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Pial Arteriovenous Malformations
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ac
d
Fig. 3.20a–e. Brain AVM with a high fl ow fi stulous compartment (arrow). Elimination of the fi stula (arrowhead) with coils
and Onyx could be achieved during proximal fl ow interruption using a microballoon (Hyperglide, MTI)
b
e
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C. Cognard, L. Spelle, and L. Pierot
a
c
b
Fig. 3.21a–d. Temporal small brain AVM with superfi cial
venous drainage in a patient with seizures. Complete obliteration with Onyx could be achieved; the Onyx cast demonstrates penetration of Onyx into the proximal part of the
vein (arrow)
fl ow and to achieve stasis to be able to inject Onyx or
a combination of coils and Onyx (Fig. 3.24).
Onyx has some advantages and some drawbacks
to its use in AVMs:
Advantages
The major advantage to the use of Onyx compared
with cyanoacrylates is the ease of injection. The
catheter should be placed in the same wedge situation as for intranidal glue injection. The injection
should be very slow, as well. It may be stopped for
d
a few seconds or minutes to wait for precipitation
of Onyx in order to avoid refl ux, and then resumed.
Control angiography may be performed during
Onyx injection for a better understanding of material progression and of nidus and vein occlusion.
Onyx always behaves as a column, and the formation
of small drops fl owing into the vein that may be seen
when glue is injected too fast normally do not occur.
In a brain AVM associated with a high fl ow fi stula
passover of Onyx into the venous system might occur. In such a condition, high concentration Onyx
(Onyx 34) should be used sometimes necessarily in
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a
c
b
d
Fig. 3.22a–e. Small infratentorial brain AVM with two as-
sociated aneurysms along the PICA in a patient with SAH.
Complete endovascular cure could be performed while coiling the proximal aneurysm and embolising the AVM with
Onyx through the superior cerebellar artery. Note: after
AVM-treatment the more distal aneurysm disappeared
e
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C. Cognard, L. Spelle, and L. Pierot
a
b
c
d
e
f
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Fig. 3.23a–h. Large occipital brain AVM in a patient with
longstanding migraine and learning problems. This AVM
(Spetzler grade IV) could be completely obliterated with
Onyx in two sessions. 3 month control showed stable occlusion of the AVM, the migraine was completely gone
109
h
association with proximal fl ow reduction, e.g. with
adjunct microballoon. The injection may last for
several minutes or even tens of minutes. The total
amount of Onyx injected at one time in one single
pedicle may therefore be much more than with glue.
It reduces the number of catheters used and the total
number of procedures needed to achieve a complete
cure of the AVM. The other major advantage is that
because injection is more prolonged and the decision to stop or continue the injection does not have
to be made immediately, as it does for g lue injection,
the training of young neuroradiologists to perform
Onyx injection is much easier than the mastering
of glue injection.
Disadvantages
The toxicity of DMSO has been discussed in a few
reports (Chaloupka et al. 1994; Sampei et al. 1996;
Murayama et al. 1998; Chaloupka et al. 1999). The
fi rst paper of Chaloupka and coworkers emphasized
the risk of severe vasospasm after injection of 0.8 ml
EVOH and DMSO in the swine rete mirabile with
subsequent infarction. Injection of 0.5 ml resulted in
delayed (7–14 days) subarachnoid hemorrhage with
angionecrosis on histology and arterial microaneurysms. Two other studies reexamined this toxicity
and concluded that the two major points are contact
time with the arterial wall and volume of injection
(Murayama et al. 1998; Chaloupka et al. 1999).
Finally, it has been proved that injection of 0.3 ml for
40 s produced neither vasospasm nor angionecrosis.
The protocol of injection is as follows: Prior to injection the microcatheter is fl ushed with 5 ml normal
saline. Then 0.25 ml DMSO is injected over more
than 40 s for dead space catheter fi ll ing. Ony x i s then
injected slowly (Jahan et al. 2001). Nevertheless,
despite the fact that this protocol was used in all the
23 patients treated, histology showed angionecrosis
of many vessels in two of four patients operated on
1 day after embolization. Consequently, there is still
some question of a likely toxicity of DMSO. One issue may be that because of the wedge position of the
catheter, there might be a stagnation of DMSO in the
pedicle and nidus, with prolonged contact of DMSO
with the vessel wall and risk of necrosis.
At the beginning of injection there is frequently a
refl ux of Onyx along the tip of the catheter. The injection must be stopped and resumed a few seconds
or minutes later until a progression within the nidus
is observed. As soon as it has precipitated around
the tip of the catheter, Onyx tends to open different
compartments of the nidus and the injection may be
prolonged. This technique carries two risks: the oc-
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C. Cognard, L. Spelle, and L. Pierot
a b
Fig. 3.24a–d. Temporo-frontal brain AVM (Spetzler grade III) in a very eloquent area in a 36-year-old patient with a hem-
orrhage a year ago clinically associated with transient speech problems. Preoperative tremendous nidal reduction could
be achieved in two sessions using Onyx. After resection of the residual nidus the patient was neurologically intact without
any speech problems
clusion of an adjacent normal branch due to refl ux
of Onyx in the feeding pedicle; gluing of the tip of
the catheter because of a very prolonged injection.
Although Onyx is not adhesive, catheter withdrawal
may be diffi cult and result in either gluing or breaking of the catheter, or stretching and rupture of the
AVM and artery. Attachment of the catheter is due to
physically clutching the microcatheter, if that condition occurs it is important to withdraw the catheter very slowly under continuous gentle pulling. In
the posterior circulation this may result in very low
heart frequency until asystolie. Pushing back the
microcatheter will immediately recover heart beat
and the manoeuvre should be redone. But in general, very prolonged injection with serious refl ux
more than 1.5 cm along the catheter tip should be
unconditionally avoided.
One of the major advantages of Onyx is that a
large volume may be introduced in one single catheter injection. However, there is a risk of hemorrhage.
The operator may be temped to occlude a very large
portion of the nidus in one procedure. Many years
ZZ
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c
ago it was proven that staged embolization aimed at
reducing the nidus in several sessions is mandatory
to progressively modify the fl ow dynamics. Very
sudden and large-scale occlusion of the nidus surely
increases the risk of postprocedural hemorrhage, as
discussed above.
There are still two situations in which Onyx
should not be used today: direct fi stula, in which
the Onyx cannot occlude solely a high-fl ow large
shunt because it is not adhesive, and a feeding pedicle “en passage”, in which refl ux on the tip of the
d
catheter is not allowed due to major risk of normal
vessel occlusion like in any other liquid embolic
material. But if the “en passage-vessel” could be
catheterized far enough slowly injection of Onyx
might be possible and other compartments of the
nidus could be reached from this position. A very
important point is that one should be aware of the
amount of refl ux. To avoid extensive amount of refl ux the concept is to wait and plug the “way back”
which can take some minutes but time investment
is justifi ed.
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C. Cognard, L. Spelle, and L. Pierot
3.5.4
Therapeutic Strategy
It is extremely diffi cult to establish a therapeutic
algorithm for brain AVM. The indication for treatment basically depends on:
Clinical presentation (hemorrhage or not)
Patient age
Natural risk, roughly evaluated by the presence
or not of likely risk factors of bleeding (associated
aneurysm or false aneurysm, venous stenosis or
ectasia)
AVM size, location (superfi cial or deep, eloquent
or not) and angioarchitecture (compact or diffuse)
The goal of treatment may be:
Defi nitive complete obliteration to protect from
hemorrhage
Partially targeted treatment (embolization) to
eliminate risk factors of bleeding/rebleeding
(feeding artery aneurysms, intranidal aneurysms,
false aneurysms)
Partial treatment in case of AVM presenting with
worsening neurologic defi cits (although the effi cacy of such treatment is yet to be proven)
Partial treatment should not be performed to:
Decrease bleeding risk, because even subtotal
therapy does not confer protection from hemorrhage
Improve seizures, because of treatment-induced
risks and unproved effi ciency
The indication for treatment, goal of treatment,
and therapeutic strategy should be decided on by an
experienced multidisciplinary team in agreement
with the patient, who has been precisely informed of
natural and therapeutic risks. Multimodality treatment is frequently performed – either as a planned
maneuver, typically with embolization followed by
radiosurgery or surgery, or as an unplanned maneuver when one modality fails and a second modality
is required for complete obliteration. Goals of the
different modalities should be clear at the outset. In
our experience, embolization is the fi rst-intention
approach in the vast majority of the patients, followed by either surgery or radiosurgery. Nevertheless, because of the extreme variability of resources
available in any one area of the country or world, as
well as very different skills and experience on the
part of neurosurgeons and interventional neurora-
diologists, it is impossible to draft any recommendations about strategy itself. Because there is almost
never a need for brain AVM treatment in emergency
(as opposed to aneurysm treatment), patients with
brain AVMs should be sent to very specialized and
experienced centers that can afford the most up-todate multimodality therapy.
Acknowledgements go to Drs. Zhang Peng and Zhu
Fengshiu for their major contribution to the bibliographic research.
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