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Posterior fossa brain arteriovenous malformations

Clinical features and outcomes of endovascular embolization, adjuvant microsurgery and radiosurgery

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Abstract

Background

Posterior fossa brain arteriovenous malformations (PFbAVM) are relatively rare brain disorders but have a high risk of hemorrhage. Endovascular embolization to reduce the lesion size before treatment may improve the outcome of PFbAVM. The purposes of this study were to identify risk factors associated with hemorrhage in PFbAVM and to assess clinical outcomes in patients receiving initial endovascular embolization.

Material and methods

From 1999 to 2013 a total of 63 patients with PFbAVMs were treated (31 males and 32 females, 14.1 % of all AVM cases). A retrospective examination of patient demographics, clinical presentation, angiographic features, treatment modalities, complications and outcomes was carried out. The re-hemorrhage rate, obliteration rate and modified Rankin scale (MRS) were used as measures of outcome.

Results

Of the 63 PFbAVM patients 54 (85.7 %) exhibited hemorrhage and 15 had confirmed aneurysms. The cerebellar location (P = 0.007) and deep venous drainage (P = 0.012) were independent predictors of hemorrhage in multivariate analyses. The mean estimated devascularization was 46.9 % (range 10–100 %) in the 20 patients (31.7 %) treated by endovascular embolization. The 16 patients with residual niduses were further treated by radiosurgery, microsurgery or embolization. Complete obliteration was attained in 12 patients (67 %) while 2 (5.7 %) were left with persisting neurological deficits and 1 had a re-hemorrhage 3 years later (annual rate of 4.6 %). Favorable outcome (MRS ≤ 2) was obtained in the 20 patients receiving initial endovascular embolization (P = 0.039 versus preoperative MRS).

Conclusion

Cerebellar location and deep venous drainage are predictors of hemorrhage in PFbAVM. Adjuvant endovascular embolization is useful and safe for PFbAVM prior to microsurgery or radiosurgery.

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References

  1. da Costa L, Thines L, Dehdashti AR, Wallace MC, Willinsky RA, Tymianski M, Schwartz ML, ter Brugge KG. Management and clinical outcome of posterior fossa arteriovenous malformations: Report on a single-centre 15-year experience. J Neurol Neurosurg Psychiatry. 2009;80(4):376–9.

    Article  CAS  PubMed  Google Scholar 

  2. Yang W, Wang JY, Caplan JM, Braileanu M, Shang H, Upadhyay U, Zenonos GA, Rigamonti D, Colby GP, Coon AL, Tamargo RJ, Huang J. Predictors of functional outcome following treatment of posterior fossa arteriovenous malformations. J Clin Neurosci. 2015;22(2):357–62.

    Article  PubMed  Google Scholar 

  3. Khaw AV, Mohr JP, Sciacca RR, Schumacher HC, Hartmann A, Pile-Spellman J, Mast H, Stapf C. Association of infratentorial brain arteriovenous malformations with hemorrhage at initial presentation. Stroke. 2004;35(3):660–3.

    Article  CAS  PubMed  Google Scholar 

  4. Choi JH, Mohr JP. Brain arteriovenous malformations in adults. Lancet Neurol. 2005;4(5):299–308.

    Article  PubMed  Google Scholar 

  5. Garcia MR, Alvarez H, Goulao A, Pruvost P, Lasjaunias P. Posterior fossa arteriovenous malformations. Angioarchitecture in relation to their hemorrhagic episodes. Neuroradiology. 1990;31(6):471–5.

    Article  Google Scholar 

  6. Kouznetsov E, Weill A, Ghostine JS, Gentric JC, Raymond J, Roy D. Association between posterior fossa arteriovenous malformations and prenidal aneurysm rupture: Potential impact on management. Neurosurg Focus. 2014;37(3):E4.

    Article  PubMed  Google Scholar 

  7. Schmidt NO, Reitz M, Raimund F, Treszl A, Grzyska U, Westphal M, Regelsberger J. Clinical relevance of associated aneurysms with arteriovenous malformations of the posterior fossa. Acta Neurochir Suppl. 2011;112:131–5.

    Article  PubMed  Google Scholar 

  8. Arnaout OM, Gross BA, Eddleman CS, Bendok BR, Getch CC, Batjer HH. Posterior fossa arteriovenous malformations. Neurosurg Focus. 2009;26(5):E12.

    Article  PubMed  Google Scholar 

  9. Rodriguez-Hernandez A, Kim H, Pourmohamad T, Young WL, Lawton MT. Cerebellar arteriovenous malformations: Anatomic subtypes, surgical results, and increased predictive accuracy of the supplementary grading system. Neurosurgery. 2012;71(6):1111–24.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Torne R, Rodriguez-Hernandez A, Arikan F, Romero-Chala F, Cicuendez M, Vilalta J, Sahuquillo J. Posterior fossa arteriovenous malformations: Significance of higher incidence of bleeding and hydrocephalus. Clin Neurol Neurosurg. 2015;134:37–43.

    Article  PubMed  Google Scholar 

  11. Almeida JP, Medina R, Tamargo RJ. Management of posterior fossa arteriovenous malformations. Surg Neurol Int. 2015;6:31.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Lawton MT, Hamilton MG, Spetzler RF. Multimodality treatment of deep arteriovenous malformations: Thalamus, basal ganglia, and brain stem. Neurosurgery. 1995;37(1):29–35, discussion 35–36.

    Article  CAS  PubMed  Google Scholar 

  13. Maruyama K, Kondziolka D, Niranjan A, Flickinger JC, Lunsford LD. Stereotactic radiosurgery for brainstem arteriovenous malformations: Factors affecting outcome. J Neurosurg. 2004;100(3):407–13.

    Article  PubMed  Google Scholar 

  14. Spetzler RF, Martin NA. A proposed grading system for arteriovenous malformations. J Neurosurg. 1986;65(4):476–83.

    Article  CAS  PubMed  Google Scholar 

  15. Richling B, Lasjaunias P, Byrne J, Lindsay KW, Matge G, Trojanowski T. Standards of training in endovascular neurointerventional therapy: As approved by the ESNR, EBNR, UEMS Section of Neurosurgery and EANS (February 2007). Enclosed the standards of practice as endorsed by the WFITN. Acta Neurochir. 2007;149(6):613–616, discussion 616.

    Article  CAS  PubMed  Google Scholar 

  16. Magro E, Chainey J, Chaalala C, Al JH, Fournier JY, Bojanowski MW. Management of ruptured posterior fossa arteriovenous malformations. Clin Neurol Neurosurg. 2015;128:78–83.

    Article  PubMed  Google Scholar 

  17. Stefani MA, Porter PJ, TerBrugge KG, Montanera W, Willinsky RA, Wallace MC. Large and deep brain arteriovenous malformations are associated with risk of future hemorrhage. Stroke. 2002;33(5):1220–4.

    Article  PubMed  Google Scholar 

  18. Hirai S, Mine S, Yamakami I, Ono J, Yamaura A. Angioarchitecture related to hemorrhage in cerebral arteriovenous malformations. Neurol Med Chir. 1998;38(Suppl):165–70.

    Article  Google Scholar 

  19. Stapf C, Mast H, Sciacca RR, Choi JH, Khaw AV, Connolly ES, Pile-Spellman J, Mohr JP. Predictors of hemorrhage in patients with untreated brain arteriovenous malformation. Neurology. 2006;66(9):1350–5.

    Article  CAS  PubMed  Google Scholar 

  20. Nataf F, Meder JF, Roux FX, Blustajn J, Merienne L, Merland JJ, Schlienger M, Chodkiewicz JP. Angioarchitecture associated with haemorrhage in cerebral arteriovenous malformations: A prognostic statistical model. Neuroradiology. 1997;39(1):52–8.

    Article  CAS  PubMed  Google Scholar 

  21. Da CL, Wallace MC, Brugge KG Ter, O’Kelly C, Willinsky RA, Tymianski M. The natural history and predictive features of hemorrhage from brain arteriovenous malformations. Stroke. 2009;40(1):100–5.

    Article  Google Scholar 

  22. Gross BA, Du R. Natural history of cerebral arteriovenous malformations: A meta-analysis. J Neurosurg. 2013;118(2):437–43.

    Article  PubMed  Google Scholar 

  23. Abecassis IJ, Xu DS, Batjer HH, Bendok BR. Natural history of brain arteriovenous malformations: A systematic review. Neurosurg Focus. 2014;37(3):E7.

    Article  PubMed  Google Scholar 

  24. Viñuela F, Nombela L, Roach MR, Fox AJ, Pelz DM. Stenotic and occlusive disease of the venous drainage system of deep brain AVM’s. J Neurosurg. 1985;63(2):180–4.

    Article  PubMed  Google Scholar 

  25. Willinsky R, Lasjaunias P, Terbrugge K, Pruvost P. Brain arteriovenous malformations: Analysis of the angio-architecture in relationship to hemorrhage (based on 152 patients explored and/or treated at the hopital de Bicetre between 1981 and 1986). J Neuroradiol. 1988;15(3):225–37.

    CAS  PubMed  Google Scholar 

  26. Abla AA, Nelson J, Rutledge WC, Young WL, Kim H, Lawton MT. The natural history of AVM hemorrhage in the posterior fossa: Comparison of hematoma volumes and neurological outcomes in patients with ruptured infra- and supratentorial AVMs. Neurosurg Focus. 2014;37(3):E6.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Stein KP, Wanke I, Schlamann M, Dammann P, Moldovan AS, Zhu Y, Sure U, Sandalcioglu IE. Posterior fossa arterio-venous malformations: Current multimodal treatment strategies and results. Neurosurg Rev. 2014;37(4):619–28.

    Article  PubMed  Google Scholar 

  28. Bowden G, Kano H, Tonetti D, Niranjan A, Flickinger J, Lunsford LD. Stereotactic radiosurgery for arteriovenous malformations of the cerebellum. J Neurosurg. 2014;120(3):583–90.

    Article  PubMed  Google Scholar 

  29. Sahlein DH, Mora P, Becske T, Nelson PK. Nidal embolization of brain arteriovenous malformations: Rates of cure, partial embolization, and clinical outcome. J Neurosurg. 2012;117(1):65–77.

    Article  PubMed  Google Scholar 

  30. Panagiotopoulos V, Gizewski E, Asgari S, Regel J, Forsting M, Wanke I. Embolization of intracranial arteriovenous malformations with ethylene-vinyl alcohol copolymer (Onyx). Am J Neuroradiol. 2009;30(1):99–106.

    Article  CAS  PubMed  Google Scholar 

  31. Weber W, Kis B, Siekmann R, Kuehne D. Endovascular treatment of intracranial arteriovenous malformations with onyx: Technical aspects. Am J Neuroradiol. 2007;28(2):371–7.

    CAS  PubMed  Google Scholar 

  32. Drake CG, Friedman AH, Peerless SJ. Posterior fossa arteriovenous malformations. J Neurosurg. 1986;64(1):1–10.

    Article  CAS  PubMed  Google Scholar 

  33. Han PP, Ponce FA, Spetzler RF. Intention-to-treat analysis of Spetzler-Martin grades IV and V arteriovenous malformations: Natural history and treatment paradigm. J Neurosurg. 2003;98(1):3–7.

    Article  PubMed  Google Scholar 

  34. Dashti SR, Spalding AC, Yao TL. Multimodality treatment of a ruptured grade IV posterior fossa arteriovenous malformation in a patient pregnant with twins: Case report. J Neurointerv Surg. 2012;4(5):e21.

    Article  PubMed  Google Scholar 

  35. Nozaki K, Hashimoto N, Kikuta K, Takagi Y, Kikuchi H. Surgical applications to arteriovenous malformations involving the brainstem. Neurosurgery. 2006;58(4 Suppl 2):ONS-270-8; discussion ONS-278-9.

  36. Hernesniemi JA, Dashti R, Juvela S, Vaart K, Niemela M, Laakso A. Natural history of brain arteriovenous malformations: A long-term follow-up study of risk of hemorrhage in 238 patients. Neurosurgery. 2008;63(5):823–31.

    Article  PubMed  Google Scholar 

  37. Symon L, Tacconi L, Mendoza N, Nakaji P. Arteriovenous malformations of the posterior fossa: A report on 28 cases and review of the literature. Br J Neurosurg. 1995;9(6):721–32.

    Article  CAS  PubMed  Google Scholar 

  38. Choi HJ, Choi SK, Lim YJ. Radiosurgical techniques and clinical outcomes of gamma knife radiosurgery for brainstem arteriovenous malformations. J Korean Neurosurg Soc. 2012;52(6):534–40.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Maruyama K, Koga T, Niranjan A, Kondziolka D, Flickinger JC, Lunsford LD. Radiosurgery for brainstem arteriovenous malformation. Prog Neurol Surg. 2013;27:67–72.

    Article  PubMed  Google Scholar 

  40. Robert T, Blanc R, Ciccio G, Gilboa B, Boissonnet H, Fahed R, Redjem H, Pistocchi S, Bartolini B, Piotin M. E‑053 multi-modality management of posterior fossa arteriovenous malformations: clinical and angiographic outcomes. J Neurointerv Surg. 2014;6(suppl 1):A63.

    Google Scholar 

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Authors and Affiliations

  1. The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, 510282, Guangzhou, China

    Ling-Feng Lai, Jia-Xiang Chen, Kuang Zheng, Xu-Ying He, Xi-Feng Li, Xin Zhang, Qiu-Jing Wang, Chuan-Zhi Duan & Min Chen

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  1. Ling-Feng Lai
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Correspondence to Chuan-Zhi Duan.

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Conflict of interest

L.-F. Lai, J.-X. Chen, K. Zheng, X.-Y. He, X.-F. Li, X. Zhang, Q.-J. Wang, C.-Z. Duan and M. Chen state that there are no conflicts of interest.

Ethical standards

The study was scrutinized and accepted by the institutional review board of Zhujiang Hospital. All procedures were carried out in accordance with the Helsinki Declaration of 1975 (in its most recently amended version). Informed consent was obtained from all patients included in the study.

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Lai, LF., Chen, JX., Zheng, K. et al. Posterior fossa brain arteriovenous malformations. Clin Neuroradiol 28, 17–24 (2018). https://doi.org/10.1007/s00062-016-0514-3

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