Tutorials in Endovascular Neurosurgery and Interventional Neuroradiology by James Vincent Byrne

Author:James Vincent Byrne
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

9.5.7.4 Embolisation

Embolisation is used alone or as an adjuvant treatment combined with surgery or radiotherapy. The techniques will be covered in a separate tutorial and the emphasis here is to understand its indications and why it is chosen. The goals of treatment are different if it is attempted for complete cure, to facilitate surgery or radiotherapy or used as palliative treatment.

Role of Embolisation

Its role in the multimodal management of brain AVMs depends, to some extent, on where you work. In many countries, embolisation is performed as the initial intervention for BAVMs for a variety of ‘unscientific’ reasons such as lack of alternative expertise, unavailable resources and because of patient preference, whereas in others, its role is primarily as a presurgical or preradiotherapy adjunct treatment.

The list of milestones in Table 9.5 highlights some of the technical advances that have allowed endovascular navigation and location techniques to develop. This field is not static, and in the last 10 years, the introduction of detachable tip microcatheters and re-formulation of liquid embolic agents has altered the way embolisation is performed and its efficacy. The cyanoacrylate agent, N-butyl-2-cyanoacrylate (NBCA), was approved by the FDA after a randomised controlled trial showing its equivalence to the injection of polyvinyl alcohol particles [135]. Ethylene vinyl alcohol copolymer was introduced in 1990 but used almost exclusively in Japan [136] until it was reformulated and marketed as Onyx (ev3 Endovascular Inc. Irvine, CA USA).

As with other interventions, publication of the interim results of ARUBA has reduced the number of patients with unruptured BAVMs undergoing endovascular treatments. To redefine its role, a series of related prospective randomised studies have been recently proposed [137]. This initiative reflects the evolving clinical role and the new technologies associated with embolisation for BAVM patients.

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