Curative Endovascular Treatment of Cerebral Pial AVMs: A New Treatment Philosophy with long term results of 350 patients. Saruhan Cekirge, Serdar Geyik, Kivilcim Yavuz, Isil Saatci Hacettepe University Hospitals Interventional Neuroradiology Ankara

Current ‘Facts’: Treatment of cerebral AVMs remains still controversial both for low and high-grade lesions Numerous variables effect the results Natural course of the disease is dispersed. So far, for the management strategy in this very heterogenous group of patients, the decisions are being taken based on the experience of the institutions rather than based on a generally accepted guideline.

Why do we prefer now,using ONYX? Nidal Onyx injection vs glue Much longer duration (up to 2-3 hours) of intranidal inj; better penetration. Lesser tendency to reflux to veins and if it refluxes, it is much less thrombogenic. During nidal penetration, retrograde filling of the other AVM feeders from the nidus..

The treatment targets are: The Onyx injection technique, that we have been developing since 1999, is for a different philosophy in the endovascular brain AVM management.. The treatment targets are: to cure all S-M grade 1-2 AVMs by embolization alone. able to treat high grade AVMs much more effectively!!. actually we can really start to treat those AVMs. Cekirge, Saatci et al J Neurosurg (2002) 96:173

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*:Saatci and Cekirge et al J Neurosurg (2011);115 (1):78-88 350 AVMs* (series treated w nondetach catheter and definitive treatment status achieved ) 158 grade 1-2 (84% ruptured) 192 grade 3-5 ( 17% w rupture, 83% w intractable seizures and/or progressive deficit 42 pts: nBCA was used additionally 179 (51%) complete obliteration (incl.1 ex) 136 referred to radiosurgery 27 referred to surgery after embolization 4 discontinued therapy 5 died *:Saatci and Cekirge et al J Neurosurg (2011);115 (1):78-88 12

350 AVMs. (series treated w nondetach catheter and 350 AVMs* (series treated w nondetach catheter and definitive treatment status achieved ) Presentation: 163 w hemorrhage: 47% 118 w seizures: 34% 29 w neurologic signs: 8% 27 w headache: 8% 13 other/incidental: 4% Pt distribution according to S&M grading: S&M # of pts % I 52 16 II 106 29 III 99 28 IV 69 20 V 24 7 13

155/158 (97%) Gr 1-2 AVM completely obliterated by embolization alone. 24/192 (12.5%) Gr 3-5 AVM obliterated by embolization alone. In all 178 completely obliterated AVMs by embo alone (1 pt died), 1 yr control angiography (obtained in all) and/or 2-8 yrs control angiography (126 pts) confirmed the stable obliteration except for two patients who showed a very small recruitment in the FU; one of whom received an additional session of embolization Ultimate cure rate w embolization alone is: 178/350 (50.6 %) 14

That is a ‘totally new’ treatment concept against several DOGMAs about the liquid embolic injection into the AVM nidus. A mindset change is certainly needed!!

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Complications All patients had immediate post embo CT scan and pre-post embo MRI w diff & perf. studies. Any new finding w or w/o symptoms were recorded as adverse findings.

Complications Mortality developed in 5 pts (1.4%).Procedure related in 4 pts (1.1%). 4 patients developed intracranial hemorrhage after the embolization, one of whom had total obliteration of AVM. Another patient with a partially embolized insular AVM developed IC hematoma 3 months after the second session Neurologic morbidity (disabling and nondisabling) developed in 25 pts (7.1%) Technical results/complications 28 catheters left in place in 27 patients 2 asymptomatic vessel occlusion due to left microcaths (1 VA, 1 segmental femoral art.); 1 pt developed inguinal cellulitis and abscess formation who necessitated surgical intervention. Vessel perforation resulting in permanent deficit Focal alopecia in 22 pts (6.3%): all rev (19 pts in occipital) 39

ANY NEW FINDING on IMAGING 27.1% : no neurologic deficit; no symptom except for headache (n=95) ANY NEW FINDING on IMAGING 137 pts 39.1% 3.7% transient symptom n=13 7.1% neurologic deficit n=25 4.3% mRS >2 in 3-6 mo n=15 14 due to bleeding: 3.4% 15 due to ischemic: 4% 40

S-M Grade 1-2 S-M grade 3-5 57/95 adverse events w/o neurological deficit observed in this group Transient hemiparesis in 1 pt. Permanent deficit in 4 pts (2 hemianopsia, sensorial dysphasia, leg monoparesis 1 died (0.6% mortality) 4/158 2.5% morbidity. Late outcome in 3-6 months showed good recovery w mRS< 2 in all. 38/95 adverse events with no neurological deficit observed Transient deficit in 12 pts Permanent deficit in 21 pts 33/192 (17%), immediate postop disabling or nondisabling morbidity 4 died (2.1% mortality) 21/192, 10.9% neurologic morbidity at post op 4 wks Late outcome in 3-6 mos; 15/21 pts were in mRS > 2 (7.8%). 41

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Patient Selection ≤3cm -If bled (unless located in brainstem): do embolization -If unruptured and in critical location, single drainage vein (esp.deep):primarily refer to RT -If unruptured but compact w more than one draining vein, likely to obliterate from single pedicle injection: do embolization -If unruptured but have weak points i.e. intranidal aneurysms, venous stricture: do embolization

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Patient Selection >3cm -If bled: do embolization -If unruptured but older than 60yrs, embolize only if there exist architectural weak points i.e. intranidal aneurysms,venous stricture etc If pt having progressive neurologic deficit; increasing mental deterioration; symptoms of venous HT; intractable seizures despite proper medication -If unruptured, but symptomatic and younger than 60 yrs of age: embolization after pt’s informed consent -If unruptured, asymptomatic other than mild to moderate headache once in a while, FOLLOW UP?

3 months control before the pt sent to GK

Conclusion: We believe that embolization w ONYX is a curative treatment in brain AVMs w a mortality rate of 1.4% and permanent morbidity rate of 7.1% w an ultimate total cure rate of 50.6% w a permanent closure in 98.9% (2/178)

Conclusion: AVM embolization w ONYX is a radical treatment that it is to compare w surgery not w glue/particule etc embolization

Thanks…..

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