Data regarding anatomic and clinical results of flow diversion treatment in complex bifurcation aneurysms of the anterior circulation are scarce.
To present our results of treatment of these lesions ...with special emphasis on the fate of 'jailed' cortical branches and perforating arteries.
Seventeen patients were treated with flow diverters (FDs) for 18 aneurysms of the middle cerebral artery bifurcation (n=13) and the anterior communicating artery complex (n=5). Nineteen cortical branches were covered. A single FD was used in all patients.
At latest follow-up (mean 7.9 months; range 3-36; median 4.0) 2/19 (10.5%) of the covered branches were occluded, 9/19 (47.4%) showed a decreased caliber and the remaining branches were unchanged. All branch modifications were clinically asymptomatic. Mortality and permanent morbidity were 0%. Symptomatic ischemic events in perforator territories occurred in three patients (17.6%), which were reversible in all of them within 24 h. Follow-up MRI disclosed asymptomatic lacunar defects corresponding to covered perforating artery territories in five patients (29.4%). Altogether, perforator lesions-symptomatic and asymptomatic-occurred in 7/17 patients (41.2%). 33.3% of the aneurysms were occluded at latest follow-up; decreased diameters were seen in the other 66.7%.
Flow diversion of bifurcation aneurysms is feasible with low rates of permanent morbidity and mortality. Caliber reduction and asymptomatic occlusion of covered cortical branches seems to be common, yet ischemic complications are rather linked to perforator occlusions. Our results on aneurysm occlusion rates are preliminary and longer follow-up periods are warranted.
Dosimetric radiosurgery incidents are rare and probably insufficiently reported in scientific publications. After a long follow-up (FU), the authors studied the outcomes of patients treated with ...overexposure radiation for arteriovenous malformation (AVM) administered via stereotactic radiosurgery (SRS) at their department.
Between May 2006 and June 2007, 22 patients were treated for AVM with SRS. The mean (range) patient age was 43.5 (11.8-78) years. Previous treatments were embolization (n = 10), SRS (1), and surgery (1). The average (range) volume was 2.1 (0.2-6.4) cm3. The median prescribed minimal dose was 18.0 Gy. An initial error in the estimation of scatter factors led to overexposure to radiation. Due to this incident, the median delivered minimum dose was 25.0 Gy. All patients were prospectively followed with clinical examination and imaging.
The mean (range) clinical FU was 14.5 (12.0-15.2) years. AVM obliteration after SRS was completed in 90.9% of patients at a mean (range) of 39.4 (24.4-70.4) months. No patient had post-SRS AVM bleeding. Three patients (13.6%) had new permanent deficits due to radiation-induced changes (RICs). Obliteration without new deficits was achieved in 18 patients (81.8%). Two patients had new epilepsy that was probably due to RIC but well controlled. The median (range) MRI FU was 13.8 (2.5-14.9) years. During MRI FU, two RIC periods were observed: one classic period during the first 3 years showed T1-weighted annular irregular enhancement (13%), and the other period between 5 and 15 years after SRS showed the occurrence of cystic and hemorrhagic lesions (22.7%). There were no cases of radiation-induced tumor.
The present long-term report showed that this overexposure incident probably increased the AVM obliteration rate. This overexposure seems to have induced RIC and in particular a higher rate of cystic and hemorrhagic late lesions with nevertheless moderate clinical consequences. Long-term FU for AVM is mandatory due to the risk of late RIC.
The authors report the cases of four patients who presented with progressive myelopathy (one patient had been asymptomatic for 25 years) due to spinal epidural arteriovenous fistulas (AVFs). Clinical ...symptoms and magnetic resonance imaging findings were similar to those of dural AVFs. In contrast to dural AVFs, angiography showed that the lesions were fed by multiple vessels and drained in one case in multiple veins. Perimedullary venous drainage was visible in three of the four cases. All fistulas were cured by embolization; arterial access was used in two cases and venous in two. The authors' aim in this paper is to emphasize the differences between dural and epidural AVFs in terms of their physiopathology and angioarchitecture as well as the therapeutic strategy.
Abstract
BACKGROUND
Curative transvenous embolization is an emerging strategy for treatment of cerebral arteriovenous malformations (AVMs).
OBJECTIVE
To assess contemporary outcomes of transvenous ...embolization as a stand-alone therapy for cerebral AVMs
METHODS
We prospectively followed 40 patients with 41 AVMs who underwent transvenous endovascular therapy between January 2008 and January 2015. Patient demographics, AVM characteristics, endovascular techniques used, angiographic results, clinical outcomes, and complications were assessed independently.
RESULTS
Thirty-eight of 41 (92.6%) AVMs were anatomically cured. The mean patient age was 37.7 yr (range, 18-69 yr) and 55% were female. Twenty-seven (67.5%) patients presented with hemorrhage. The mean size of the AVM nidus was 2.8 ± 1.2 cm, and low Spetzler-Martin grade AVMs comprised 41.5% of lesions. The majority of patients were treated in 1 session (56%; n = 23). The mean follow-up period was 28.4 (range, 6-106 mo). There was 1 (2.5%) hemorrhagic complication related to microcatheter navigation and 1 (2.5%) venous infarction was observed without clinical consequences. At 6-mo follow-up, 1 (2.5%) patient had significant disability. There were no recurrences during the follow-up period. Overall mortality was 2.5% and procedure-related mortality was 0%.
CONCLUSION
This prospective contemporary series demonstrates a high rate of complete AVM obliteration and excellent functional outcomes in patients with both ruptured and unruptured AVMs treated with transvenous embolization. This approach is promising and warrants further investigation as a treatment for select AVMs
BACKGROUND AND PURPOSE—Flow diverters are used for endovascular therapy of intracranial aneurysms. We did a nationwide prospective study to investigate the safety and effectiveness of flow diversion ...at 12 months.
METHODS—DIVERSION was a national prospective cohort study including all flow diverters placement between October 2012 and February 2014 in France. The primary end point was the event-free survival rate at 12 months, defined as the occurrence of morbidity (intracranial hemorrhage, ischemic stroke, noncerebral hemorrhage, or neurological deficit due to mass effect), retreatment, or death within 12 months post-treatment. A quality control was carried out on 100% of the collected data and of at least 10% of the included patients in each center, chosen at random. All reported serious events were adjudicated by an independent Data Safety and Monitoring Board. Satisfactory occlusion was defined as 3 or 4 on Kamran scale by an independent imaging core laboratory at 12 months.
RESULTS—We enrolled 398 patients harboring 477 intracranial aneurysms. At least 1 morbidity-mortality event was noted in 95 of 408 interventions representing an event-free survival rate of 75.7% (95% CI, 71.1–79.7). The rate of permanent-related serious events and mortality was 5.9% and 1.2% at 12 months, respectively. Multivariate analysis showed that high baseline blood pressure (hazard ratio, 2.54; 95% CI, 1.35–4.79; P=0.039), diabetes mellitus (hazard ratio, 3.70; 95% CI, 1.60–8.6; P=0.0022), and larger aneurysms (hazard ratio, 1.07; 95% CI, 1.04–1.11; P<0.0001) were associated with the occurrence of a neurological deficit. The satisfactory occlusion rate at 12 months was 79.9%, and the absence of high baseline blood pressure (odds ratio, 2.01; 95% CI, 1.12–3.71; P=0.0193) and postprocedural satisfactory occlusion (odds ratio, 2.75; 95% CI, 1.49–5.09; P=0.0012) were associated with a 12-month satisfactory occlusion.
CONCLUSIONS—A satisfactory occlusion was achieved in almost 80% of cases after flow diverter treatment with a permanent-related serious event and mortality rates of 5.9% and 1.2% at 12 months, respectively.
IMPORTANCE: General anesthesia and procedural sedation are common practice for mechanical thrombectomy in acute ischemic stroke. However, risks and benefits of each strategy are unclear. OBJECTIVE: ...To determine whether general anesthesia or procedural sedation for anterior circulation large-vessel occlusion acute ischemic stroke thrombectomy are associated with a difference in periprocedural complications and 3-month functional outcome. DESIGN, SETTING, AND PARTICIPANTS: This open-label, blinded end point randomized clinical trial was conducted between August 2017 and February 2020, with final follow-up in May 2020, at 10 centers in France.Adults with occlusion of the intracranial internal carotid artery and/or the proximal middle cerebral artery treated with thrombectomy were enrolled. INTERVENTIONS: Patients were assigned to receive general anesthesia with tracheal intubation (n = 135) or procedural sedation (n = 138). MAIN OUTCOMES AND MEASURES: The prespecified primary composite outcome was functional independence (a score of 0 to 2 on the modified Rankin Scale, which ranges from 0 no neurologic disability to 6 death) at 90 days and absence of major periprocedural complications (procedure-related serious adverse events, pneumonia, myocardial infarction, cardiogenic acute pulmonary edema, or malignant stroke) at 7 days. RESULTS: Among 273 patients evaluable for the primary outcome in the modified intention-to-treat population, 142 (52.0%) were women, and the mean (SD) age was 71.6 (13.8) years. The primary outcome occurred in 38 of 135 patients (28.2%) assigned to general anesthesia and in 50 of 138 patients (36.2%) assigned to procedural sedation (absolute difference, 8.1 percentage points; 95% CI, −2.3 to 19.1; P = .15). At 90 days, the rate of patients achieving functional independence was 33.3% (45 of 135) with general anesthesia and 39.1% (54 of 138) with procedural sedation (relative risk, 1.18; 95% CI, 0.86-1.61; P = .32). The rate of patients without major periprocedural complications at 7 days was 65.9% (89 of 135) with general anesthesia and 67.4% (93 of 138) with procedural sedation (relative risk, 1.02; 95% CI, 0.86-1.21; P = .80). CONCLUSIONS AND RELEVANCE: In patients treated with mechanical thrombectomy for anterior circulation acute ischemic stroke, general anesthesia and procedural sedation were associated with similar rates of functional independence and major periprocedural complications. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03229148
Abstract only Background and Purpose: The FRAME study demonstrated that even in the early time window (<6hrs) perfusion imaging profiles can influence response to mechanical thrombectomy. Perfusion ...imaging (PWI) can also be used to measure damage to the blood-brain barrier (BBB) which has been shown to be associated with increased risk of hemorrhagic complications (HC) with treatment. We aimed to determine if BBB profiles in the FRAME study would influence outcome after mechanical thrombectomy (MT). Methods: This was a post-hoc analysis of the FRAME study which enrolled stroke patients with large vessel occlusion who received MT within 6 hours of stroke onset. Patients with successful pre-treatment MRI PWI were included. We tested the hypothesis that more severe pre-treatment BBB disruption is associated with higher frequency of HC after MT. BBB disruption was measured as the percent of signal change due to gadolinium leakage on the PWI source images. Mean permeability derangement (MPD) was defined as the average of all voxels in the stroke core that are two standard deviations above normal. The outcome of HC was defined as any type of parenchymal hematoma (PH1 or PH2); poor functional outcome was defined as mRS >2 at 90 days. MPD was compared with HC and functional outcome using the Wilcoxon signed-rank test and logistic regression. A prespecified MPD threshold of 20% was tested as a predictor of HC based on prior studies. Results: There were 164 patients included in the analysis, median age 74 and 48% female. HC occurred in 57 patients. The average MPD was 15.1% for patients with HC and 8.7% for patients without HC. Elevated MPD was significantly associated with HC (p<0.0001) with a 25% increased risk of HC for each 5% increase in MPD (OR 1.25; CI 1.09:1.45; p=0.0018). Increased MPD was also associated with poor functional outcome (p=0.0002). ROC analysis confirmed the prespecified MPD threshold, identifying 19.7% as the optimal cut point for classification. MPD greater than 20% more than tripled the risk of HC (OR 3.37; CI 1.49:7.85; p=0.004). Conclusions: Increased pre-treatment BBB disruption has a substantial influence on the risk of HC after MT. Integration of BBB imaging into patient selection algorithms to improve MT outcomes should be tested further.
The role of endovascular treatment in the management of patients with brain arteriovenous malformations (AVMs) remains uncertain. AVM embolization can be offered as stand-alone curative therapy or ...prior to surgery or stereotactic radiosurgery (SRS) (pre-embolization). The Treatment of Brain AVMs Study (TOBAS) is an all-inclusive pragmatic study that comprises two randomized trials and multiple registries.
Results from the TOBAS curative and pre-embolization registries are reported. The primary outcome for this report is death or dependency (modified Rankin Scale mRS score > 2) at last follow-up. Secondary outcomes include angiographic results, perioperative serious adverse events (SAEs), and permanent treatment-related complications leading to an mRS score > 2.
From June 2014 to May 2021, 1010 patients were recruited in TOBAS. Embolization was chosen as the primary curative treatment for 116 patients and pre-embolization prior to surgery or SRS for 92 patients. Clinical and angiographic outcomes were available in 106 (91%) of 116 and 77 (84%) of 92 patients, respectively. In the curative embolization registry, 70% of AVMs were ruptured, and 62% were low-grade AVMs (Spetzler-Martin grade I or II), while the pre-embolization registry had 70% ruptured AVMs and 58% low-grade AVMs. The primary outcome of death or disability (mRS score > 2) occurred in 15 (14%, 95% CI 8%-22%) of the 106 patients in the curative embolization registry (4 12%, 95% CI 5%-28% of 32 unruptured AVMs and 11 15%, 95% CI 8%-25% of 74 ruptured AVMs) and 9 (12%, 95% CI 6%-21%) of the 77 patients in the pre-embolization registry (4 17%, 95% CI 7%-37% of 23 unruptured AVMs and 5 9%, 95% CI 4%-20% of 54 ruptured AVMs) at 2 years. Embolization alone was confirmed to occlude the AVM in 32 (30%, 95% CI 21%-40%) of the 106 curative attempts and in 9 (12%, 95% CI 6%-21%) of 77 patients in the pre-embolization registry. SAEs occurred in 28 of the 106 attempted curative patients (26%, 95% CI 18%-35%, including 21 new symptomatic hemorrhages 20%, 95% CI 13%-29%). Five of the new hemorrhages were in previously unruptured AVMs (n = 32; 16%, 95% CI 5%-33%). Of the 77 pre-embolization patients, 18 had SAEs (23%, 95% CI 15%-34%), including 12 new symptomatic hemorrhages 16%, 95% CI 9%-26%). Three of the hemorrhages were in previously unruptured AVMs (3/23; 13%, 95% CI 3%-34%).
Embolization as a curative treatment for brain AVMs was often incomplete. Hemorrhagic complications were frequent, even when the specified intent was pre-embolization before surgery or SRS. Because the role of endovascular treatment remains uncertain, it should preferably, when possible, be offered in the context of a randomized trial.
The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is a pragmatic study that includes 2 randomized trials and registries of treated or conservatively managed patients. The authors ...report the results of the surgical registry.
TOBAS patients are managed according to an algorithm that combines clinical judgment and randomized allocation. For patients considered for curative treatment, clinicians selected from surgery, endovascular therapy, or radiation therapy as the primary curative method, and whether observation was a reasonable alternative. When surgery was selected and observation was deemed unreasonable, the patient was not included in the randomized controlled trial but placed in the surgical registry. The primary outcome of the trial was mRS score > 2 at 10 years (at last follow-up for the current report). Secondary outcomes include angiographic results, perioperative serious adverse events, and permanent treatment-related complications leading to mRS score > 2.
From June 2014 to May 2021, 1010 patients were recruited at 30 TOBAS centers. Surgery was selected for 229/512 patients (44%) considered for curative treatment; 77 (34%) were included in the surgery versus observation randomized trial and 152 (66%) were placed in the surgical registry. Surgical registry patients had 124/152 (82%) ruptured and 28/152 (18%) unruptured arteriovenous malformations (AVMs), with the majority categorized as low-grade Spetzler-Martin grade I-II AVM (118/152 78%). Thirteen patients were excluded, leaving 139 patients for analysis. Embolization was performed prior to surgery in 78/139 (56%) patients. Surgical angiographic cure was obtained in 123/139 all-grade (89%, 95% CI 82%-93%) and 105/110 low-grade (95%, 95% CI 90%-98%) AVM patients. At the mean follow-up of 18.1 months, 16 patients (12%, 95% CI 7%-18%) had reached the primary safety outcome of mRS score > 2, including 11/16 who had a baseline mRS score ≥ 3 due to previous AVM rupture. Serious adverse events occurred in 29 patients (21%, 95% CI 15%-28%). Permanent treatment-related complications leading to mRS score > 2 occurred in 6/139 patients (4%, 95% CI 2%-9%), 5 (83%) of whom had complications due to preoperative embolization.
The surgical treatment of brain AVMs in the TOBAS registry was curative in 88% of patients. The participation of more patients, surgeons, and centers in randomized trials is needed to definitively establish the role of surgery in the treatment of unruptured brain AVMs. Clinical trial registration no.: NCT02098252 (ClinicalTrials.gov).
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