Abstract
Introduction
Intracranial arteriovenous malformations (AVMs) are the most frequent cause of hemorrhagic strokes in the pediatric population. The study aim was to retrospectively assess the safety and efficacy of Onyx embolization with the intention to cure AVMs in a pediatric population.
Methods
A retrospective analysis of all patients (<18 years) who underwent endovascular embolization using Onyx at our institution was conducted. The primary endpoint was the composite complete angiographic occlusion of AVM immediately after the last embolization session that had no procedure-related complication requiring emergency surgery. Secondary endpoints were angiographic occlusion rates, procedure-related complications, and clinical outcomes after treatment and at the 6-month follow-up
Results
Twenty-three patients (mean age, 11.7 years) underwent a total of 45 embolization sessions. The median Spetzler-Martin grade was 3 (range 1 to 4). The primary endpoint was achieved in 19 patients (82.6 %). Complete angiographic occlusion of the AVM was obtained in 21 patients (91.3 %) immediately after embolization and at the 6-month follow-up. Embolization-related complications were observed in three patients (13 %). None of the complications resulted in permanent functional disability or death. In two patients (8.7 %), the AVM could not be completely occluded by embolization alone and the patients were referred to radiosurgery and microsurgery, respectively.
Conclusion
Onyx embolization of AVM in pediatric patients with the intention to cure resulted in high occlusion rates without increasing neurological disability or death. The development of new embolization techniques and devices seems to improve the safety of Onyx embolization.
Similar content being viewed by others
References
Toma AK, Davagnanam I, Ganesan V, Brew S (2013) Cerebral arteriovenous shunts in children. Neuroimaging Clin N Am 23:757–770
Mohr JP, Parides MK, Stapf C, International ARUBA Investigators et al (2014) Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet 383:614–621
Al-Shahi Salman R, White PM, Counsell CE et al (2014) Scottish Audit of Intracranial Vascular Malformations Collaborators. Outcome after conservative management or intervention for unruptured brain arteriovenous malformations. JAMA 311:1661–1669
Dorfer C, Czech T, Bavinzski G, Kitz K, Mert A, Knosp E, Gruber A (2010) Multimodality treatment of cerebral AVMs in children: a single-centre 20 years experience. Childs Nerv Syst 26:681–687
Darsaut TE, Guzman R, Marcellus ML et al (2011) Management of pediatric intracranial arteriovenous malformations: experience with multimodality therapy. Neurosurgery 69:540–556, discussion 556
Nair AP, Kumar R, Mehrotra A, Srivastava AK, Sahu RN, Nair P (2012) Clinical, radiological profile and outcome in pediatric Spetzler-Martin grades I-III arteriovenous malformations. Childs Nerv Syst 28:593–598
Skjøth-Rasmussen J, Obbekjær T, Birkeland P, Hauerberg J, Juhler M (2012) Multimodality treatment approach in children with cerebral arteriovenous malformation—a survey in the Danish population. Childs Nerv Syst 28:587–592
Blauwblomme T, Bourgeois M, Meyer P et al (2014) Long-term outcome of 106 consecutive pediatric ruptured brain arteriovenous malformations after combined treatment. Stroke 45:1664–1671
Eiras J, Gómez-Perún J, Carcavilla LI, Alberdi J (1987) Surgical experience with arteriovenous malformations in children. Childs Nerv Syst 3:156–160
Ventureyra EC, Herder S (1987) Arteriovenous malformations of the brain in children. Childs Nerv Syst 3:12–18
Gaballah M, Storm PB, Rabinowitz D et al (2014) Intraoperative cerebral angiography in arteriovenous malformation resection in children: a single institutional experience. J Neurosurg Pediatr 13:222–228
Sheth SA, Potts MB, Sneed PK et al (2014) Angiographic features help predict outcome after stereotactic radiosurgery for the treatment of pediatric arteriovenous malformations. Childs Nerv Syst 30:241–247
Blamek S, Larysz D, Miszczyk L (2013) Stereotactic linac radiosurgery and hypofractionated stereotactic radiotherapy for pediatric arteriovenous malformations of the brain: experiences of a single institution. Childs Nerv Syst 29:651–656
Börcek AÖ, Emmez H, Akkan KM et al (2014) Gamma Knife radiosurgery for arteriovenous malformations in pediatric patients. Childs Nerv Syst 30:1485–1492
Potts MB, Sheth SA, Louie J et al (2014) Stereotactic radiosurgery at a low marginal dose for the treatment of pediatric arteriovenous malformations: obliteration, complications, and functional outcomes. J Neurosurg Pediatr 14:1–11
Rodesch G, Malherbe V, Alvarez H, Zerah M, Devictor D, Lasjaunias P (1995) Nongalenic cerebral arteriovenous malformations in neonates and infants. Review of 26 consecutive cases (1982–1992). Childs Nerv Syst 11:231–241
Thiex R, Williams A, Smith E, Scott RM, Orbach DB (2010) The use of Onyx for embolization of central nervous system arteriovenous lesions in pediatric patients. AJNR Am J Neuroradiol 31:112–120
Berenstein A, Ortiz R, Niimi Y et al (2010) Endovascular management of arteriovenous malformations and other intracranial arteriovenous shunts in neonates, infants, and children. Childs Nerv Syst 26:1345–1358
Ashour R, Aziz-Sultan MA, Soltanolkotabi M et al (2012) Safety and efficacy of onyx embolization for pediatric cranial and spinal vascular lesions and tumors. Neurosurgery 71:773–784
Soltanolkotabi M, Schoeneman SE, Alden TD et al (2013) Onyx embolization of intracranial arteriovenous malformations in pediatric patients. J Neurosurg Pediatr 11:431–437
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, Initiative STROBE (2007) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370:1453–1457
Maimon S, Strauss I, Frolov V, Margalit N, Ram Z (2010) Brain arteriovenous malformation treatment using a combination of Onyx and a new detachable tip microcatheter, SONIC: short-term results. AJNR Am J Neuroradiol 31:947–954
Paramasivam S, Altschul D, Fifi J, Ortega Gutiarrez S, Berenstein A (2014) Safety and efficacy of detachable tip microcatheter for embolization of brain arteriovenous malformation. J Neurointerv Surg 6(Suppl 1):A14
Abud DG, Riva R, Nakiri GS, Padovani F, Khawaldeh M, Mounayer C (2011) Treatment of brain arteriovenous malformations by double arterial catheterization with simultaneous injection of Onyx: retrospective series of 17 patients. AJNR Am J Neuroradiol 32:152–158
Kessler I, Riva R, Ruggiero M, Manisor M, Al-Khawaldeh M, Mounayer C (2011) Successful transvenous embolization of brain arteriovenous malformations using Onyx in five consecutive patients. Neurosurgery 69:184–193, discussion 193
Iosif C, Mendes GA, Saleme S et al (2015) Endovascular transvenous cure for ruptured brain arteriovenous malformations in complex cases with high Spetzler-Martin grades. J Neurosurg 122:1229–1238
Mendes GA, Silveira EP, Saleme S et al (2015) Balloon-assisted microcatheter navigation for AVM embolization: technical note. J Neurosurg 17:1–5
Chapot R, Stracke P, Velasco A et al (2014) The pressure cooker technique for the treatment of brain AVMs. J Neuroradiol 41:87–91
Abud DG, Abud TG, Nakiri GS (2013) Management of brain AVM procedural hemorrhagic complication by the “security” catheter technique. J Neuroradiol 40:45–49
Pierot L, Cognard C, Herbreteau D et al (2013) Endovascular treatment of brain arteriovenous malformations using a liquid embolic agent: results of a prospective, multicenter study (BRAVO). Eur Radiol 23:2838–2845
Crowley RW, Ducruet AF, Kalani MY et al (2015) Neurological morbidity and mortality associated with the endovascular treatment of cerebral arteriovenous malformations before and during the Onyx era. J Neurosurg 122:1492–1497
Katsaridis V, Papagiannaki C, Aimar E (2008) Curative embolization of cerebral arteriovenous malformations (AVMs) with Onyx in 101 patients. Neuroradiology 50:589–597
Saatci I, Geyik S, Yavuz K, Cekirge HS (2011) Endovascular treatment of brain arteriovenous malformations with prolonged intranidal Onyx injection technique: long-term results in 350 consecutive patients with completed endovascular treatment course. J Neurosurg 115:78–88
Baharvahdat H, Blanc R, Termechi R et al (2014) Hemorrhagic complications after endovascular treatment of cerebral arteriovenous malformations. AJNR Am J Neuroradiol 35:978–983
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
We declare that all human and animal studies have been approved by the ethics committee for research of our institution and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. We declare that the study protocol was approved by the institutional review board, which waived the need for written informed consent.
Conflict of interest
We declare that we have no conflict of interest
Rights and permissions
About this article
Cite this article
de Castro-Afonso, L.H., Nakiri, G.S., Oliveira, R.S. et al. Curative embolization of pediatric intracranial arteriovenous malformations using Onyx: the role of new embolization techniques on patient outcomes. Neuroradiology 58, 585–594 (2016). https://doi.org/10.1007/s00234-016-1666-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00234-016-1666-1