Gunnar Wikholm

Embolization of cerebral arteriovenous malformations: Part I--Technique, morphology, and complications.

OBJECTIVE The aim of this two-part study is to give a full account of all patients referred for embolization of arteriovenous malformations (AVMs) from 1987 to 1993. This article (Part I of II) presents the patient study, including angiographic features and their relation to the immediate outcome of embolization. METHODS Of the 192 patients referred, 150 were subsequently treated. Most patients were referred by neurosurgeons, and 85% of the AVMs were Spetzler-Martin Grade > or = 3. We have accounted for the 42 patients who did not undergo embolization. RESULTS Occlusion from embolization alone (total embolization) was obtained in 13% of patients. Full treatment (total embolization or embolization and then stereotactic radiation or surgery) was achieved in two-thirds of all patients (n = 100, 66%), and combined treatment with stereotactic gamma radiation was the most important part of the treatment strategy. The procedural mortality was 1.3%. The total incidence of complications after embolization was high (40%), but only 6.7% of cases were labeled severe. Of all angiographic features that were considered, large size and the presence of deep feeders were predictors of failure to achieve full treatment. Thirty-four patients with AVMs < 8 cc were included in the study. These could have been irradiated as the sole treatment. In this group of small AVMs, the results of embolization were far better than in the whole group. Fourteen of the AVMs had volumes of < 4 cc, and 10 of these (71%) were totally embolized. One patient had a hemianopsia. Among AVMs 4 to 8 cc in volume (n = 20), the total embolization rate was 15%, the full treatment rate in combination with gamma treatment was 75%, and 10% of the patients were operated on after embolization. Severe complications occurred in 15% of patients, but no complications occurred after November 1990. CONCLUSION In a series of AVMs, most of which were regarded as unsuitable for surgical excision, two-thirds were reduced to a size suitable for gamma knife treatment or totally occluded by embolization alone. The total complication rate was high, but the combined rate of death and complications affecting lifestyle was 8.0%, equal to approximately 3.2 years of natural history.

Percutaneous Sclerotherapy of Venous Malformations of the Head and Neck Using Sodium Tetradecyl Sulphate (Sotradecol)

Thirty-eight patients with venous malformations of the face, neck, and tongue underwent percutaneous sclerotherapy with direct puncture and instillation of sodium tetradecyl sulphate (Sotradecol) (33-67% solution, mixed with contrast material) into the lesions. Each patient underwent from one to seven treatment sessions (mean 2.2), followed by reconstructive surgery in three cases. Of the 34 patients who responded to the follow-up questionnaire, the late results were excellent or good in 23 patients (68%), moderate in eight, unchanged in three, and were worse in one. Compared with our previous experience of embolisation of such malformations with ethanol, the results with Sotradecol were slightly worse. There was one serious complication, unilateral loss of vision in a patient with a large malformation that extended to the orbit. In conclusion, percutaneous sclerotherapy with Sotradecol is effective treatment for venous malformations of the head and neck. Careful planning is essential to reduce the risks of the treatment.

The Göteborg cohort of embolized cerebral arteriovenous malformations: a 6-year follow-up.

OBJECTIVETo present a follow-up of the results after endovascular treatment of cerebral arteriovenous malformations (AVMs) with acrylic glue. An initial follow-up was published in 1996. METHODSA cohort of 150 patients with cerebral AVMs underwent embolization between 1987 and 1993. Fifty-seven patients had supplemental stereotactic irradiation, and 13 had subsequent surgery. The follow-up was carried out clinically and radiologically. RESULTSThe mean follow-up time was 6.2 years. Only four patients were lost to follow-up. If at least 90% of the AVM had been obliterated, the clinical course was stable and there were no new manifestations from the AVM. No recanalization occurred in any AVM that had been totally obliterated with glue. For patients in whom it was not possible to totally obliterate the AVM either with glue alone or glue supplemented with stereotactic irradiation or surgery, the long-term outcome was discouraging. CONCLUSIONObliteration of an AVM with acrylic glue seems to offer stability. If the AVM is totally obliterated, the patient had a stable clinical course. Patients with large AVMs with minor occlusion after embolization may have a worse clinical outcome than expected.

General Anesthesia Versus Conscious Sedation for Endovascular Treatment of Acute Ischemic Stroke

Background and Purpose— Retrospective studies have found that patients receiving general anesthesia for endovascular treatment in acute ischemic stroke have worse neurological outcome compared with patients receiving conscious sedation. In this prospective randomized single-center study, we investigated the impact of anesthesia technique on neurological outcome in acute ischemic stroke patients. Methods— Ninety patients receiving endovascular treatment for acute ischemic stroke in 2013 to 2016 were included and randomized to general anesthesia or conscious sedation. Difference in neurological outcome at 3 months, measured as modified Rankin Scale score, was analyzed (primary outcome) and early neurological improvement of National Institutes of Health Stroke Scale and cerebral infarction volume. Age, sex, comorbidities, admission National Institutes of Health Stroke Scale score, intraprocedural blood pressure, blood glucose, Paco2 and Pco2 modified Thrombolysis in Cerebral Ischemia score, and relevant time intervals were recorded. Results— In the general anesthesia group 19 of 45 patients (42.2%) and in the conscious sedation group 18 of 45 patients (40.0%) achieved a modified Rankin Scale score ⩽2 (P=1.00) at 3 months, with no differences in intraoperative blood pressure decline from baseline (P=0.57); blood glucose (P=0.94); PaCO2 (P=0.68); time intervals (P=0.78); degree of successful recanalization, 91.1% versus 88.9% (P=1.00); National Institutes of Health Stroke Scale score at 24 hours 8 (3–5) versus 9 (2–15; P=0.60); infarction volume, 20 (10–100) versus 20(10–54) mL (P=0.53); and hospital mortality (13.3% in both groups; P=1.00). Conclusions— In endovascular treatment for acute ischemic stroke, no difference was found between general anesthesia and conscious sedation in neurological outcome 3 months after stroke. Clinical Trial Registration— URL: https://www.clinicaltrials.gov. Unique identifier: NCT01872884.

Embolization of cerebral arteriovenous malformations: Part II--Aspects of complications and late outcome.

OBJECTIVE From 1987 through 1993, we performed embolizations on 150 patients with cerebral arteriovenous malformations (AVMs) at Sahlgrenska University Hospital. The patients ranged in age from 5 to 70 years (35.5 +/- 14.8 yr, mean +/- standard deviation) and were selected by neurosurgeons in Scandinavia. We analyzed the risk of complications and late outcome to have a better basis for the decision to perform embolization. METHODS The follow-up was a personal clinical examination of all surviving patients by a neurologist. Files for all patients were also studied. RESULTS In 34 patients, the AVMs were eliminated by embolization alone (20 patients) or by supplementary surgery (14 patients). In 66 patients, the AVMs were embolized to a size suitable for supplementary stereotactic radiation. The clinical course was stable for those 100 patients. Another group of 50 patients who had undergone embolization was only partially treated, and as a group, those patients had less favorable outcomes. The manifestations or symptoms leading to diagnosis were in concordance with other studies. Headache and epilepsy showed a positive response to treatment in patients whose AVMs had been eliminated as well as in those who received only partial treatment. A history of cerebral bleeding did not influence the prognosis of recurrent bleeding. Conversely, AVMs with feeder or nidus aneurysms were related to an increased risk of bleeding. If there was a history of bleeding in a patient with large, partially treated AVMs, the prognosis for survival was diminished. CONCLUSION The indication for treatment increases with the occurrence of AVMs with associated aneurysms. For patients with large AVMs, a history of bleeding justifies a more aggressive approach to treatment. The reduced risk of complications during the last years of the study also increases the indication for embolization.

Transarterial embolization of the uterine arteries, patient reactions and effects on uterine vasculature

BACKGROUND Therapeutic embolization of the uterine arteries has been successfully used to manage profuse gynecological hemorrhage. In the present study we aimed to investigate whether embolization of uterine arteries may serve as a safe and effective alternative treatment in cases of menorrhagia in fertile and perimenopausal women. As a first step, we have evaluated the methodology, patient reactions and effects on the uterine vasculature. METHODS The distal part of the uterine artery was embolized with polyvinyl alcohol particles via catheterization of the right femoral artery. Total abdominal hysterectomy was performed the next day. RESULTS Bilateral embolization in two patients resulted in considerable pain that required morphine analgesic medication and epidural analgesia. One patient was embolized unilaterally and experienced only slight discomfort with no need for analgesic medication at all, indicating that unilateral embolization is a well-tolerated method. After embolization, angiography showed stagnant flow in embolized vessels without contrast filling of distal branches. Angiography of the specimen showed normal vascular architecture in non-treated vessels. In treated vessels the main arterial trunks were patent but all smaller branches were occluded. Histology showed that most of the particles lodged in small arteries and that arterioles never showed injected material. CONCLUSION The study indicates that the procedure involves an efficient occlusion of uterine vessels and that unilateral embolization of uterine arteries is well tolerated.

Direct puncture of large arteriovenous malformations in head and neck for embolisation and subsequent reconstructive surgery

Five patients with large arteriovenous malformations (AVM) of the head and neck, which were too large or inconveniently placed for operation alone, were treated by embolisation after direct puncture; two of them were subsequently operated upon. They all recovered without complications. Embolisation of the nidus and subsequent operation is a good alternative for the treatment of large AVM. Ligating the supplying arteries is not a treatment. If the arterial routes to the nidus have previously been closed by ligatures selective catheterisation is impossible, though direct puncture of the nidus is a possibility. The nidus of the AVM can then be obliterated by embolisation either as a treatment, or as a preoperative procedure.

Superselective Transarterial Embolization of Renal Arteriovenous Malformations of Cryptogenic Origin

Renal arteriovenous (AV) shunts of unknown origin are rare clinical findings. When symptomatic they can as other renal AV shunts and malformations cause hypertension, congestive heart failure and hematuria. During the last few years the treatment has tended to go from surgery to the more gentle and renal parenchyma sparing but yet effective endovacular embolization techniques. Two cases of renal vascular malformations with severe clinical symptoms necessitating treatment are presented. Treatment was successfully performed with tissue adhesive and coils.

Mechanical Embolectomy for Acute Ischemic Stroke in the Anterior Cerebral Circulation: The Gothenburg Experience during 2000–2011

Safety and efficacy of intra-arterial treatment using the AmplatzGooseNeck device in acute anterior circulation strokes were assessed in 156 patients. High recanalization rates were obtained with the AmplatzGooseNeck snare without any device-related complications. Favorable outcome, mortality, and symptomatic intracerebral hemorrhage were comparable with results of newer embolectomy devices. BACKGROUND AND PURPOSE: Intra-arterial treatment of proximal occlusions in the cerebral circulation have become an important tool in the management of acute ischemic stroke. Our goal was to evaluate the safety and efficacy of intra-arterial acute ischemic stroke treatment performed in our institution in consecutive patients with anterior circulation occlusion during 2000–2011. MATERIALS AND METHODS: We identified, in our data base, 156 consecutive cases with anterior acute ischemic stroke treated intra-arterially during 2000–2011. Stroke severity was defined according to the National Institutes of Health Stroke Scale, the results of the procedure were defined according to the modified Thrombolysis in Cerebral Infarction score, and clinical outcome was defined according to the modified Rankin scale, with favorable outcome ≤2 at 90 days. RESULTS: The mean admission NIHSS score was 19.4 (median, 20), with a mean time from stroke onset to groin puncture of 197 minutes (median, 171 minutes). The embolectomy tool of choice was the Amplatz GooseNeck snare (83%). Successful recanalization (modified TICI 2b +3) was seen in 74% of cases. A mRS ≤ 2 at 90 days was seen in 42% with a mortality rate of 17% and symptomatic intracerebral hemorrhage in 4%. CONCLUSIONS: A high recanalization rate was obtained with the Amplatz GooseNeck snare without any device-related complications. Favorable outcome, mortality, and symptomatic intracerebral hemorrhage are comparable with results of newer embolectomy devices.

Brain CT perfusion in stroke in progression.

acute CT brain scan revealed subtle hypodensity of the left MCA territory with narrowing of the proximal MCA on CT angiography ( fig. 1 a). Due to symptom regression during the next 30 min and the unknown time of symptom onset, aspirin was given but not thrombolysis. The next morning she had minimal dysphasia and central facial paresis only (NIHSS score 2). However, her symptoms were fluctuating and on day 3 she again progressed to global aphasia. Brain CT with angiography was unchanged ( fig. 1 a). Brain CTP was performed, consisting of a 50-second series using cinemode scanning and nonionic contrast medium, which is believed to have no brain damaging effects during acute stroke [9] . A significant decrease of relative cerebral blood flow (rCBF) to approximately 30 ml/100 g brain tissue/min in the left MCA territory was seen ( fig. 1 b). Conventional angiography with angioplasty of the occluded M1 segment was performed. Due to immediate normalization of the blood flow we renounced stenting. After the procedure our patient again exhibited minimal dysphasia only. Brain CTP 2 days and angiography 8 days later showed complete restoration of rCBF to approximately 70 ml/100 g/min ( fig. 2 a and b). Magnetic resonance imaging on day 5 revealed minor infarcts in the left insular lobe and internal capsule. Despite extensive cardiovascular workup an embolic source was not found. Having made Dear Sir, Brain CT perfusion imaging (CTP) has been used to study cerebral blood flow (CBF) in acute ischemic [1] and hemorrhagic [2] stroke, vasospasm secondary to subarachnoidal hemorrhage [3] and in brain trauma [4] . CTP using new generation multislice scanners is a relatively recent technique with the potential of becoming a widely used tool of standard stroke assessment due to its better access in general medical emergency departments compared to magnetic resonance perfusion [5] . In patients with suspected acute stroke the site of vascular occlusion, infarct core, salvageable brain tissue and collateral circulation is best assessed by a combination of CTP and CT angiography [6, 7] . CTP may help decision-making for thrombolysis when there is no clear time of symptom debut [8] . Moreover, as shown below, CTP may assist decision-making for endovascular neuroradiologic treatment in patients with stroke in progression. To our knowledge, this is the first report of brain CTP in stroke in progression due to middle cerebral artery (MCA) occlusion.