Multicenter trials are needed to determine if less specialized centers can attain similar outcomes using this technique, researchers say.
A novel endovascular technique can safely and effectively treat both ruptured and unruptured low-grade Spetzler-Martin brain arteriovenous malformations (AVMs), according to a single-center analysis published online January 2, 2019, ahead of print in the Journal of NeuroInterventional Surgery. The therapy can be done in a single session, with a low risk of complications and a high cure rate.
Low-grade Spetzler-Martin AVMs have a rupture rate of about 2-3%, lead author Christina Iosif, MD (Dupuytren University Hospital, Limoges, France and Erasmus University Hospital, Brussels, Belgium), explained to Neurovascular Exchange. As a result, any proposed treatment approach should have an extremely low complication rate.
In the case of ruptured AVMs, “a safe and effective treatment, with a high and relatively rapid total nidus occlusion rate ensures a good clinical outcome for patients, either during the first 3 weeks postrupture [or] in the first 2-3 months,” Iosif noted in an email.
Until now, the gold-standard treatment was open microsurgery, but this may be riskier and more invasive than is warranted in the case of unruptured AVMs, she noted. Proposed endovascular techniques “typically involve either more than one embolization session, which increases the cumulative risk of the procedures [or] partial nidus exclusion, which does not protect the patient from rupture.”
As an alternative, Iosif and colleagues developed a stand-alone endovascular technique that “allows for a rapid and complete occlusion of the nidus, with a rapid drop in the rupture risk, in a single session, and with a minimally invasive technique that allows the patient to leave the hospital in 48 hours, in cases of unruptured AVMs.”
Good Functional Outcomes at 6 Months
For the prospective, single-center study, 73 patients (age 40.5 ± 17.8 years) with ruptured (60.3%) and unruptured (39.7%) brain AVMs of Spetzler-Martin grades I (22%) and II (78%) were treated between January 2008 and January 2016.
Depending on the AVM’s angioarchitecture and location, Iosif said more than one microcatheter intra-arterially and/or intravenously is used.
“For the technique described in this study to be highly effective,” she continued, “careful hemodynamic evaluation and planning is needed, as well as very good clinical assessment. Selective and hyperselective angiographic runs should be performed and should be evaluated by a team of highly trained specialists, in order to decide on the technical strategy. Three or four-dimensional DSA acquisitions are also needed in order to clearly understand the AVM angio-architecture.”
The preprocedural mRS was 0-2 in 72.6% of patients, 3 in 16.4%, 4 in 6.8%, and 5 in 4.1%. The procedure-related morbidity rate was 2.7%, and there were no procedure-related deaths.
At 6 months, 90.5% of the patients were independent in their everyday lives, as evidenced by an mRS 0-2. In all but one case, the procedure was curative.
“Our findings suggest that single-session, minimally invasive endovascular treatment is feasible and safe for low-[grade] Spetzler-Martin brain AVMs, when offered by appropriately-trained and highly specialized teams,” concluded Iosif. “[This] means that more patients will profit in the future from this technique and will be effectively protected from rupture or re-rupture, with just one intervention.”
She added that multicenter trials are needed to confirm their results. It remains unknown, for example, whether teams with less specialized training will be able to achieve similar outcomes to those of the current study.
Source:
Iosif C, de Lucena AF, Abreu-Mattos LG, et al. Curative endovascular treatment for low-grade Spetzler-Martin brain arteriovenous malformations: a single-center prospective study. J NeuroInterv Surg. 2019;Epub ahead of print.
Disclosures:
Iosif reports no relevant conflicts of interest.
