Search Results (23)

Dural arteriovenous fistulas (dAVFs) are a heterogeneous group of intracranial vascular anomalies characterized by abnormal arteriovenous shunting within the dura mater. While they are often considered acquired lesions—associated with trauma, surgery, venous sinus stenosis, or thrombosis—their precise etiology remains unclear in many cases. The clinical presentation of dAVFs varies widely depending on location and venous drainage patterns. Benign forms may manifest as pulsatile tinnitus or headache, whereas lesions with retrograde venous drainage and cortical venous reflux are considered aggressive and carry a heightened risk of hemorrhage and progressive neurological decline. Multiple classification systems, primarily based on angioarchitecture and venous outflow characteristics, have been developed to stratify risk and guide treatment strategies, as these features largely determine the natural history and clinical course of dAVFs. Endovascular embolization, microsurgical disconnection, and stereotactic radiosurgery (SRS) represent the mainstays of treatment, aiming to prevent hemorrhage or rebleeding and to alleviate symptoms related to venous congestion. Over the past two decades, advances in endovascular techniques have driven a paradigm shift in management, positioning embolization as the first-line therapy for most dAVFs. This review begins with a comprehensive overview of dAVF pathogenesis, classification systems, and angioarchitecture. It then focuses on the endovascular management of dAVFs, offering a detailed appraisal of current and emerging techniques, key technical considerations, and lesion-specific treatment strategies. Finally, we discuss the role of microsurgery and SRS. Full article

Introduction: Cerebral arteriovenous malformations (CAVMs) are rare, with an estimated prevalence of 0.01%. Symptoms typically present in adults under 40, often beginning with hemorrhage in 61% of cases. The annual risk of hemorrhage is between 2–4%, with a mortality rate of 10%, and 50% of survivors may experience permanent neurological deficits. Embolization can induce changes in the angioarchitecture of the affected vessels. Our case uniquely demonstrates a morphological alteration in the carotid artery (CA) and its primary branches, associated with the presence of a CAVM. Detailed Case Presentation: A 52-year-old patient presented to the Emergency Department with weakness, shortness of breath, dizziness, nausea, and vomiting that began earlier that morning. Clinical and radiological evaluations suggested acute bleeding from a ruptured CAVM. The patient was admitted for digital subtraction angiography (DSA) and potential embolization. DSA confirmed the presence of a CAVM, supplied by the middle meningeal and occipital arteries, with distortion of the left CA angioarchitecture. Selective catheterization and embolization using Onyx 18 were successfully performed. After receiving supportive treatment, the patient was discharged in good condition. A follow-up CT scan three months later showed complete resolution of the brain pathologies. A repeat angiogram revealed no recanalization of the CAVM, with normalization of the CA and its branches. The patient is currently asymptomatic. Conclusions: Detection of pathological changes in the head and neck arteries linked to CAVM can predict rupture risk and complicate endovascular access. Identifying these changes early warrants consideration of interventions to prevent hemorrhage, though alternative access routes or strategies may be needed for safe, effective treatment. Full article

Background and Objectives: Vein of Galen aneurysmal malformations (VGAMs) represent the most common vascular malformations of the brain at the pediatric age. Comprehension of its angioarchitecture and clinical features may influence their treatment options and functional outcomes. The aim of this review is to give an update of the anatomical and technical aspects of the management of VGAMs after endovascular treatment. Materials and Methods: We conducted a systematic review of original articles published between 1 January 2014 and 1 February 2024 in Pubmed, Web of Science (WOS), and Scopus databases following PRISMA guidelines. Variables such as age, sex, angioarchitecture of the malformation, clinical presentation, embolization technique, rate of occlusion, post-procedural complications, follow-up time, and mortality were collected. Random-effect meta-analysis of proportions was performed. Results: Fifteen studies on a total of 400 patients with VGAMs were collected. A total of 65.1% was male. The age at diagnosis was 12% prenatal, 35.5% neonates, 34.1% infants, 15.1% children, and 3.3% adults. Clinical presentation included 31.4% increased head size, 25.7% congestive heart failure, 12.9% neurological deficits, 10% seizures, 9.3% prominence of facial veins, and 8.9% developmental delay. A total of 339 patients underwent endovascular treatment (84.8%) with an average of 2.1 procedures per patient. The embolization technique was defined by transarterial access and glue material. Radiological occlusion was complete in 62.3% of the patients. The most frequent periprocedural incidents included hemorrhagic events (28.4%), embolization material migration (25.7%), and death (22%). The functional outcome was good in 68% of the surviving patients. The average follow-up time was 43.18 months. High heterogeneity was found in all outcomes but mortality rate. Conclusions: The angioarchitecture of VGAMs is significantly important when planning endovascular treatment and may have an influence on functional outcomes. More research into endovascular techniques and the risks of periprocedural complications must be performed. Indeed, a homogeneous protocol for the assessment of surviving VGAM patients during follow-up is necessary. Full article

This study aims to assess the diagnostic accuracy of non-contrast-enhanced 4D MR angiography (NCE-4D-MRA) compared to contrast-enhanced 4D MR angiography (CE-4D-MRA) for the detection and angioarchitectural characterisation of brain arteriovenous malformations (bAVMs). Utilising a retrospective design, we examined 54 MRA pairs from 43 patients with bAVMs, using digital subtraction angiography (DSA) as the reference standard. Both NCE-4D-MRA and CE-4D-MRA were performed using a 3-T MR imaging system. The primary objectives were to evaluate the diagnostic performance of NCE-4D-MRA against CE-4D-MRA and DSA and to assess concordance between imaging modalities in grading bAVMs according to four main scales: Spetzler–Martin, Buffalo, AVM embocure score (AVMES), and R2eDAVM. Our results demonstrated that NCE-4D-MRA had a higher accuracy and specificity compared to CE-4D-MRA (0.85 vs. 0.83 and 95% vs. 85%, respectively) and similar agreement, with DSA detecting shunts in bAVMs or residuals. Concordance in grading bAVMs was substantial between NCE-4D-MRA and DSA, particularly for the Spetzler–Martin and Buffalo scales, with CE-4D-MRA showing slightly higher kappa values for interobserver agreement. The study highlights the potential of NCE-4D-MRA as a diagnostic tool for bAVMs, offering comparable accuracy to CE-4D-MRA while avoiding the risks associated with gadolinium-based contrast agents. The safety profile of imaging techniques is a significant concern in the long-term follow up of bAVMs, and further prospective research should focus on NCE-4D-MRA protocol improvement for clinical use. Full article

Cone-beam computed tomography (CBCT) is a widely used imaging technique in interventional radiology. Although CBCT offers great advantages in terms of improving comprehension of complex angioarchitectures and guiding therapeutic decisions, its additional degree of radiation exposure has also aroused considerable concern. In this study, we aimed to assess radiation exposure and its influential factors in patients undergoing CBCT scans of the head and abdomen during interventional procedures. A total of 752 patients were included in this retrospective study. Dose area product (DAP) and reference air kerma (RAK) were used as measures of patient dose. The results showed that the median values of DAP were 53.8 (50.5–64.4) Gy⋅cm² for head CBCT and 47.4 (39.6–54.3) Gy⋅cm² for that of the abdomen. Male gender and body mass index (BMI) were characterized by increased DAP and RAK values in both head and abdominal CBCT scans. Larger FOV size was associated with a higher DAP but a lower RAK value, especially in head CBCT scans. Exposure parameters under automatic exposure control (AEC) also varied according to patient BMI and gender. In conclusion, the patients received slightly higher radiation doses from head CBCT scans than from those applied to the abdomen. BMI, gender, and FOV size were the key factors that influenced the radiation dose administered to the patients during CBCT scans. Our results may help to define and minimize patients’ exposure to radiation. Full article

A cerebral arteriovenous malformation (AVM) is a tangle of abnormal blood vessels that irregularly connects arteries and veins. Stereotactic radiosurgery (SRS) has been shown to be an effective treatment for AVM patients, but the factors associated with AVM obliteration remains a matter of debate. In this study, we aimed to develop a model that can predict whether patients with AVM will be cured 36 months after intervention by means of SRS and identify the most important predictors that explain the probability of being cured. A machine learning (ML) approach was applied using decision tree (DT) and logistic regression (LR) techniques on historical data (sociodemographic, clinical, treatment, angioarchitecture, and radiosurgery procedure) of 202 patients with AVM who underwent SRS at the Instituto de Radiocirugía del Perú (IRP) between 2005 and 2018. The LR model obtained the best results for predicting AVM cure with an accuracy of 0.92, sensitivity of 0.93, specificity of 0.89, and an area under the curve (AUC) of 0.98, which shows that ML models are suitable for predicting the prognosis of medical conditions such as AVM and can be a support tool for medical decision-making. In addition, several factors were identified that could explain whether patients with AVM would be cured at 36 months with the highest likelihood: the location of the AVM, the occupation of the patient, and the presence of hemorrhage. Full article

The distinct placental angioarchitecture in monochorionic (MC) pregnancies increases the risk of complications such as twin–twin transfusion syndrome (TTTS), twin anemia polycythemia sequence (TAPS), and selective fetal growth restriction (sFGR). The aim of this systematic review was to evaluate the incidence, type, and severity of cerebral injury and structural brain development on fetal and/or neonatal cerebral magnetic resonance imaging (MRI) in MC twins with or without complications. Twenty-three studies were included, covering a wide range of complications observed during MC pregnancies, with studies involving sIUFD (n = 12), TTTS (n = 7), mixed complications (n = 2), TAPS (n = 1), and uncomplicated MC pregnancy (n = 1). TAPS and sFGR were largely underrepresented in the current literature. The included studies reported that MC pregnancies with single intrauterine fetal demise (sIUFD) are most at risk for cerebral injury during the fetal period. The overall median incidence of cerebral injury after sIUFD was 28.3% (0–55%). Severe antenatal cerebral injury after sIUFD was detected antenatally in 6.5% (0–36%) of the cases. Three of the included studies described the incidence, type, and severity of cerebral injury on neonatal MRI in MC twins. Structural brain development based on cerebral biometry was only assessed in two studies, revealing significantly smaller biometric measurements of the cerebrum in cases of single sIUFD or smaller twins compared to singleton pregnancies. To enhance our understanding of the potential risks and pathophysiological mechanisms associated with cerebral injury and structural brain development in MC twins, there is a need for future studies and standardized protocols using serial fetal and neonatal MRI imaging in addition to routine ultrasound imaging. Full article

We aimed to determine whether the hemorrhage risks of cerebral arteriovenous malformation (AVM), evaluated through digital subtraction angiography (DSA) using a neural network, were superior to those assessed through angioarchitecture. We conducted a retrospective review of patients with cerebral AVM who underwent DSA from 2011 to 2017. Angioarchitecture parameters, age, and sex were analyzed using univariate and multivariate logistic regression. Additionally, a neural network was trained using a combination of convolutional neural network (CNN) and recurrent neural network (RNN) architectures. The training dataset consisted of 118 samples, while 29 samples were reserved for testing. After adjusting for age at diagnosis and sex, single venous drainage (odds ratio [OR] = 2.48, p = 0.017), exclusive deep venous drainage (OR = 3.19, p = 0.005), and venous sac (OR = 0.43, p = 0.044) were identified as independent risk factors for hemorrhage. The angioarchitecture-based hemorrhagic prediction model achieved 69% accuracy with an AUC (area under the ROC curve) of 0.757, while the CNN–RNN-based model achieved 76% accuracy with an AUC of 0.748. We present a diagnostic performance for hemorrhagic risk assessment of AVMs that is comparable to the angioarchitectural analysis. By leveraging larger datasets, there is significant potential to enhance prediction accuracy further. The CNN–RNN algorithm not only can potentially streamline workflow within the angio-suite but also serves as a complementary approach to optimize diagnostic accuracy and treatment strategies. Full article

Small vessel diseases (SVD) is an umbrella term including several entities affecting small arteries, arterioles, capillaries, and venules in the brain. One of the most relevant and prevalent SVDs is cerebral amyloid angiopathy (CAA), whose pathological hallmark is the deposition of amyloid fragments in the walls of small cortical and leptomeningeal vessels. CAA frequently coexists with Alzheimer’s Disease (AD), and both are associated with cerebrovascular events, cognitive impairment, and dementia. CAA and AD share pathophysiological, histopathological and neuroimaging issues. The venular involvement in both diseases has been neglected, although both animal models and human histopathological studies found a deposition of amyloid beta in cortical venules. This review aimed to summarize the available information about venular involvement in CAA, starting from the biological level with the putative pathomechanisms of cerebral damage, passing through the definition of the peculiar angioarchitecture of the human cortex with the functional organization and consequences of cortical arteriolar and venular occlusion, and ending to the hypothesized links between cortical venular involvement and the main neuroimaging markers of the disease. Full article

The paradigm is gradually shifting, with radiosurgery and endovascular embolization being increasingly chosen over surgical resection in the selected cases of brain arteriovenous malformations. Routinely used X-ray monitoring of liquid embolic infusion has very good spatial and temporal resolution but is not without significant drawbacks regarding poor visualization of the complex AVM angioarchitecture, especially after many embolizations in the past and therefore limiting the technical ability of the embocure—total occlusion of the feeding arteries, nidus, and draining veins. The purpose of this study was to evaluate the use of real-time MRI guidance in endovascular embolization with Onyx (instead of X-ray) in a single swine rete mirabile (RM) AVM model in order to provide the scaffolding for the real-time MRI guidance method. Onyx propagation was observed in real-time dynamic GE-EPI scan with initial ipsilateral RM filling followed by main cerebral arterial branch distribution. The relatively bright signal within RM and the brain prior to Onyx injection provided a good background for the dark, low signal of the embolic agent spreading in rete mirabile and brain arteries. X-ray picture confirmed Onyx cast distribution at the end of the procedure. In this initial experience, real-time MRI seems to be a promising method that may significantly improve liquid embolic agent infusion monitoring in the future, although requiring further development before clinical use. Full article

Background: Intracranial arteriovenous malformations (AVMs) are lesions containing complex vessels with a lack of buffering capillary architecture which might result in hemorrhagic cerebrovascular accidents (CVAs). Intraoperative navigation can improve resection rates and functional preservation in patients with lesions in eloquent areas, but current systems have limitations that can distract the operator. Augmented Reality (AR) surgical technology can reduce these distractions and provide real-time information regarding vascular morphology and location. Methods: In this case report, an adult patient was admitted to the emergency department after a fall, and diagnostic imaging revealed a Spetzler–Martin grade I AVM in the right parietal region with evidence of rupture. The patient underwent a stereotactic microsurgical resection with assistance from augmented reality technology, which allowed for a hologram of the angioarchitecture to be projected onto the cortical surface, aiding in the recognition of the angiographic anatomy during surgery. Results: The patient’s postoperative recovery went smoothly. At 6-month follow-up, the patient had remained in stable condition, experiencing complete relief from his previous symptoms. The follow-up examination also revealed complete obliteration of the AVMs without any remaining pathological vascular structure. Conclusions: AR-assisted microsurgery makes both the dissection and resection steps safer and more delicate. As several innovations are occurring in AR technology today, it is likely that this novel technique will be increasingly adopted in both surgical applications and education. Although certain limitations exist, this technique may still become more efficient and precise as this novel technology its continues to develop further. Full article

Objective: To investigate the angioarchitectural factors associated with postoperative cerebral infarction in ischemic moyamoya disease. Methods: Data on patients who underwent surgery for ischemic MMD from 1 October 2015 to 31 October 2020, at Peking University International Hospital were collected and retrospectively analyzed. General conditions such as patient sex, age, site of surgery, preoperative manifestations such as TIA attack and old cerebral infarction, and seven angioarchitectural factors of the MMD based on DSA were selected and measured. Statistical analysis was performed by the Pearson chi-square statistic, analysis of variance (ANOVA), and multifactor logistic regression analysis. Results: Age (OR, 0.969; 95%CI, 0.939–1.000; p = 0.049), A1stenosis (OR, 5.843; 95%CI, 1.730–19.732; p = 0.004), M1stenosis (OR, 6.206; 95%CI, 2.079–18.526; p = 0.001), PCA anomalies (OR, 4.367; 95%CI, 1.452–13.129; p = 0.049), Unstable compensation (OR, 5.335; 95%CI, 1.427–19.948; p = 0.013), TIA (OR, 4.264; 95%CI, 1.844–9.863; p = 0.001), Old cerebral infarction (OR, 2.972; 95%CI, 1.194–7.397; p = 0.019). The above seven factors can be used in the regression equation to predict the probability of postoperative cerebral infarction. The prediction accuracy is 90.2%. Conclusions: Age, TIA attack, old cerebral infarction, and five angioarchitectural factors of MMD are strongly associated with postoperative cerebral infarction. Seven factors, including age, TIA attack, old infarction, and four angioarchitectural factors, can be taken to quantify the probability of surgical cerebral infarction in MMD. Full article

Vascular dysfunction and structural abnormalities in Alzheimer’s disease (AD) are known to contribute to the progression of the pathology, and studies have tended to ignore the role of the vasculature in AD progression. We utilized the 3xTg-AD mouse model of AD to examine individual cerebral vessels and the cortical vascular network across the lifespan. Our vessel painting approach was used to label the entire cortical vasculature, followed by epifluorescence microscopy. The middle cerebral artery (MCA) tree was assessed with confocal microscopy, and a new method was developed to assess branching patterns as a measure of aging-related changes. We found that vascular remodeling was profoundly altered at 4–6 months of age, when the 3xTg-AD mouse is known to transition to cognitive impairment and Aβ deposition in both sexes. Analysis of vascular features (density, junctions, length) of the MCA territory highlighted sex-dependent differences across the 3xTg-AD mouse lifespan, with no alterations in branching patterns. Our current cerebrovascular angioarchitectural analyses demonstrate progressive alterations in individual cortical vessels, as well as in the vascular network of the cortex. These new findings advance our understanding of brain anatomy and physiology in the 3xTg-AD mouse, while potentially identifying unique diagnostic signatures of AD progression. Full article

Spinal arteriovenous shunts (sAVSs) are an uncommon disease, constituting 3 to 4% of intradural lesions; 70% of these lesions are spinal arteriovenous fistulas (sAVFs), whereas spinal arteriovenous malformations (sAVMs) are rarer. Both share the problem of their classification due to the heterogeneity of their angioarchitecture. The aim of this study is to report a series of sAVSs treated in the neurosurgery department of the Hospital Nacional Guillermo Almenara during the 2018–2020 period and to present an overview of the current literature on sAVS classification. We reviewed all medical records of patients diagnosed with sAVFs and sAVMs during the 2018–2020 period, and then we analyzed images with Horos v4.0.0, illustrated some cases with Clip Studio Paint v1.10.5, and performed a descriptive statistical analysis with SPSS v25. Twelve patients were included in this study, eight of which were women (67%) and four of which were men (33%); the age range was from 3 to 74 years. Eight sAVSs were sAVFs, whereas four were sAVMs. The most frequent clinical manifestation was chronic myelopathy in seven patients (58%). Of those treated only by embolization, seven (70%) resulted in complete occlusion (five sAVFs and two sAVMs), while three (30%) remained with a residual lesion. At last follow-up, five patients (42%) improved clinically, and the seven remaining (58%) maintained the same neurological state. sAVSs require a detailed study of their angioarchitecture for proper management. The endovascular treatment is safe with acceptable cure rates. The surgical option should not be set aside. Full article

Despite intensive research, glioblastoma remains almost invariably fatal. Various promising drugs targeting specific aspects of glioma biology, in addition to or as an alternative to antiproliferative chemotherapy, were not successful in larger clinical trials. Further insights into the biology of glioma and the mechanisms behind the evasive-adaptive response to targeted therapies is needed to help identify new therapeutic targets, prognostics, or predictive biomarkers. As a modulator of the canonically oncogenic Rho-GTPase pathway, Lipid phosphate phosphatase-related protein type 5 (LPPR5) is pivotal in influencing growth, angiogenesis, and therapeutic resistance. We used a GL261 murine orthotopic allograft glioma model to quantify the tumor growth and to obtain tissue for histological and molecular analysis. Epicortical intravital epi-illumination fluorescence video microscopy of the tumor cell spheroids was used to characterize the neovascular architecture and hemodynamics. GL261-glioma growth was delayed and decelerated after LPPR5 overexpression (LPPR5^OE). We observed increased tumor cell apoptosis and decreased expression and secretion of vascular endothelial growth factor A in LPPR5^OE glioma. Hence, an altered micro-angioarchitecture consisting of dysfunctional small blood vessels was discovered in the LPPR5^OE tumors. Sunitinib therapy eliminated these vessels but had no effect on tumor growth or apoptosis. In general, LPPR5 overexpression generated a more benign, proapoptotic glioma phenotype with delayed growth and a dysfunctional vascular architecture. Full article