Search Results (20)

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

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

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

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

The paradigm is gradually shifting, with radiosurgery and endovascular embolization being increasingly chosen over surgical resection in the selected cases of brain arteriovenous malformations. Routinely used X-ray monitoring of liquid embolic infusion has very good spatial and temporal resolution but is not without significant drawbacks regarding poor visualization of the complex AVM angioarchitecture, especially after many embolizations in the past and therefore limiting the technical ability of the embocure—total occlusion of the feeding arteries, nidus, and draining veins. The purpose of this study was to evaluate the use of real-time MRI guidance in endovascular embolization with Onyx (instead of X-ray) in a single swine rete mirabile (RM) AVM model in order to provide the scaffolding for the real-time MRI guidance method. Onyx propagation was observed in real-time dynamic GE-EPI scan with initial ipsilateral RM filling followed by main cerebral arterial branch distribution. The relatively bright signal within RM and the brain prior to Onyx injection provided a good background for the dark, low signal of the embolic agent spreading in rete mirabile and brain arteries. X-ray picture confirmed Onyx cast distribution at the end of the procedure. In this initial experience, real-time MRI seems to be a promising method that may significantly improve liquid embolic agent infusion monitoring in the future, although requiring further development before clinical use. Full article

This study aimed to evaluate prognostic factors associated with nidus obliteration following stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations. From January 2001 to January 2018, 119 patients who underwent SRS with AVM were studied to analyze major prognostic factors (age, prescription dose (Gy), volume (mm³), nidus size (cm), and Spetzler–Martin (SM) grade) for nidus obliteration. A random forest and tree explainer was used to construct a predictive model of nidus obliteration. The prognostic factors affecting nidus obliteration from most to least important were age, nidus size, volume, total prescription dose, and SM grade, using a predictive model. In a specific case for nidus size (1.5 cm), total dose (23 Gy), and SM grade (2), the result showed a high obliteration score of 0.75 with the actual obliteration period of 6 months spent; the mean AUC was 0.90 in K-fold cross validation. The predictive model identified the main contributing factors associated with a prognostic of nidus obliteration from linear accelerator-based SRS for cerebral AVM. It was confirmed that the results, including the prognostic factors, are potentially useful for outcome prediction for patient and treatment. Full article

Introduction: microRNAs (miRNAs) are a class of non-coding RNAs playing a myriad of important roles in regulating gene expression. Of note, recent work demonstrated a critical role of miRNAs in the genesis and progression of brain arteriovenous malformations (bAVMs). Accordingly, here we examine miRNA signatures related to bAVMs and associated gene expression. In so doing we expound on the potential prognostic, diagnostic, and therapeutic significance of miRNAs in the clinical management of bAVMs. Methods: A PRISMA-based literature review was performed using PubMed/Medline database with the following search terms: “brain arteriovenous malformations”, “cerebral arteriovenous malformations”, “microRNA”, and “miRNA”. All preclinical and clinical studies written in English, regardless of date, were selected. For our bioinformatic analyses, miRWalk and miRTarBase machine learning algorithms were employed; the Kyoto Encyclopedia of Genes and Genomes (KEGG) database was quired for associated pathways/functions. Results: four studies were ultimately included in the final analyses. Sequencing data consistently revealed the decreased expression of miR-18a in bAVM-endothelial cells, resulting in increased levels of vascular endodermal growth factor (VEGF), Id-1, matrix metalloproteinase, and growth signals. Our analyses also suggest that the downregulation of miR-137 and miR-195* within vascular smooth muscle cells (VSMCs) may foster the activation of inflammation, aberrant angiogenesis, and phenotypic switching. In the peripheral blood, the overexpression of miR-7-5p, miR-629-5p, miR-199a-5p, miR-200b-3p, and let-7b-5p may contribute to endothelial proliferation and nidus development. The machine learning algorithms employed confirmed associations between miRNA-related target networks, vascular rearrangement, and bAVM progression. Conclusion: miRNAs expression appears to be critical in managing bAVMs’ post-transcriptional signals. Targets of microRNAs regulate canonical vascular proliferation and reshaping. Although additional scientific evidence is needed, the identification of bAVM miRNA signatures may facilitate the development of novel prognostic/diagnostic tools and molecular therapies for bAVMs. Full article

Objective: To evaluate the efficacy of liquid embolization agents for treating various hemorrhagic peripheral intracranial aneurysms. Methods: We retrospectively analyzed 38 patients who suffered from hemorrhagic peripheral intracranial aneurysms and were treated with liquid embolization agents. We used the modified Rankin scale for follow-up at 6 months postoperatively, and digital subtraction angiography follow-up was performed 6 months postoperatively. Results: Of the 38 patients (ten of simple peripheral intracranial aneurysms, six of Moyamoya disease (MMD), and 22 of arteriovenous malformation (AVM)), posterior circulation accounted for the most significant proportion (57.9%), followed by anterior circulation (21.1%) and intranidal aneurysms (21.1%). Intraoperative hemorrhage occurred in four cases, postoperative cerebral infarction occurred in four cases, two patients encountered microcatheter retention, and intraoperative thrombosis took place in the basilar artery of a patient with an arteriovenous malformation. A postoperative hemorrhage occurred in only one patient. At 6-month follow-up, 84.2% of patients had good prognosis outcomes, and 13.5% had poor outcomes. Conclusion: Liquid embolization agents are effective for hemorrhagic peripheral intracranial aneurysms; however, safety depends on the subtypes. For peripheral hemorrhagic aneurysms in MMD, the vessel architecture must be carefully evaluated before embolization. Full article

Inoculation with the Pfizer-BioNTech coronavirus infection-19 (COVID-19) vaccine (BNT162b2) has been approved in Korea. Although it is generally safe, several possible side effects have been reported. The present report describes a 28-year-old woman who developed an intracerebral hemorrhage in her right temporal lobe after the first dose of the Pfizer-BioNTech COVID-19 vaccine. The patient complained of a persistent headache for four days after the first dose, along with right third nerve palsy and drowsiness. Non-enhanced brain computed tomography confirmed a 5.0 × 3.7 × 5.0 cm³-sized intracranial hemorrhage in the right temporal lobe due to the rupture of an arteriovenous malformation (AVM). Transfemoral cerebral angiography revealed that blood was supplied to the AVM by the right middle cerebral artery branch and drained into the right transverse sinus. The patient underwent surgical treatment for AVM nidus removal with hematoma evacuation on the day of admission. Her condition stabilized 10 days postoperatively. These findings indicate that clinicians should be aware that cerebral hemorrhage caused by AVM rupture may be a side effect of inoculation with the BNT162b2 mRNA COVID-19 vaccine. Full article