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Fistula component of cerebral arteriovenous malformations: morphologic change after stereotactic radiosurgery and outcome of embolisation

  • Clinical Article - Vascular
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Abstract

Background

The angioarchitecture of arteriovenous fistulas (AVFs) of cerebral arteriovenous malformation (CAVM) after stereotactic radiosurgery (SRS) remain unclear. The purpose of this study is to report the angiographic change of AVF components of CAVMs after SRS and outcomes of endovascular embolisation.

Methods

From 2002 to 2012, a total of 523 CAVMs had been treated primarily by SRS with more than 3-year latency. Among these databases, there were 19 patients with 21 AVFs undergoing embolization after SRS. We retrospectively analyzed the angioarchitecture of the CAVM to identify AVFs, morphologic change and outcomes of AVFs after SRS and embolisation.

Results

Eight AVFs were in the periphery of CAVMs, the other 13 were in a central location. Eighteen of 21 AVFs remained constant in morphology after SRS, while three feeders of AVFs were associated with radiation arteritis. The causes of failure to identify AVFs before SRS were overlooked (n = 7) or there was superimposition with feeders, nidus and/or venous drains of CAVMs (n = 14). Total fistula occlusion was achieved in all 21 AVFs; residual CAVMs was totally obliterated by embolisation and/or additional SRS in 12 patients. One patient had a small procedure-related intracerebral hemorrhage. Mean follow-up period was 26 months.

Conclusions

Early detection of AVF components of CAVMs prior to SRS may be difficult, particularly those in a central location. However, most AVFs became evident and showed consistency in angiographic morphology after obliteration of the majority nidus parts of CAVMs. Endovascular embolisation is effective in managing these AVF components.

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Acknowledgments

Source of support: This work was supported in part by a grant from the Taipei Veterans General Hospital (V98C1-153, V99C1-012) and the National Science Council (97-2314-B-075-062-my2, 99-2314-B-075-045-my2).

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Department of Radiology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan, Republic of China

    Chao-Bao Luo, Wan-Yuo Guo, Feng-Chi Chang, Hsiu-Mei Wu, Michael M. H. Teng, Chung-Jung Lin & Cheng-Yen Chang

  2. Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China

    David H. C. Pan & Wen-Yuh Chung

  3. Department of Radiology, National Yang-Ming University School of Medicine, Taipei, Taiwan, Republic of China

    Chao-Bao Luo, Wan-Yuo Guo, Feng-Chi Chang, Hsiu-Mei Wu, Michael M. H. Teng, Chung-Jung Lin, David H. C. Pan, Wen-Yuh Chung & Cheng-Yen Chang

  4. Department of Radiology, National Defense Medical Center, Taipei, Taiwan, Republic of China

    Chao-Bao Luo

Authors
  1. Chao-Bao Luo
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  2. Wan-Yuo Guo
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  3. Feng-Chi Chang
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  4. Hsiu-Mei Wu
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  5. Michael M. H. Teng
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  6. Chung-Jung Lin
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  7. David H. C. Pan
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  8. Wen-Yuh Chung
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  9. Cheng-Yen Chang
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Corresponding author

Correspondence to Chao-Bao Luo.

Additional information

Comment

The authors hypothesize that a cerebral AVM consists of two independent components which are relevant for occlusion following radiosurgery (RS). One is the nidus and the other one are high flow shunts (HFS) within the AVM which may or may not be present. They further hypothesize that the response rate to RS is different for the nidus and for HFS with HFS being more radioresistant. The literature on this topic is controversial (1, 2).

Naturally, all AVMs consist of a nidus. Only a fraction of AVMs contain HFS in addition. The percentage of AVMs containing HFS undergoing RS has been reported to be 38.5 % (3). If the authors’ hypothesis is true and considering that occlusion rates for AVMs following RS are about 80 %, the percentage of non-responding HFS cannot be high. This is supported by this study’s finding that only 4 % of AVMs required embolization for the HFS component following RS.

Based on their study, the authors recommend for a number of reasons the following concept in the treatment for cerebral AVMs: deliver RS to the nidus which may or may not contain HFS and for the small percentage of AVMs with non-responding HFS embolize the HFS following RS as opposed to prior to RS. This is an interesting and novel approach for which this study may serve as a proof-of-concept.

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2) Nagaraja S, Lee KJ, Coley SC, Capener D, Walton L, Kemeny AA, Wilkinson ID, Griffiths PD (2006) Stereotactic radiosurgery for brain arteriovenous malformations: quantitative MR assessment of nidal response at 1 year and angiographic factors predicting early obliteration. Neuroradiol 48:821-829

3) Yuki I, Kim RH, Duckwiler G, Jahan R, Tateshima S, Gonzalez N, Gorgulho A, Diaz JL, De Salles AA, Vinuela F (2010) Treatment of brain arteriovenous malformations with high-flow arteriovenous fistulas: risk and complications associated with endovascular emolization in multimodality treatment. J Neurosurg 113:715–722

Thomas Mindermann

Zurich,Switzerland

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Luo, CB., Guo, WY., Chang, FC. et al. Fistula component of cerebral arteriovenous malformations: morphologic change after stereotactic radiosurgery and outcome of embolisation. Acta Neurochir 156, 85–92 (2014). https://doi.org/10.1007/s00701-013-1939-y

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  • DOI: https://doi.org/10.1007/s00701-013-1939-y

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