Acta Neurochirurgica

, Volume 153, Issue 4, pp 869–878 | Cite as

Onyx embolization for the treatment of brain arteriovenous malformations

Clinical Article
First Online:
Received:
Accepted:

Abstract

Background

Onyx has emerged in recent years for the endovascular treatment of brain arteriovenous malformations (AVMs). However, the role of Onyx embolization is still under discussion. We report our initial experiences in the treatment of brain AVMs with Onyx embolization.

Methods

Between January 2004 and December 2007, 86 patients with brain AVMs were embolized with Onyx. Clinical presentation included intracerebral hemorrhage in 32 patients, seizures in 25 patients, headaches in 20 patients, neurologic deficits in 3 patients, and in 6 patients the AVM was an incidental finding. According to the Spetzler–Martin scale, three AVMs were grade I, 13 were grade II, 45 were grade III, 19 were grade IV, and 6 were grade V. Seventy-four AVMs were located in eloquent regions.

Results

Initial complete obliteration after final embolization was achieved in 16 patients (18.6%), with an average of 80.5% (range, 30–100%) volume reduction. Partial embolization was followed by surgery in 18 patients, whereas 17 AVMs were cured. In 48 patients treated by embolization and radiosurgery, four patients were lost to follow-up. Three-year follow-up angiography was performed on 30 patients and showed complete obliteration after radiosurgery in 23 patients. The remaining 14 patients are awaiting 3-year postradiosurgery results. Embolization-related permanent morbidity was 3.5%, whereas mortality was 1.2%.

Conclusions

Although Onyx allows moderate obliteration rates, combined management, such as adjunctive embolization with microsurgery or radiosurgery, may be effective for selected large AVMs.

Keywords

Brain arteriovenous malformations Embolization Endovascular treatment Onyx 
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Notes

Acknowledgment

We thank all the anonymous reviewers for their helpful suggestions on the quality improvement of our paper.

Conflicts of interest

None.

References

  1. 1.
    Alexander MJ, Tolbert ME (2006) Targeting cerebral arteriovenous malformations for minimally invasive therapy. Neurosurgery 59:S178–S183PubMedCrossRefGoogle Scholar
  2. 2.
    Chyatte D (1997) Normal pressure perfusion breakthrough after resection of arteriovenous malformation. J Stroke Cerebraovasc Dis 6:130–136CrossRefGoogle Scholar
  3. 3.
    Debrun GM, Aletich V, Ausman JI, Charbel F, Dujovny M (1997) Embolization of nidus of brain arteriovenous malformations with n-butyl cyanoacrylate. Neurosurgery 40:112–121PubMedCrossRefGoogle Scholar
  4. 4.
    Fiorella D, Albuquerque FC, Woo HH, McDougall CG, Rasmussen PA (2006) The role of neuroendovascular therapy for the treatment of brain arteriovenous malformations. Neurosurgery 59:S163–S177PubMedGoogle Scholar
  5. 5.
    Fleetwood IG, Steinberg GK (2002) Arteriovenous malformations. Lancet 359:863–873PubMedCrossRefGoogle Scholar
  6. 6.
    Gobin YP, Laurent A, Merienne L, Schlienger M, Aymard A, Houdart E, Casasco A, Lefkopoulos D, George B, Merland JJ (1996) Treatment of brain arteriovenous malformations by embolization and radiosurgery. J Neurosurg 85:19–28PubMedCrossRefGoogle Scholar
  7. 7.
    Hamilton MG, Spetzler RF (1994) The prospective application of a grading system for arteriovenous malformations. Neurosurgery 34:2–7PubMedCrossRefGoogle Scholar
  8. 8.
    Hartmann A, Pile-Spellman J, Stapf C, Sciacca RR, Faulstich A, Mohr JP, Schumacher HC, Mast H (2002) Risk of endovascular treatment of brain arteriovenous malformations. Stroke 33:1816–1820PubMedCrossRefGoogle Scholar
  9. 9.
    Hauck EF, Welch BG, White JA, Purdy PD, Pride LG, Samson D (2009) Preoperative embolization of cerebral arteriovenous malformations with Onyx. AJNR Am J Neuroradiol 30:492–495PubMedCrossRefGoogle Scholar
  10. 10.
    Haw CS, terBrugge K, Willinsky R, Tomlinson G (2006) Complications of embolization of arteriovenous malformations of the brain. J Neurosurg 104:226–232PubMedCrossRefGoogle Scholar
  11. 11.
    Henkers H, Nahser HC, Berg-Dammer E, Weber W, Lange W, Kühne D (1998) Endovascular therapy of brain AVMs prior to radiosurgery. Neurol Res 20:479–492Google Scholar
  12. 12.
    Izawa M, Chernov M, Hayashi M, Iseki H, Hori T, Takakura K (2009) Combined management of intracranial arteriovenous malformations with embolization and Gamma Knife radiosurgery: comparative evaluation of the long-term results. Surg Neurol 71:43–53PubMedCrossRefGoogle Scholar
  13. 13.
    Jafar JJ, Davis AJ, Berenstein A, Choi IS, Kupersmith MJ (1993) The effect of embolization with N-butyl cyanoacrylate prior to surgical resection of cerebral arteriovenous malformations. J Neurosurg 78:60–69PubMedCrossRefGoogle Scholar
  14. 14.
    Jahan R, Murayama Y, Gobin YP, Duckwiler GR, Vinters HV, Viñuela F (2001) Embolization of arteriovenous malformations with Onyx: clinicopathological experience in 23 patients. Neurosurgery 48:984–987PubMedCrossRefGoogle Scholar
  15. 15.
    Jayaraman M, Cloft HJ (2009) Embolization of brain arteriovenous malformations for cure: because we could or because we should? AJNR Am J Neuroradiol 30:107–108PubMedCrossRefGoogle Scholar
  16. 16.
    Jayaraman MV, Marcellus ML, Hamilton S, Do HM, Campbell D, Chang SD, Steinberg GK, Marks MP (2008) Neurologic complications of arteriovenous malformation embolization using liquid embolic agents. AJNR Am J Neuroradiol 29:242–246PubMedCrossRefGoogle Scholar
  17. 17.
    Katsaridis V, Papagiannaki C, Aimar E (2008) Curative embolization of cerebral arteriovenous malformations (AVMs) with Onyx in 101 patients. Neuroradiology 50:589–597PubMedCrossRefGoogle Scholar
  18. 18.
    Ledezma CJ, Hoh BL, Carter BS, Pryor JC, Putman CM, Ogilvy CS (2006) Complications of cerebral arteriovenous malformation embolization: multivariate analysis of predictive factors. Neurosurgery 58:602–611PubMedCrossRefGoogle Scholar
  19. 19.
    Leonardi M, Simonettti L, Cenni P, Raffi L (2005) Brain AVM embolization with Onyx: analysis of treatment in 34 patients. Interv Neuroradiol 11:185–204PubMedGoogle Scholar
  20. 20.
    Loh Y, Duckwiler GR (2010) A prospective, multicenter, randomized trial of the Onyx liquid embolic system and N-butyl cyanoacrylate embolization of cerebral arteriovenous malformations. J Neurosurg 113:733–741PubMedCrossRefGoogle Scholar
  21. 21.
    Lopes DK, Bagan B, Wells K (2010) Onyx embolization of arteriovenous malformation using 2 microcatheters. Neurosurgery 66:616–618PubMedCrossRefGoogle Scholar
  22. 22.
    Lundqvist C, Wihkolm G, Svendsen P (1996) Embolization of cerebral arteriovenous malformations. Part II. Aspects of complications and late outcome. Neurosurgery 39:460–467PubMedCrossRefGoogle Scholar
  23. 23.
    Maimon S, Strauss I, Frolov V, Margalit N, Ram Z (2010) Brain arteriovenous malformation treatment using a combination of Onyx and a new detachabale tip microcatheter, SONIC: short-term results. AJNR Am J Neuroradiol 31:947–954PubMedCrossRefGoogle Scholar
  24. 24.
    Mattle HP, Schroth G, Seiler RW (2000) Dilemmas in the management of patients with arteriovenous malformations. J Neurol 247:917–928PubMedCrossRefGoogle Scholar
  25. 25.
    Mounayer C, Hammami N, Piotin M, Spelle L, Benndorf G, Kessler I, Moret J (2007) Nidal embolization of brain arteriovenous malformations using Onyx in 94 patients. AJNR Am J Neuroradiol 28:518–523PubMedGoogle Scholar
  26. 26.
    Murayama Y, Vinuela F, Ulhoa A, Akiba Y, Duckwiler GR, Gobin YP, Vinters HV, Greff RJ (1998) Nonadhesive liquid embolic agent for cerebral arteriovenous malformations: preliminary histopathological studies in swine rete mirabile. Neurosurgery 43:1164–1175PubMedCrossRefGoogle Scholar
  27. 27.
    Ogilvy CS, Stieg PE, Awad I, Brown RD Jr, Kondziolka D, Rosenwasser R, Young WL, Hademenos G, Special Writing Group of the Stroke Council, American Stroke Association (2001) AHA scientific statement: recommendations for the management of intracranial arteriovenous malformations: a statement for healthcare professionals from a special writing group of the Stroke Council, American Stroke Association. Stroke 32:1458–1471PubMedGoogle Scholar
  28. 28.
    Panagiotopoulos V, Gizewski E, Asgari S, Regel J, Forsting M, Wanke I (2009) Embolization of intracranial arteriovenous malformations with ethylene–vinyl alcohol copolymer (Onyx). AJNR Am J Neuroradiol 30:99–106PubMedCrossRefGoogle Scholar
  29. 29.
    Pasqualin A, Barone G, Cioffi F, Rosta L, Scienza R, Da Pian R (1991) The relevance of anatomic and hemodynamic factors to a classification of cerebral arteriovenous malformations. Neurosurgery 28:370–379PubMedCrossRefGoogle Scholar
  30. 30.
    Pérez-Higueras A, Rossi Lopez R, Quinones Taria D (2005) Endovascular treatment of cerebral AVM: our experience with Onyx. Interv Neuroradiol 11:141–157PubMedGoogle Scholar
  31. 31.
    Pierot L, Januel AC, Herbreteau D, Barreau X, Drouineau J, Berge J, Sourour N, Cognard C (2005) Endovascular treatment of brain arteriovenous malformations using Onyx: preliminary results of a prospective multicenter study. Interv Neuroradiol 11:159–164PubMedGoogle Scholar
  32. 32.
    Richling B, Killer M, Al-Schameri AR, Ritter L, Agic R, Krenn M (2006) Therapy of brain arteriovenous malformations: multimodality treatment from a balanced standpoint. Neurosurgery 59:S148–S157PubMedGoogle Scholar
  33. 33.
    Söderman M, Andersson T, Karlsson B, Wallace MC, Edner G (2003) Management of patients with brain arteriovenous malformations. Eur J Radiol 46:195–205PubMedCrossRefGoogle Scholar
  34. 34.
    Sorimachi T, Koike T, Takeuchi S, Minakawa T, Abe H, Nishimaki K, Ito Y, Tanaka R (1999) Embolization of cerebral arteriovenous malformations achieved with polyvinyl alcohol particles: angiographic reappearance and complications. AJNR Am J Neuroradiol 20:1323–1328PubMedGoogle Scholar
  35. 35.
    Spetzler RF, Martin NA (1986) A proposed grading system for arteriovenous malformations. J Neurosurg 65:476–483PubMedCrossRefGoogle Scholar
  36. 36.
    van Rooij WJ, Sluzewsld M, Beute GN (2007) Brain AVM embolization with Onyx. AJNR Am J Neuroradiol 28:172–177PubMedGoogle Scholar
  37. 37.
    Wallace RC, Flom RA, Khayata MH, Dean BL, McKenzie J, Rand JC, Obuchowski NA, Zepp RC, Zabramski JM, Spetzler RF (1995) The safety and effectiveness of brain arteriovenous malformation embolization using acrylic and particles: the experiences of a single institution. Neurosurgery 37:606–618PubMedCrossRefGoogle Scholar
  38. 38.
    Weber W, Kis B, Siekmann R, Kuehne D (2007) Endovascular treatment of intracranial arteriovenous malformation with Onyx: technical aspects. AJNR Am J Neuroradiol 28:371–377PubMedGoogle Scholar
  39. 39.
    Weber W, Kis B, Siekmann R, Jans P, Laumer R, Kühne D (2007) Preoperative embolization of intracranial arteriovenous malformations with Onyx. Neurosurgery 61:244–254PubMedCrossRefGoogle Scholar
  40. 40.
    Zabel-du Bois A, Milker-Zabel S, Huber P, Huber P, Schlegel W, Debus J (2007) Risk of hemorrhage and obliteration rates of LINAX-based radiosurgery for cerebral arteriovenous malformations treated after prior partial embolization. Int J Radiat Oncol Biol Phys 68:999–1003PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  1. 1.Department of Neurosurgery, Huashan HospitalFudan UniversityShanghaiChina

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