Treatment of brain arteriovenous malformations by double arterial catheterization with simultaneous injection of Onyx: retrospective series of 17 patients

Abstract

Background and purpose: The use of Onyx in the treatment of intracranial AVMs has increased the cure rate of endovascular embolization compared with the use of liquid adhesive agents. Inadvertent occlusion of the draining veins before the complete exclusion of the nidus constitutes a major risk of bleeding. We report a case series using the technique of double simultaneous arterial catheterization as an approach to achieve the complete exclusion of the nidus before reaching the venous drainage, through a more controlled hemodynamic filling.

Materials and methods: Between April 2008 and November 2009, 17 patients with brain AVMs were treated by the DACT. The mean age of the patients was 32.7 years (range, 6-54 years), with 9 females and 8 males. The clinical onset was characterized by intracranial hemorrhage in 8 patients and by seizures in 7. The size of the AVMs ranged from 13 to 54 mm (average, 26.2 mm). The DACT was always used with the objective of curing the AVM.

Results: All 17 patients completed the EVT. The average number of sessions conducted was 1.4 (range, 1-3 sessions), with the average injection amount of 6.9 mL of Onyx (range, 2-25.2 mL). Sixteen AVMs (94.1%) were angiographically cured by embolization. Clinical complications occurred in 2 patients (11.7%); 1 of these was permanent (5.9%). No deaths were registered.

Conclusions: This preliminary series shows that the DACT presents satisfactory results when used with curative intent.

Fig 1.

A 51-year-old female patient harboring a right frontal AVM previously treated with embolization with n-BCA, followed by radiosurgery in 2001. A, DSA, frontal view, right ICA injection, demonstrates the remaining nidus fed by tiny branches from the ACA and MCA. B, DSA, lateral view, right ECA, shows arterial nourishing from the MCA, through collaterals with a frontal branch of the ACA, which are filled by arterioarterial aspiration of the MMA. A superficial draining vein is also visualized. C, Plain radiography shows the 2 microcatheters, 1 placed in the MMA and the other positioned in the MCA (black arrows). D, DSA, right ICA, right oblique view, shows persistence of a small residual nidus after injection of 3.2 mL of Onyx (black arrow). E, Plain radiography, frontal view, shows the final cast of Onyx and glue after the end of the treatment. F and G, DSA, ICA frontal view (F) and ECA lateral view (G), demonstrates complete exclusion of the AVM after embolization.

Fig 2.

A 13-year-old girl harboring a ruptured right frontal AVM. A, DSA, right oblique view, right ICA injection, demonstrates a frontal AVM nidus fed by branches from ACA and MCA. B, DSA, right oblique view, right ICA injection, shows a deep remnant nidus after 2 sessions of embolization. C, Plain radiography, right oblique view, shows the 2 microcatheters, 1 placed in the ACA and the other placed in the MCA (black arrows). D, DSA, right ICA, right oblique view, demonstrates the small remnant nidus after the injection of 9.5 mL of Onyx (black arrow). E, ICA roadmap image, left oblique view, shows the catheterization of the feeder artery helped by a HyperForm balloon. F, DSA, right ICA, plain radiography, right oblique view, shows the final cast of Onyx after the end of treatment. G, DSA, right common carotid artery, lateral view, at the end of treatment, demonstrates complete exclusion of the AVM. H, DSA, right ICA, frontal view at 6-month follow-up, shows the stability of the occlusion.