Endovascular treatment of small cerebral arteriovenous malformations as a primary therapy

Abstract

Purpose: The patient population that would benefit most from endovascular curative treatment of intracranial arteriovenous malformations is not clearly established. The aim of the study was to determine the effect of curative embolization of cerebral arteriovenous malformations with special regard to radiographic and clinical outcomes and procedure-related complications.

Material and methods: Between January 2009 and December 2014, 18 patients with intracranial arteriovenous malformations were embolized with Onyx with intent to cure. There were 4 women and 14 men with a mean age of 40 years (range 10-62 years). Inclusion criteria were: maximal diameter of the lesions ≤ 3 cm and arterial supply consisting of no more than 2 major arteries. There were 5 (27.8 %) patients with ruptured and 13 (72.2%) with unruptured lesions. Mean arteriovenous malformations size was 2.3 cm (range 1.5-2.9 cm).

Results: Thirty-three procedures were performed in 18 patients. Total obliteration was achieved in 5 patients (27.8%). The most common reason for initial incomplete angiographic occlusion were unfavorable angioarchitectural features of arteriovenous malformations with the rate of 44.4%. The mean follow-up of patients with complete occlusion was 35.2 months (range 18-60 months). Complication rate was 12.1%. One patient had permanent neurological deficit with resulting morbidity of 5.6%. There were no deaths.

Conclusions: Embolization of intracranial arteriovenous malformations plays a limited role as a sole therapeutic modality even in terms of small lesions with two or less arterial feeders, although larger prospective series are necessary to confirm your findings. Associated complications are not trivial and should be considered when choosing this form of treatment.

Keywords: cerebral arteriovenous malformations; embolization; endovascular treatment.

Figure 1

A 53-year-old man presented with incidentally discovered arteriovenous malformation (AVM). Coronal (A) and sagittal (B) projections of computed tomography angiography demonstrated a right perirolandic AVM measuring 2.9 cm. Right internal carotid angiogram (C) before embolization showed the AVM that was supplied by the middle cerebral artery and drained into the superior sagittal sinus via a cortical vein. Instant post-embolisation angiogram (D) detected a residual portion of the nidus with persistent venous drainage (white arrow). The nidus remnant was not accessible through arterial pedicles, thus further embolisation was not possible. Anteroposterior (E) and lateral (F) right carotid angiograms taken eight months later revealed disappearance of the residual cluster and no evidence of venous drainage, which was confirmed by control angiogram taken 16 months later (not shown)

Figure 2

A 47-year-old man presented with increasing headaches. Anteroposterior and lateral left carotid angiograms (A) as well as anteroposterior and lateral left vertebral angiograms (B) demonstrated a left medial parieto-occipital arteriovenous malformation (AVM). The first session of embolisation was performed through the posterior cerebral artery (C) and the second and third ones through the anterior cerebral artery (D). Total occlusion of the AVM was achieved (E). The internal carotid and vertebral angiograms taken 50 months after endovascular treatment revealed no recanalisation, which is presented in oblique projections (F)