Endovascular treatment of unruptured and ruptured brain arteriovenous malformations with Onyx18: a monocentric series of 84 patients.

BACKGROUND: Brain arteriovenous malformations (AVMs) are a rare pathology, and their treatment is discussed. The development of techniques and materials in endovascular, radiosurgical, and neurosurgical fields led to higher rates of complete occlusions and good clinical outcomes. MATERIALS AND METHODS: 84 patients (52 men, 32 women; mean age 38.2 years; range, 9-70 years) were treated at our institution with Onyx18 from 2001 to 2011. Patients treated with other embolic agents, with micro-AVMs, were not included in the analysis. RESULTS: Complete occlusion was achieved in 27/84 patients (32.2%), in 40/84 (47.6%) brain AVMs occlusion of 80-90% of the nidus was obtained, and in 17/84 (20.3%) cases <80% of the nidus was occluded. Intraprocedural adverse events occurred in 11/84 patients (13.1%), and overall mortality and disabling permanent morbidity were 2.3% (2/84) and 4.7% (4/84), respectively. CONCLUSIONS: Endovascular treatment may be considered a safe and effective approach in superficial small brain AVMs in addition to surgery, mostly in ruptured AVMs. The therapeutic strategy should be to cure small and medium AVMs with endovascular treatment alone or combined treatment. Large unruptured AVMs (Spetzler-Martin grades IV-V) should be treated with target embolization of high flow fistulas or intranidal aneurysms.

Endovascular treatment with 'kissing' flow diverter stents of two unruptured aneurysms at a fenestrated vertebrobasilar junction.

BACKGROUND AND PURPOSE: Fenestration of the vertebrobasilar junction (VBJ) is a rare condition which may be associated with the presence of aneurysms. The endovascular approach is usually the first-line treatment in these cases since the location of the aneurysm may be unsuitable for a surgical approach. This anatomical variation may even influence the endovascular strategy, particularly in those cases in which the sacrifice of a vessel could be avoided. This paper describes an innovative approach of flow diversion in such challenging situations. METHODS: Two women were admitted after an occasional diagnosis of an aneurysm arising from a fenestrated VBJ. In both cases the endovascular approach was performed with two flow diverter stents and dual antiplatelet therapy was administered for 6 months. RESULTS: Complete exclusion of the two aneurysms was obtained after 6 and 7 months, respectively, and the clinical outcome was excellent. CONCLUSIONS: Endovascular treatment of unruptured aneurysms located on a fenestrated VBJ with flow diverter stents represents a valid therapeutic approach with excellent clinical and radiological outcomes.

Double arterial catheterization technique for embolization of brain arteriovenous malformations with onyx.

BACKGROUND: Arteriovenous malformation (AVM) treatment is multidisciplinary, and the patient may undergo embolization, neurosurgery, or radiosurgery combined. Great improvement in endovascular techniques was provided by the introduction of Onyx with different kinds of approach. OBJECTIVE: To evaluate the efficacy and the safety of Onyx embolization of brain AVMs with the double arterial catheterization technique (DACT). METHODS: This was a retrospective study. From January 2006 until June 2011, 61 AVMs eligible for the DACT were treated. Forty-one of the 61 AVMs were treated with single arterial catheterization technique and 20 of 61 with DACT; patient age and Spetzler-Martin AVM grade were similar in the 2 groups. RESULTS: In the DACT group, we obtained complete occlusion of the nidus in all small AVMs, whereas in the single arterial catheterization technique group, we obtained complete occlusion in only 1 of the 36% of the cases. Among the medium-size AVMs, there were no significant differences in the 2 groups, but we performed fewer procedures per patient when we used the DACT (1.4 vs 2.2). In the DACT group, we observed fewer hemorrhagic complications (3.4% vs 12.5% per procedure) and lower morbidity (5% vs 7% per patient) and mortality (0% vs 2.4%) rates. CONCLUSION: The DACT in multifeeder AVMs may lead to a higher occlusion rate of the nidus for small AVMs and reduce the number of procedures, ensuring a higher standard of safety because of the possibility of managing the progression of Onyx into venous drainage.

Anatomical variations of the posterior circulation: case reports and a review of literature.

INTRODUCTION: The intracranial vascular anatomical variations, although rare, represent a interesting field of research, since many anomalous variants are possible and in most cases they remain asymptomatic. The capability of the cerebral circulation to adapt to several flow changes is confirmed by the fact that in several cases these anatomical variation compensate for an eventual unsuccessful development of the normal circulation, expecially in the posterior section of cerebral circulation. MATERIALS AND METHODS: A comprehensive review of PubMed literature was performed and three clinical cases have been analyzed. RESULTS: Several angiographic and MR-angiography reports have been evaluated, regarding general and specific anatomical variants of the posterior circulation. DISCUSSION: Although rare, the anatomical variations of the posterior intracranial circulation represent an interesting field of investigation in order to achieve a better comprehension of the embryological development of the circulatory system.