation of the patient, and the presence of hemorrhage. Full article

We aimed to determine whether the hemorrhage risks of cerebral arteriovenous malformation (AVM), evaluated through digital subtraction angiography (DSA) using a neural network, were superior to those assessed through angioarchitecture. We conducted a retrospective review of patients with cerebral AVM who underwent DSA from 2011 to 2017. Angioarchitecture parameters, age, and sex were analyzed using univariate and multivariate logistic regression. Additionally, a neural network was trained using a combination of convolutional neural network (CNN) and recurrent neural network (RNN) architectures. The training dataset consisted of 118 samples, while 29 samples were reserved for testing. After adjusting for age at diagnosis and sex, single venous drainage (odds ratio [OR] = 2.48, p = 0.017), exclusive deep venous drainage (OR = 3.19, p = 0.005), and venous sac (OR = 0.43, p = 0.044) were identified as independent risk factors for hemorrhage. The angioarchitecture-based hemorrhagic prediction model achieved 69% accuracy with an AUC (area under the ROC curve) of 0.757, while the CNN–RNN-based model achieved 76% accuracy with an AUC of 0.748. We present a diagnostic performance for hemorrhagic risk assessment of AVMs that is comparable to the angioarchitectural analysis. By leveraging larger datasets, there is significant potential to enhance prediction accuracy further. The CNN–RNN algorithm not only can potentially streamline workflow within the angio-suite but also serves as a complementary approach to optimize diagnostic accuracy and treatment strategies. Full article