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made intravenously. The heparin is reverse atthe end of the embolization. On the technicalpoint of view, there is no difference with His-toacryl except the color of the mixture. We al-ways mixed Glubran with Lipiodol“ (Guerbet,Aulnay s/s bois, France). The concentration isadapted to the nidus type angio architecture(the size of the nidus and the flow of theshunt). Commonly, we use a concentration be-tween 25 and 50%. We think that experience isvery important and that the neuroradiologistmust master different concentrations of glueand the different kind of behaviour of the mi-crocatheter 2.
Even if we try to control the flow during theinjection, the situation of the tip of the micro-catheter also influence the concentration ofglue. For bAVM, most of the time we use aflow-dependant catheter (1,2 to 1,5 Fr). We tryto navigate without guide wire to reach thenidus , and when it is possible in a wedge posi-tion. Before injecting the glue, we do a biplanesuperselective angiography in the “workingprojection”. The working projection is chosento allow visual control of the nidus penetrationand arterial reflux when the glubran will be de-posited. Then we flush the microcatheter withglucose and we inject the glue with a 3cc sy-ringe during a biplane run. The quantity of gluedepends of the size of the nidus (0,7 to 2cc), atthe end of the injection the operator must aspi-
New agents of liquid acrylic glue for em-bolization of brain vascular malformation havemade their appearance in the therapeutic arse-nal. Among those, we have change using previ-ously Histoacryl“ (Braun, Aesculap AG, Tuttin-gen, Germany) to choose Glubran“ (GEM Srl,Viareggio, Italy) in 2003. Since this date, wehave used Glubran for around 150 emboliza-tions mostly in bAVM, dural arteriovenousshunt, direct fistulae and exceptionallyaneurysms. The fact that Glubran bears the CEtrademark with specific indication for neurora-diological endovascular use is very importanton the legal point of view even if Histoacryl hasbeen used worldwide by the most experienceteams in cerebral vascular malformation en-dovascular field treatment 3. To our experience,and in agreement with experimental works,Glubran does not produce bubbles and seemsto diffuse more homogeneously and in a morepredictable way than Histoacryl 1.
The principle of intra nidal embolizationwith cyanoacrylate remains exactly the sameand Glubran does not change the concept oftreatment. It requires extensive experiencewhich was acquired with Histoacryl and easilytranslates with Glubran.
All patients are treated under general anaes-thesia, a 5 french guiding catheter is used tocatheterize the main feeding trunk (flush withsaline) and a bolus of 1000 UI of heparin is
Brain Arteriovenous MalformationsTechnical Note of EndovascularTreatment with Glubran®
H.-A. DESAL*, F. TOULGOAT*, S. RAOUL***, B. GUILLON**, R. AL HAMMADIBRAHIM***, E. AUFFRAY-CALVIER*, A. DE KERSAINT-GILLY** Neuroradiology, Hôpital G&R Laënnec, CHU de Nantes; France, ** Neurology, Stroke Center, Hôpital G&R Laënnec,CHU de Nantes, France, *** Neurosurgery, Hôpital G&R Laënnec, CHU de Nantes; France
Key words: brain arteriovenous malformation, embolization, cyanoacrylate, Glubran
Brain Arteriovenous Malformation (bAVM): Technical Note of Endovascular Treatment with Glubran® H.-A. Desal
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rate back the glue and rapidly pull the micro-catheter inside the guiding catheter. What arethe main complications we have to avoid?
During the navigation, the operator must bevery cautious when using guidewire to preventany perforation. We preferred not to push the
Figure 1 A 47-year-old man presenting with a left occipitalhaematoma. Left internal carotid angiography frontal (A)and lateral view (B): direct arteriovenous fistula fed by theposterior cerebral artery. Supraselective angiography of thefistula (C). Cast of glue injection (D). Control post em-bolization angiography, lateral view (E).
A B
C
E
D
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guidewire out of the tip of the microcatheter.During the glue injection, venous penetra-
tion must be carefully recognized. In case of
single draining vein, this is a dangerous situa-tion and the nidus has to be occluded totally toprevent haemorrhagic complication. In case of
A B
C D
Figure 2 A 3-year-old boy presenting an acute right hemiparesis with left frontal arteriovenous malformation. (A) leftcarotid artery angiography lateral view, direct arteriovenous fistula fed by the precentral artery. Supraselective angiography,lateral view, direct venous opacification (B). Immediate control post embolization with Glubran (C). One year control postembolization with remodelling of the feeding vessel which has now a normal size (D).
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Figure 3 A 12-year-old boy presenting with a temporo-oc-cipital haematoma. Left vertebral angiography antero-pos-terior (A) and lateral view (B), arteriovenous malformationof the right occipital lobe. Supraselective injection frontal(C) and lateral (D) views. Control post embolization (E).
A D
B
E
C
multiple draining veins, one of them can be oc-cluded without any complication if the up-stream nidus is already occluded.
The arterial reflux during the glue injectionmust be mastered to prevent any normal brainartery occlusion.
During the withdrawing, we have not hadcatheter rupture while using Glubran nor glu-ing the microcatheter in place.
Conclusion
The concept of intranidal embolization forbAVM has not changed since we use Glubran.We have not modified our injection technique.
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Figure 4 A 37-year-old man presenting with a left frontalhaematoma and aphasia. Left internal carotid artery frontal(A) and lateral (B) views. Small arteriovenous shunt with asingle venous drainage (C) at the supraselective angiogra-phy. Cast of glue post embolization (D). Three months con-trol angiogram of the left internal carotid artery angiogram,lateral view (E).
A B
D
E
C
In our experience, Glubran polymerization ismore reliable and predictable than othercyanoacrylate we used before. Even if new em-
bolic agents (like Onyx) will probably be morewidely used, Glubran will remains interestingfor high flow single hole fistula occlusion.
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Bibliographie1 Leonardi M, Barbara C et Al: Glubran 2: a new acrylic
glue for neuroradiological endovascular use (experi-mental study on animals). Interventional Neuroradiol-ogy 8: 245-50, 2002.
2 Wikholm G, Lunquist C et Al: Transarterial emboliza-tion of cerebral arteriovenous malformations: improve-ment of results with experience. Am J Neuroradiol 16:1811-7, 1995.
3 Lasjaunias P, Berenstein A et Al: Surgical Neuro-an-
H.-A. Desal, MDHôpital LaennecService de NeuroradiologieB.F. 1005F 44035 NANTES Cédex 01 France
giography, vol 2.2, Springer, Berlin, Heidelberg, NewYork. 2003, 695-735.
