Posterior fossa AVMs; endovascular management challenges
Transcript of Posterior fossa AVMs; endovascular management challenges
Posterior fossa AVMs; endovascular management challenges
Hany A. Fikry Eldawoody1, 2,
Mohamed Mostafa Aziz3
Wasem Aziz4
Department of Neurosurgery Mansoura University, Egypt 1
Department of Neurosurgery, Prince Mohamed Bin Abdel Aziz Hospital, Riyadh, Saudi Arabia2
Department of Neurosurgery, Ain Shams University, Egypt3
Department of Neurosurgery, Alexandria University, Egypt4
SANS 2016 , Ritz Carlton Hotel, Riyadh, SA,1-3/3/2016
• Posterior fossa arteriovenous malformations (AVMs)are complex neurovascular lesions
• Nearby eloquent areas
• Relatively infrequent < 15% of all AVMs
• More aggressive natural history
Background
Background“Cerebral arteriovenous malformation (AVM)”
• Etiology:Abnormality of primordial angiogenesis
- Agenesis of capillary system
- Retention of primordial vascular connections
Epidemiology
• 1 /100,000 person/year (all detected)
• caused 2% of hemorrhagic stroke
• 2~4% annual rate of hemorrhage
• Enlargement/shrinkage rate: unknown
Global consensus To obtain
Better outcome..
Maximize Team Effort:
Microsurgery
Embolization
Radiosurgery
• Between January 2012 to August 2015.
• 20 patients’ data with posterior fossa AVMs treated withendovascular techniques, radiosurgery and/or surgery wereanalyzed.
Patients and methods
Master tableAge Sex Presentation GCS Site
Size
cmSMG Feeder Drainer Procedure
Immediate
Outcome
Oblteration
%ageComplications GOS
Follow up
Radiology
55 m 4th vent Hage 15 Rt Cerebellar 3 2Rt SCA, Rt
PICA, PICA AnDeep AN Coiling FC, Intact NO NO 5 No
16 fIVH, Cerebellar
Hage12 Rt Cerebellar 3 2 Rt SCA Deep Evacuation+onyx emb FC, Intact 90% no 5 -
44 m IVH 15 Lt cerebellar 1.5 2 Lt SCA Deep Onyx embolization 3, ataxia 100% SCA infarction 4 100%
52 m IVH, HCP Lt cerebellar 3 2 Lt SCA Deep 2 sessions onyx emb FC, Intact 95% NO 5 95%
56 mDizziness,
Vertigo15 Lt CPA 3 3
Lt PICA, AICA,
SCADeep 2 sessions onyx emb, GK 3, ataxia < 50% SCA infarction 4 < 50%
45 fCerebellar Hage,
IVH, HCP
Vermian, Lt
Cerebellar4 3 Lt AICA, Lt SCA Deep Onyx embolization, GK 3, ataxia 80% cerebellar signs 4 Recanalization
50 m Recurrent SAH Lt CPA 4 3 Lt AICA, PICA Deep Onyx embolization Died 75% Died 1 -
30 f HCP, Dist. Consc 10BS & Bilat
Cerebellar6 5
Bilat AICA,
PICA, SCADeep
VP Shunt & 3 sessions onyx
emb
Improved
gradually50% NO 5 50%
28 f, P.cerebellar Hage,
Ataxia13 Lt cerebellar 2.5 2 Lt SCA, PICA
Transverse
SigmoidEvacuation+onyx emb 3, ataxia 100% No 5 100%
65 f IVH 9 Rt Cerebellar 3 2Rt PICA, PICA
AnDeep
Ventriculostomy, Surgical
excision1 100% No 1 -
40 m IVH 9 vermian 1.5 2 Rt SCA transverse surgical excisionimproved
gradually100% No 5 100%
35 f, P.cerebellar hage,
IVH10 vermian 4.5 4
Lt PICA, AICA,
SCADeep
Evacuation+onyx emb 2
sessions
improved
gradually90% No 4 90%
14 f Incidental 15 Rt Cerebellar 2 1 Superficial Embolization & excision FC, Intact 100% No 5 100%
52 m Headache 15 Rt Cerebellar 3.2 2 Superficial 2 sessions onyx emb FC, Intact 70% No 5 70%
30 f Brain stem Hge Brain stem 1.2 3 Deep surgical excisionImproved
gradually100% NO 4 100%
21 f Headache 15 Lt cerebellar 5.6 4 Deep 7 sessions onyx FC, Intact 75% NO 5 75%
24 f
recurrent
cerebllar
hematoma
15 Rt Cerebellar 2.5 1Rt. SCA, AICA,
PICASuperficial
partial evacuation of the
hematoma and biopsy then
one session onyx 2 ampouls
FC, Intact 50%P SAH, resolved
completely5 50%
55 mRt. trigeminal
neuralgia15 Rt Cerebellar 4 2 Rt. SCA Superficial
one session onyx, 3
ampoules
FC, transient Rt.
hemihypothesia 60% No 5
60% referred to
GNRS
1.3 m
venous
hypertention,
large head, sinus
pericranii
15 superior vermis 4 3bilateral SCA, Lt.
PICASuperficial
one session onyx, 3
ampoulesFC, Intact 75%
temporary
repeated
vomiting
575% for another
session
22 m
cerebellar
hematoma,
disturbed
conscious level
9upper cerebellar
surface1.5 1
left pica, Bilateral
SCASuperficial surgical excision FC, Intact total No 5 Total
Results
20%
45%5%
10%
15%5%
TREATMENT MODALITY
surgery only
onyx only
coiling of associated AN
onyx then surgery
onyx then GN
NBCA then GN
Results©
2
21
3
DIFFICULTIES IN ENDOVASCULAR TREATMENT
catheter navigation in SCA
catheter navigations in AICA
catheter navigations in PICA
identifications of onyx inWA
Challengeschallenges How to solve
Proximal access in the VA -5F guiding with soft tip- Transbrachial artery in right sided VA access
Navigation Detachable tip microcatheterTry smaller .007 hybrid
MCR Catheter stuck in the nidus Detachable tip microcatheter
Visualization of onyx flow Shack well before useUse flat panel angio machine
Blank map
Proximal Reflux of LE agent Allowed
Not well definedPICA after second lobe
As distal as possible; Nidal wedgingDetachable tip microcatheter – 3rd marker
Nondetachable tip MCR 0.5-1 cmIn cm from brain stem ?! Working on
Extravasation Not under pressureDrop like accumulation
Better user Phil
Example of tortuousity (AICA)
Example of tortuousity (SCA)
Example of post fossa AVM total occlusion in two session using onyx
A 28 years female patient
presented during the second
month of pregnancy with acute
hemiataxia. CT brain showed Left
cerebellar hematoma. DSA
showed Lt hemispheric
cerebellar AVM supplied by
hemispheric branches of
Posterior Inferior Cerebellar
Artery (PICA) and small branch
from the superior cerebellar
artery. Onyx embolization was
done and eventual near complete
obliteration was achieved.
Patient has marked symptomatic
improvement 6 months later.
Example of post fossa AVM near total occlusion in one session using onyx
Example of subtotal occlusion of posterior fossa AVM using onyx in one session
Example of subtotal occlusion of posterior fossa AVM using onyx in one session ©
• The task is difficult but not (mission impossible).
• Careful study of angiogram & use the best WA andbest easy access main feeder first.
• Precise controlled intra-nidal injection to be stronglyconsidered.
• Consider the use of detachable tip MCR catheter.
• The controllability & diffusability of the LE Agent(phil>onyx>nBCA).
conclusion
• Multiple sessions on intervals is generally better inmultifeeder AVM.
• Give the patient the best chance by Using all tools;donot be dogmatic (only endovascular!!!!)
Conclusion©
Thanks