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Tuleasca C, Peciu-Florianu I, Leroy HA, Vermandel M, Faouzi M, Reyns N. Biologically effective dose and prediction of obliteration of unruptured arteriovenous malformations treated by upfront Gamma Knife radiosurgery: a series of 149 consecutive cases. J Neurosurg 2021; 134:1901-1911. [PMID: 32707557 DOI: 10.3171/2020.4.jns201250] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/24/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Arteriovenous malformations (AVMs) present no pathologic tissue, and radiation dose is confined in a clear targeted volume. The authors retrospectively evaluated the role of the biologically effective dose (BED) after Gamma Knife radiosurgery (GKRS) for brain AVMs. METHODS A total of 149 consecutive cases of unruptured AVMs treated by upfront GKRS in Lille University Hospital, France, were included. The mean length of follow-up was 52.9 months (median 48, range 12-154 months). The primary outcome was obliteration, and the secondary outcome was complication appearance. The marginal dose was 24 Gy in a vast majority of cases (n = 115, 77.2%; range 18-25 Gy). The mean BED was 220.1 Gy2.47 (median 229.9, range 106.7-246.8 Gy2.47). The mean beam-on time was 32.3 minutes (median 30.8, range 9-138.7 minutes). In the present series, the mean radiation dose rate was 2.259 Gy/min (median 2.176, range 1.313-3.665 Gy/min). The Virginia score was 0 in 29 (19.5%), 1 in 61 (40.9%), 2 in 41 (27.5%), 3 in 18 (12.1%), and 4 in 0 (0%) patients, respectively. The mean Pollock-Flickinger score was 1.11 (median 1.52, range 0.4-2.9). Univariate (for obliteration and complication appearance) and multivariate (for obliteration only) analyses were performed. RESULTS A total of 104 AVMs (69.8%) were obliterated at the last follow-up. The strongest predictor for obliteration was BED (p = 0.03). A radiosurgical obliteration score is proposed, derived from a fitted multivariable model: (0.018 × BED) + (1.58 × V12) + (-0.013689 × beam-on time) + (0.021 × age) - 4.38. The area under the receiver operating characteristic curve was 0.7438; after internal validation using bootstrap methods, it was 0.7088. No statistically significant relationship between radiation dose rate and obliteration was found (p = 0.29). Twenty-eight (18.8%) patients developed complications after GKRS; 20 (13.4%) of these patients had transient adverse radiological effects (perilesional edema developed). Predictors for complication appearance were higher prescription isodose volume (p = 0.005) and 12-Gy isodose line volume (V12; p = 0.001), higher Pollock-Flickinger (p = 0.02) and Virginia scores (p = 0.003), and lower beam-on time (p = 0.03). CONCLUSIONS The BED was the strongest predictor of obliteration of unruptured AVMs after upfront GKRS. A radiosurgical score comprising the BED is proposed. The V12 appears as a predictor for both efficacy and toxicity. Beam-on time was illustrated as statistically significant for both obliteration and complication appearance. The radiation dose rate did not influence obliteration in the current analysis. The exact BED threshold remains to be established by further studies.
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Affiliation(s)
- Constantin Tuleasca
- 1Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
- 2Lausanne University Hospital (CHUV), Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne
- 3University of Lausanne, Faculty of Biology and Medicine, Lausanne
- 4Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne
| | - Iulia Peciu-Florianu
- 1Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
| | - Henri-Arthur Leroy
- 1Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
| | - Maximilien Vermandel
- 1Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
- 6University of Lille, Inserm, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, Lille, France
| | - Mohamed Faouzi
- 5Division of Biostatistics, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Switzerland; and
| | - Nicolas Reyns
- 1Centre Hospitalier Regional Universitaire de Lille, Roger Salengro Hospital, Neurosurgery and Neurooncology Service, Lille, France
- 6University of Lille, Inserm, CHU Lille, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, Lille, France
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Zainaee S, Mahdipour R, Mahdavi Rashed M, Sobhani-Rad D. Dysgraphia and dysprosody in a patient with arteriovenous malformation: a case report. Neurocase 2021; 27:259-265. [PMID: 34106816 DOI: 10.1080/13554794.2021.1929332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Arteriovenous malformation (AVM) results from development of abnormal connections between veins and arteries. This study reported anAVM case suffering from dysgraphia and dysprosody. According to the results after the trauma, the patient's handwriting was identified as macrographic and illegible, and written letters and verbs were neglected in free writing or dictation. Moreover, prosody of the patient's utterances was changed. Finally, an intervention was conducted to improve the writing impairments whereby they eventually enhanced. AVM can adversely affect communication opportunities and working life due to these impairments. Thus referring the patient to speech and language pathologists seems sensible and necessary.
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Affiliation(s)
- Shahryar Zainaee
- Department of Speech Therapy, School of Paramedical Sciences, Mashhad University of Medical Sciences
| | - Ramin Mahdipour
- Department of Anatomy and Cell Biology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Davood Sobhani-Rad
- Department of Speech Therapy, School of Paramedical Sciences, Mashhad University of Medical Sciences
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Karki P, Sharma GR, Joshi S, Paudel P, Shah DB. Retrospective Study and Outcome Predictor after Microsurgical Resection of Cerebral Arteriovenous Malformations in Nepal. Asian J Neurosurg 2021; 16:355-362. [PMID: 34268164 PMCID: PMC8244694 DOI: 10.4103/ajns.ajns_509_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 11/30/2022] Open
Abstract
Objective: The purpose of this study is to assess demographic, clinical, and morphological characteristics of patients with brain arteriovenous malformations (bAVMs). The relation of outcome using modified Ranklin Scale (mRS) at time of discharge, early and last follow ups with respect to various factors. Materials and Methods: Demographic data, arteriovenous malformation characteristics, and treatment outcomes were evaluated in 43 bAVMs treated with microsurgery between 2009 and 2019. For this series, 43 patients were retrospectively reviewed. A subgroup analysis for Spetzler-Martin grades (SMG) I/II, III, IV/V and III–V were performed. The mRS was used to assess functional outcomes. Results: Overall, mean age at diagnosis was 33 years (standard deviation = 19). Transient deficit, mRS deterioration and impaired functional outcome occurred less frequently in SMG I–II patients compared with Grade III–V patients combined (29% vs. 32% respectively, P = 0.00). All patients with SMG Grade I, Supplemented SMG Grade 2, 3, 4 and 6 had a mRS score of 2 or less at the last follow-up. Age was the only significant predictor of overall outcome after bAVM surgery on Chi-square test (P = 0.046), i.e: all patients <20 years had mRS score of 2 or less on last follow-up. Unfavorable outcome (mRS score of 3 or more than 3) level increased with higher grades in SMG on long term follow-up. Conclusion: The results of our case series of bAVM with SMG Grade I and Suplemented Grade 2, 3, 4 and even higher grade i.e., 6 can have excellent overall outcome after microsurgical resection. Association of factors which increases the grading system of bAVM like eloquence, deep venous drainage and increasing sizes did not correlate with the predicted unfavorable outcomes, whereas age of patients was a predictor of overall outcome. Although the small sample size of this study is a limitation, age of patient plays important role on the overall outcome.
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Affiliation(s)
- Prasanna Karki
- Department of Neurosciences, Division of Neurosurgery, Nepal Mediciti Hospital, Lalitpur, Kathmandu, Nepal
| | - Gopal Raman Sharma
- Department of Neurosciences, Division of Neurosurgery, Nepal Mediciti Hospital, Lalitpur, Kathmandu, Nepal
| | - Sumit Joshi
- Department of Neurosciences, Division of Neurosurgery, Nepal Mediciti Hospital, Lalitpur, Kathmandu, Nepal
| | - Prakash Paudel
- Department of Neurosciences, Division of Neurosurgery, Nepal Mediciti Hospital, Lalitpur, Kathmandu, Nepal
| | - Damber Bikram Shah
- Department of Neurosciences, Division of Neurosurgery, Nepal Mediciti Hospital, Lalitpur, Kathmandu, Nepal
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Schmitt N, Floca RO, Paech D, El Shafie RA, Neuberger U, Bendszus M, Möhlenbruch MA, Vollherbst DF. Imaging Artifacts of Nonadhesive Liquid Embolic Agents in Conventional and Cone-beam CT in a Novel in Vitro AVM Model. Clin Neuroradiol 2021; 31:1141-1148. [PMID: 33852036 PMCID: PMC8648665 DOI: 10.1007/s00062-021-01013-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/15/2021] [Indexed: 11/05/2022]
Abstract
Background A major drawback of liquid embolic agents (LEAs) is the generation of imaging artifacts (IA), which may represent a crucial obstacle for the detection of periprocedural hemorrhage or subsequent radiosurgery of cerebral arteriovenous malformations (AVMs). This study aimed to compare the IAs of Onyx, Squid and PHIL in a novel three-dimensional in vitro AVM model in conventional computed tomography (CT) and cone-beam CT (CBCT). Methods Tubes with different diameters were configured in a container resembling an AVM with an artificial nidus at its center. Subsequently, the AVM models were filled with Onyx 18, Squid 18, PHIL 25% or saline and inserted into an imaging phantom (n = 10/LEA). Afterwards CT and CBCT scans were acquired. The degree of IAs was graded quantitatively (Hounsfield units in a defined region of interest) and qualitatively (feasibility of defining the nidus)—Onyx vs. Squid vs. PHIL vs. saline, respectively. Results Quantitative density evaluation demonstrated more artifacts for Onyx compared to Squid and PHIL, e.g. 48.15 ± 14.32 HU for Onyx vs. 7.56 ± 1.34 HU for PHIL in CT (p < 0.001) and 41.88 ± 7.22 density units (DU) for Squid vs. 35.22 ± 5.84 DU for PHIL in CBCT (p = 0.044). Qualitative analysis showed less artifacts for PHIL compared to Onyx and Squid in both imaging modalities while there was no difference between Onyx and Squid regarding the definition of the nidus (p > 0.999). Conclusion In this novel three-dimensional in vitro AVM model, IAs were higher for the EVOH/tantalum-based LEAs Onyx and Squid compared to iodine-based PHIL. Onyx induced the highest degree of IAs with only minor differences to Squid.
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Affiliation(s)
- Niclas Schmitt
- Department of Neuroradiology, INF 400, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Ralf O Floca
- Medical Image Computing, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany
| | - Daniel Paech
- Department of Neuroradiology, INF 400, Heidelberg University Hospital, 69120, Heidelberg, Germany.,Department of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Rami A El Shafie
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulf Neuberger
- Department of Neuroradiology, INF 400, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, INF 400, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, INF 400, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, INF 400, Heidelberg University Hospital, 69120, Heidelberg, Germany.
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Homocysteine Level and Risk of Hemorrhage in Brain Arteriovenous Malformations. DISEASE MARKERS 2021; 2021:8862299. [PMID: 33859768 PMCID: PMC8026282 DOI: 10.1155/2021/8862299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/10/2020] [Accepted: 03/20/2021] [Indexed: 11/17/2022]
Abstract
Objective We aimed to investigate the risk factors associated with hemorrhage and clarify the relation of homocysteine (Hcy) with brain arteriovenous malformations (bAVMs). Method We retrospectively reviewed bAVM patients from Beijing Tiantan Hospital between January 2019 and December 2019. Clinical and laboratory variables were analyzed in enrolled patients with bAVMs. Potential predictors associated with hemorrhage were evaluated by logistic regression analysis. Results A total of 143 bAVM patients were identified in the study, including 69 unruptured and 74 ruptured cases. Patients with hemorrhage were less likely to have hyperhomocysteinemia (P = 0.023). Logistic regression analysis showed that increased maximum diameter of bAVM lesions (odds ratio (OR) 0.634, 95% confidence intervals (CI) 0.479-0.839; P = 0.001) and serum Hcy level (OR 0.956, 95% CI 0.920-0.993; P = 0.021) were associated with lower risk of hemorrhage in bAVMs. Conclusion The present study provided evidence regarding the association between serum Hcy and hemorrhage in patients with bAVMs. Higher Hcy level was correlated with a lower risk of rupture. Detection of factors for subsequent hemorrhage is necessary to develop therapeutic strategies for bAVMs preferably.
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Yan KL, Ko NU, Hetts SW, Weinsheimer S, Abla AA, Lawton MT, Kim H. Maternal and Fetal Outcomes in Women with Brain Arteriovenous Malformation Rupture during Pregnancy. Cerebrovasc Dis 2021; 50:296-302. [PMID: 33640891 DOI: 10.1159/000513573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/12/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Sporadic brain arteriovenous malformations (BAVM) are a major cause of hemorrhagic stroke in younger persons. Prior studies have reported contradictory results regarding the risk of hemorrhage during pregnancy, and there are no standard guidelines for the management of pregnant women who present with BAVM rupture. The purpose of this study is to describe maternal and fetal outcomes and treatment strategies in patients with BAVM hemorrhage during pregnancy. METHODS We performed a retrospective review of the University of California, San Francisco Brain AVM Project database for female patients who were pregnant at the time of BAVM hemorrhage between 2000 and 2017. Clinical and angiographic characteristics at presentation, BAVM treatment, and maternal outcomes using modified Rankin scale (mRS) score at presentation and 2-year follow-up were recorded. Fetal outcomes were abstracted from medical records and maternal reports. RESULTS Sixteen patients presented with BAVM hemorrhage during pregnancy, 81% (n = 13) of whom were in their second or third trimester. Three patients (19%) who were in their first trimester terminated or miscarried pregnancy prior to BAVM intervention. Of the remaining 13 patients, 77% (n = 10) received emergent BAVM treatment at time of hemorrhage prior to delivery, and 85% of patients achieved BAVM obliteration and good maternal outcomes (mRS 0-2) at 2-year follow-up. All patients had uncomplicated deliveries (69% cesarean and 23% vaginal) with no reports of postnatal cognitive or developmental delays in infants at 2-year follow-up. CONCLUSIONS Our study shows good long-term maternal and fetal outcomes in ruptured BAVM patients presenting during pregnancy, the majority who received BAVM interventional treatment prior to delivery.
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Affiliation(s)
- Kimberly L Yan
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California - San Francisco, San Francisco, California, USA.,Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Nerissa U Ko
- Department of Neurology, University of California - San Francisco, San Francisco, California, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Engineering, University of California - San Francisco, San Francisco, California, USA
| | - Shantel Weinsheimer
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California - San Francisco, San Francisco, California, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California - San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Helen Kim
- Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California - San Francisco, San Francisco, California, USA,
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Schmitt N, Floca RO, Paech D, El Shafie RA, Seker F, Bendszus M, Möhlenbruch MA, Vollherbst DF. Imaging Artifacts of Liquid Embolic Agents on Conventional CT in an Experimental in Vitro Model. AJNR Am J Neuroradiol 2021; 42:126-131. [PMID: 33214178 DOI: 10.3174/ajnr.a6867] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/14/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE Endovascular embolization using liquid embolic agents is a safe and effective treatment option for AVMs and dural arteriovenous fistulas. The aim of this study was to assess the degree of artifact inducement by the most frequently used liquid embolic agents in conventional CT in an experimental in vitro model. MATERIALS AND METHODS Dimethyl-sulfoxide-compatible tubes were filled with the following liquid embolic agents (n = 10, respectively): Onyx 18, all variants of Squid, PHIL 25%, PHIL LV, and n-BCA mixed with iodized oil. After inserting the tubes into a CT imaging phantom, we acquired images. Artifacts were graded quantitatively by the use of Hounsfield units in a donut-shaped ROI using a customized software application that was specifically designed for this study and were graded qualitatively using a 5-point scale. RESULTS Quantitative and qualitative analyses revealed the most artifacts for Onyx 18 and the least artifacts for n-BCA, PHIL 25%, and PHIL LV. Squid caused more artifacts compared with PHIL, both for the low-viscosity and for the extra-low-viscosity versions (eg, quantitative analysis, Squid 18: mean ± SD, 30.3 ± 9.7 HU versus PHIL 25%: mean ± SD, 10.6 ± 0.8 HU; P < .001). Differences between the standard and low-density variants of Squid were observed only quantitatively for Squid 12. There were no statistical differences between the different concentrations of Squid and PHIL. CONCLUSIONS In this systematic in vitro analysis investigating the most commonly used liquid embolic agents, relevant differences in CT imaging artifacts could be demonstrated. Ethylene-vinyl alcohol-based liquid embolic agents induced more artifacts compared with liquid embolic agents that use iodine as a radiopaque component.
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Affiliation(s)
- N Schmitt
- From the Departments of Neuroradiology (N.S., F.S., M.B., M.A.M., D.F.V.)
| | - R O Floca
- Radiation Oncology (R.O.F., R.A.E.S.), Heidelberg University Hospital, Heidelberg, Germany
- Medical and Biological Informatics (R.O.F.)
- Heidelberg Institute for Radiation Oncology and National Center for Radiation Research in Oncology (R.O.F.), Heidelberg, Germany
| | - D Paech
- Department of Radiology (D.P.), German Cancer Research Center, Heidelberg, Germany
| | - R A El Shafie
- Radiation Oncology (R.O.F., R.A.E.S.), Heidelberg University Hospital, Heidelberg, Germany
| | - F Seker
- From the Departments of Neuroradiology (N.S., F.S., M.B., M.A.M., D.F.V.)
| | - M Bendszus
- From the Departments of Neuroradiology (N.S., F.S., M.B., M.A.M., D.F.V.)
| | - M A Möhlenbruch
- From the Departments of Neuroradiology (N.S., F.S., M.B., M.A.M., D.F.V.)
| | - D F Vollherbst
- From the Departments of Neuroradiology (N.S., F.S., M.B., M.A.M., D.F.V.)
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Graffeo CS, Sahgal A, De Salles A, Fariselli L, Levivier M, Ma L, Paddick I, Regis JM, Sheehan J, Suh J, Yomo S, Pollock BE. Stereotactic Radiosurgery for Spetzler-Martin Grade I and II Arteriovenous Malformations: International Society of Stereotactic Radiosurgery (ISRS) Practice Guideline. Neurosurgery 2020; 87:442-452. [PMID: 32065836 PMCID: PMC7426190 DOI: 10.1093/neuros/nyaa004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 11/30/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND No guidelines have been published regarding stereotactic radiosurgery (SRS) in the management of Spetzler-Martin grade I and II arteriovenous malformations (AVMs). OBJECTIVE To establish SRS practice guidelines for grade I-II AVMs on the basis of a systematic literature review. METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant search of Medline, Embase, and Scopus, 1986-2018, for publications reporting post-SRS outcomes in ≥10 grade I-II AVMs with a follow-up of ≥24 mo. Primary endpoints were obliteration and hemorrhage; secondary outcomes included Spetzler-Martin parameters, dosimetric variables, and “excellent” outcomes (defined as total obliteration without new post-SRS deficit). RESULTS Of 447 abstracts screened, 8 were included (n = 1, level 2 evidence; n = 7, level 4 evidence), representing 1102 AVMs, of which 836 (76%) were grade II. Obliteration was achieved in 884 (80%) at a median of 37 mo; 66 hemorrhages (6%) occurred during a median follow-up of 68 mo. Total obliteration without hemorrhage was achieved in 78%. Of 836 grade II AVMs, Spetzler-Martin parameters were reported in 680: 377 were eloquent brain and 178 had deep venous drainage, totaling 555/680 (82%) high-risk SRS-treated grade II AVMs. CONCLUSION The literature regarding SRS for grade I-II AVM is low quality, limiting interpretation. Cautiously, we observed that SRS appears to be a safe, effective treatment for grade I-II AVM and may be considered a front-line treatment, particularly for lesions in deep or eloquent locations. Preceding publications may be influenced by selection bias, with favorable AVMs undergoing resection, whereas those at increased risk of complications and nonobliteration are disproportionately referred for SRS.
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Affiliation(s)
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Antonio De Salles
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California
| | - Laura Fariselli
- Fondazione IRCCS Istituto Neurologico Carlo Besta Milano, Unità di Radioterapia, Milan, Italy
| | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Ian Paddick
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Jean Marie Regis
- Department of Functional Neurosurgery, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - John Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota.,Department Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Ruigrok YM. Management of Unruptured Cerebral Aneurysms and Arteriovenous Malformations. Continuum (Minneap Minn) 2020; 26:478-498. [PMID: 32224762 DOI: 10.1212/con.0000000000000835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Unruptured intracranial aneurysms and brain arteriovenous malformations (AVMs) may be detected as incidental findings on cranial imaging. This article provides a practical approach to the management of unruptured intracranial aneurysms and unruptured brain AVMs and reviews the risk of rupture, risk factors for rupture, preventive treatment options with their associated risks, and the approach of treatment versus observation for both types of vascular malformations. RECENT FINDINGS For unruptured intracranial aneurysms, scoring systems on the risk of rupture can help with choosing preventive treatment or observation with follow-up imaging. Although the literature provides detailed information on the complication risks of preventive treatment of unruptured intracranial aneurysms, individualized predictions of these procedural complication risks are not yet available. With observation with imaging, growth of unruptured intracranial aneurysms can be monitored, and prediction scores for growth can help determine the optimal timing of monitoring. The past years have revealed more about the risk of complications of the different treatment modalities for brain AVMs. A randomized clinical trial and prospective follow-up data have shown that preventive interventional therapy in patients with brain AVMs is associated with a higher rate of neurologic morbidity and mortality compared with observation. SUMMARY The risk of hemorrhage from both unruptured intracranial aneurysms and brain AVMs varies depending on the number of risk factors associated with hemorrhage. For both types of vascular malformations, different preventive treatment options are available, and all carry risks of complications. For unruptured intracranial aneurysms, the consideration of preventive treatment versus observation is complex, and several factors should be included in the decision making. Overall, it is recommended that patients with unruptured asymptomatic brain AVMs should be observed.
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Krithika S, Sumi S. Neurovascular inflammation in the pathogenesis of brain arteriovenous malformations. J Cell Physiol 2020; 236:4841-4856. [PMID: 33345330 DOI: 10.1002/jcp.30226] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/11/2020] [Accepted: 12/08/2020] [Indexed: 11/11/2022]
Abstract
Brain arteriovenous malformations (bAVM) arise as congenital or sporadic focal lesions with a significant risk for intracerebral hemorrhage (ICH). A wide range of interindividual differences is present in the onset, progression, and severity of bAVM. A growing body of gene expression and polymorphism-based research studies support the involvement of localized inflammation in bAVM disease progression and rupture. In this review article, we analyze the altered responses of neural, vascular, and immune cell types that contribute to the inflammatory process, which exacerbates the pathophysiological progression of vascular dysmorphogenesis in bAVM lesions. The cumulative effect of inflammation in bAVM development is orchestrated by various genetic moderators and inflammatory mediators. We also discuss the potential therapies for the treatment of brain AVM by targeting the inflammatory processes and mediators. Elucidating the precise role of inflammation in the bAVM growth and hemorrhage would open novel avenues for noninvasive and effectual causal therapy that may complement the current therapeutic strategies.
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Affiliation(s)
- S Krithika
- Cardiovascular Diseases and Diabetes Biology, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
| | - S Sumi
- Cardiovascular Diseases and Diabetes Biology, Rajiv Gandhi Centre for Biotechnology, Thiruvananthapuram, Kerala, India
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Prognostic Significance of Homocysteine Level on Neurological Outcome in Brain Arteriovenous Malformations. DISEASE MARKERS 2020; 2020:6661475. [PMID: 33312268 PMCID: PMC7721487 DOI: 10.1155/2020/6661475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 11/17/2022]
Abstract
Objective We aimed to investigate the serum homocysteine (Hcy) level in patients with brain arteriovenous malformation (bAVM) and their impact on neurological outcome during hospitalization. Method We retrospectively reviewed patients diagnosed with bAVMs in Beijing Tiantan Hospital from January 2019 to August 2020. Patients were divided into two groups according to the mRS (modified Rankin Scale) score at discharge. Clinical and laboratory characteristics were compared. Logistic regression analyses were performed to identify the potential risk factors for short-term neurological outcome. Results A total of 175 bAVM patients were enrolled in the study, including 139 patients with favorable outcome (mRS ≤ 2) and 36 patients with unfavorable outcome (mRS > 2). Hyperhomocysteinemia was identified in 32.6% of cases (n = 57). Serum Hcy level was related to seizure manifestation (P = 0.034) and short-term neurological outcome (P = 0.027). Logistic regression analysis showed that serum glucose (OR 1.897, 95% CI 1.115-3.229; P = 0.018) and Hcy level (OR 0.838, 95% CI 0.720-0.976; P = 0.023) were significantly associated with short-term disability. Conclusion Our results indicated that the lower serum Hcy level is strongly associated with in-hospital unfavorable outcome. Further prospective studies of Hcy natural history and managements in bAVMs are required, which would be valuable for evaluating the disease-modifying efficacy of oral nutritional supplements in bAVM patients.
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Bunevicius A, Joyner DA, Muttikkal TE, Ahn J, Sheehan J. Magnetic Resonance Perfusion Changes of Arteriovenous Malformations Treated with Stereotactic Radiosurgery. World Neurosurg 2020; 146:e1003-e1011. [PMID: 33227527 DOI: 10.1016/j.wneu.2020.11.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The latency period from stereotactic radiosurgery (SRS) to obliteration of arteriovenous malformations (AVM) requires continuous imaging surveillance. Magnetic resonance (MR) perfusion is promising for noninvasive monitoring of AVMs after SRS. We studied longitudinal MR perfusion changes of brain AVMs treated with SRS. METHODS Consecutive patients treated for brain AVMs using SRS who had MR perfusion imaging studies performed before and at least once after SRS were studied. We estimated ipsilateral/contralateral brain hemisphere ratios of MR perfusion indexes, including regional cerebral blood flow (rCBF) and relative cerebral blood volume (rCBV), in the AVM nidus, perinidal region, and remote anterior and posterior brain regions. RESULTS Eleven patients (6 women; median age, 21 years) underwent SRS (median prescription dose, 18 Gy; range, 12-20 Gy) for brain AVMs (median Spetzler-Martin grade 2 and median volume 4.6 mL). Before the SRS, rCBV and rCBF ratios were significantly higher in the AVM nidus compared with other investigated brain regions (P < 0.001). Median time from SRS to the first and last post-SRS MR perfusion studies was 8 and 35 months, respectively. There was a statically significant decrease of rCBV (P = 0.043) and rCBF (P = 0.036) ratios in the AVM nidus, but not other brain regions, during post-SRS follow-up. CONCLUSIONS There is a gradual decrease of rCBV and rCBF in the AVM nidus after SRS. MR perfusion imaging is promising for monitoring of hemodynamic changes of AVMs after SRS. Larger studies investigating clinical value of MR perfusion imaging for AVMs after SRS are warranted.
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Affiliation(s)
- Adomas Bunevicius
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - David A Joyner
- Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | | | - Jungeun Ahn
- School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.
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Zhang M, Feng Z, Yu W, Fu C. Artery of Percheron as a Rare Feeder of Hemorrhagic Thalamic Arteriovenous Malformation: A Case Report and Literature Review. Int J Gen Med 2020; 13:771-774. [PMID: 33116768 PMCID: PMC7547762 DOI: 10.2147/ijgm.s279226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 09/24/2020] [Indexed: 11/23/2022] Open
Abstract
Arteriovenous malformation (AVM) fed by the artery of Percheron (AOP) is extremely rare, with only one case described in the literature to date. We herein present a case of a 43-year-old female with hemorrhagic thalamic AVM mainly supplied by the AOP, who subsequently underwent conservative management and recovered well except for mild right hemiparesis. This case highlights that the AOP is a rarely recognized but clinically significant entity and should be identified when dealing with AOP-associated neurovascular disorder as described.
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Affiliation(s)
- Mengchao Zhang
- Department of Radiology, China-Japan Union Hospital of Jilin University, Changchun, Mainland China
| | - Zheng Feng
- Department of Pediatrics, China-Japan Union Hospital of Jilin University, Changchun, Mainland China
| | - Weidong Yu
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, Mainland China
| | - Chao Fu
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Changchun, Mainland China
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64
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Burkhardt JK, Winkler EA, Catapano JS, Spetzler RF, Lawton MT. Surgical selection and outcomes among elderly patients with brain arteriovenous malformations. Neurosurg Focus 2020; 49:E9. [PMID: 33512984 DOI: 10.3171/2020.7.focus20464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Studies of resection of brain arteriovenous malformations (AVMs) in the elderly population are scarce. This study examined factors influencing patient selection and surgical outcome among elderly patients. METHODS Patients 65 years of age and older who underwent resection of an unruptured or ruptured brain AVM treated by two surgeons at two centers were identified. Patient demographic characteristics, AVM characteristics, clinical presentation, and outcomes measured using the modified Rankin Scale (mRS) were analyzed. For subgroup analyses, patients were dichotomized into two age groups (group 1, 65-69 years old; group 2, ≥ 70 years old). RESULTS Overall, 112 patients were included in this study (group 1, n = 61; group 2, n = 51). Most of the patients presented with hemorrhage (71%), a small nidus (< 3 cm, 79%), and a low Spetzler-Martin (SM) grade (grade I or II, 63%) and were favorable surgical candidates according to the supplemented SM grade (supplemented SM grade < 7, 79%). A smaller AVM nidus was statistically significantly more likely to be present in patients with infratentorial AVMs (p = 0.006) and with a compact AVM nidus structure (p = 0.02). A larger AVM nidus was more likely to be treated with preoperative embolization (p < 0.001). Overall outcome was favorable (mRS scores 0-3) in 71% of the patients and was statistically independent from age group or AVM grading. Patients with ruptured AVMs at presentation had significantly better preoperative mRS scores (p < 0.001) and more favorable mRS scores at the last follow-up (p = 0.04) than patients with unruptured AVMs. CONCLUSIONS Outcomes were favorable after AVM resection in both groups of patients. Elderly patients with brain AVMs treated microsurgically were notable for small nidus size, AVM rupture, and low SM grades. Microsurgical resection is an important treatment modality for elderly patients with AVMs, and supplemented SM grading is a useful tool for the selection of patients who are most likely to achieve good neurological outcomes after resection. ABBREVIATIONS AVM = arteriovenous malformation; BNI = Barrow Neurological Institute; LY = Lawton-Young; mRS = modified Rankin Scale; SM = Spetzler-Martin; supp-SM = supplemented SM; UCSF = University of California, San Francisco.
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Affiliation(s)
- Jan-Karl Burkhardt
- Department of Neurosurgery, Baylor College of Medicine Medical Center, Houston, Texas
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Qiao X, Zhang D, Zhang L, Yao J, Wu X, Cai X, Boström KI, Yao Y. Pronethalol decreases RBPJκ to reduce Sox2 in cerebral arteriovenous malformation. Vasc Med 2020; 25:569-571. [PMID: 32833597 DOI: 10.1177/1358863x20942833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Xiaojing Qiao
- Division of Cardiology, David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Daoqin Zhang
- Division of Cardiology, David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Li Zhang
- Division of Cardiology, David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Jiayi Yao
- Division of Cardiology, David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Xiuju Wu
- Division of Cardiology, David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Xinjiang Cai
- Division of Cardiology, David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Kristina I Boström
- Division of Cardiology, David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, CA, USA
- The Molecular Biology Institute at UCLA, Los Angeles, CA, USA
| | - Yucheng Yao
- Division of Cardiology, David Geffen School of Medicine at University of California Los Angeles (UCLA), Los Angeles, CA, USA
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Wang AT, Pillai P, Guran E, Carter H, Minasian T, Lenart J, Vandse R. Anesthetic Management of Awake Craniotomy for Resection of the Language and Motor Cortex Vascular Malformations. World Neurosurg 2020; 143:e136-e148. [PMID: 32736129 DOI: 10.1016/j.wneu.2020.07.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/09/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although the safety and feasibility of awake craniotomy are well established for epilepsy and brain tumor surgery, its application for resection of vascular lesions, including arteriovenous malformations (AVMs) and cavernomas, is still limited. Apart from the usual challenges of awake craniotomy, vascular lesions pose several additional problems. Our goal is to determine the safety and practicality of awake craniotomy in patients with cerebral vascular malformations located near the eloquent areas, using a refined anesthetic protocol. METHODS A retrospective case series was performed on 7 patients who underwent awake craniotomy for resection of AVMs or cavernomas located in the eloquent language and motor areas. Our protocol consisted of achieving deep sedation, without a definitive airway, using a combination of propofol, dexmedetomidine, and remifentanil/fentanyl during scalp block placement and surgical exposure, then transitioning to a wakeful state during the resection. RESULTS Six patients had intracranial AVMs, and 1 patient had a cavernoma. Six patients had complete resection; however, 1 patient underwent repeat awake craniotomy for residual AVM nidus. The patients tolerated the resection under continuous awake neurologic and neurophysiologic testing without significant perioperative complications or the need to convert to general anesthesia with a definitive airway. CONCLUSIONS Awake craniotomy for excision of intracranial vascular malformations located near the eloquent areas, in carefully selected patients, can facilitate resection by allowing close neuromonitoring and direct functional assessment. A balanced combination of sedative and analgesic medications can provide both adequate sedation and rapid wakeup, facilitating the necessary patient interaction and tolerance of the procedure.
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Affiliation(s)
- Annie Ting Wang
- Departments of Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Promod Pillai
- Departments of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Elyse Guran
- Departments of Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Harmony Carter
- Departments of Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Tanya Minasian
- Departments of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - John Lenart
- Departments of Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Rashmi Vandse
- Departments of Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA.
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Zhang C, Chau N, Ho H. Patient-Specific Blood Flow Analysis for Cerebral Arteriovenous Malformation Based on Digital Subtraction Angiography Images. Front Bioeng Biotechnol 2020; 8:775. [PMID: 32793568 PMCID: PMC7390970 DOI: 10.3389/fbioe.2020.00775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 06/18/2020] [Indexed: 11/15/2022] Open
Abstract
Real-time digital subtraction angiography (DSA) is capable of revealing the cerebral vascular morphology and blood flow perfusion patterns of arterial venous malformations (AVMs). In this study, we analyze the DSA images of a subject-specific left posterior AVM case and customize a generic electric analog model for cerebral circulation accordingly. The generic model consists of electronic components representing 49 major cerebral arteries and veins, and yields their blood pressure and flow rate profiles. The model was adapted by incorporating the supplying and draining patterns of the AVM to simulate some typical AVM features such as the blood "steal" syndrome, where the flow rate in the left posterior artery increases by almost three times (∼300 ml/min vs 100 ml/min) compared with the healthy case. Meanwhile, the flow rate to the right posterior artery is reduced to ∼30 ml/min from 100 ml/min despite the presence of an autoregulation mechanism in the model. In addition, the blood pressure in the draining veins is increased from 9 to 22 mmHg, and the blood pressure in the feeding arteries is reduced from 85 to 30 mmHg due to the fistula effects of the AVM. In summary, a first DSA-based AVM model has been developed. More subject-specific AVM cases are required to apply the presented in silico model, and in vivo data are used to validate the simulation results.
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Affiliation(s)
- Changwei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Nixon Chau
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Harvey Ho
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
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68
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Peculiar Characteristics of Arteriovenous Malformations Arising in the Galenic Region. Diagnostics (Basel) 2020; 10:diagnostics10070481. [PMID: 32679835 PMCID: PMC7400176 DOI: 10.3390/diagnostics10070481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/11/2020] [Accepted: 07/13/2020] [Indexed: 11/26/2022] Open
Abstract
Arteriovenous malformations (AVM) are congenital vascular lesions fed by arterial feeders originating from branches of the internal carotid artery (ICA) or vertebrobasilar artery. We experienced unique AVMs arising in the midline Galenic region, receiving blood supply from the ICA/vertebral artery systems and the external carotid artery system. We retrospectively reviewed data on eight patients who had an AVM arising in the Galenic region and were treated in the University of Tokyo Hospital between 1990 and 2019. The median age at diagnosis was 62 years. Three cases (38%) presented with obstructive hydrocephalus due to aqueduct obstruction caused by an engorged vein of Galen. In all cases, feeders from dural arteries were present and the vein of Galen was the primary drainer. All patients underwent stereotactic radiosurgery. Five patients were followed for > two years; nidus obliteration was confirmed in one, and > 75% shrinkage was confirmed in three, while one patient died due to hemorrhage. Altogether, AVMs arising in the Galenic region are rare and exhibit several peculiar characteristics including the presence of dural feeders, an older age at presentation and presentation with obstructive hydrocephalus.
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Wright R, Järvelin P, Pekonen H, Keränen S, Rauramaa T, Frösen J. Histopathology of brain AVMs part II: inflammation in arteriovenous malformation of the brain. Acta Neurochir (Wien) 2020; 162:1741-1747. [PMID: 32306161 PMCID: PMC7295713 DOI: 10.1007/s00701-020-04328-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/04/2020] [Indexed: 12/22/2022]
Abstract
Background Hemorrhage from an arteriovenous malformation of the brain (bAVM) has been associated with focal inflammation of the bAVM. Intrigued by the possibility of anti-inflammatory drug therapy to stabilize bAVMs and prevent hemorrhage, we investigated the association of bAVM inflammation with other histological features and clinical presentation. Materials and methods Tissue samples from 85 surgically treated bAVMs were studied with histology and CD45 immunostainings. The histological data was compared with the clinical history of the patient. Univariate analysis and logistic regression were performed. Results Inflammation was found in all studied bAVMs and did not associate with rupture (p = 0.442). While multiple types of inflammatory cells were present, macrophages were clearly the dominant inflammatory cell type, especially in samples with strong inflammation (87% of the samples). Of those bAVMs that had strong inflammation, only 56% had presented with clinically evident rupture. However, hemosiderin which is a sign of prior hemorrhage was detected in 78.4% (58/74) of samples with strong inflammation and was associated with it (p = 0.003). Inflammation in the nidus and parenchyma was associated with perivascular inflammation (p < 0.001). Multivariate analysis did not reveal any independent histological or clinical risk factor for inflammation. Conclusions Since strong inflammation is present in both unruptured and ruptured bAVMs, it is not just a reaction to rupture. Our observations suggest that inflammation of the bAVM may indeed predispose to fragility and hemorrhage of the nidal vessels. Further studies in the role of inflammation in the untreated clinical course of bAVMs are indicated. Electronic supplementary material The online version of this article (10.1007/s00701-020-04328-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Roosa Wright
- Hemorrhagic Brain Pathology Research Group, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Patrik Järvelin
- Hemorrhagic Brain Pathology Research Group, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Henri Pekonen
- Hemorrhagic Brain Pathology Research Group, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Sara Keränen
- Hemorrhagic Brain Pathology Research Group, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- AIV-Institute, University of Eastern Finland, Kuopio, Finland
| | - Tuomas Rauramaa
- Hemorrhagic Brain Pathology Research Group, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Department of Pathology, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Juhana Frösen
- Hemorrhagic Brain Pathology Research Group, NeuroCenter, Kuopio University Hospital, Kuopio, Finland.
- AIV-Institute, University of Eastern Finland, Kuopio, Finland.
- Hemorrhagic Brain Pathology Research Group, University of Tampere, Tampere, Finland.
- Department of Neurosurgery, Tampere University Hospital, Teiskontie 35, PoBox 33521, Tampere, Finland.
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70
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Vollherbst DF, Bendszus M, Möhlenbruch MA. Vascular Malformations of the Brain and Its Coverings. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:285-294. [PMID: 37502170 PMCID: PMC10370599 DOI: 10.5797/jnet.ra.2020-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/19/2020] [Indexed: 07/29/2023]
Abstract
Vascular malformations of the brain and its coverings encompass several different vascular pathologies of the brain and its coverings, which substantially differ in morphology, clinical presentation, and prognosis, reaching from incidental, asymptomatic vascular abnormalities to life-threatening diseases with high risks of morbidity, most frequently caused by intracranial hemorrhage. In this article, the most common vascular malformations of the brain with and without arteriovenous shunting of blood (e.g., arteriovenous malformations [AVMs], dural arteriovenous fistulas [DAVFs], and cavernous malformations) are explained with a focus on definition, diagnosis, classification, and management.
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Affiliation(s)
- Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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71
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Wang LJ, Xue Y, Huo R, Yan Z, Xu H, Li H, Wang J, Zhang Q, Cao Y, Zhao JZ. N6-methyladenosine methyltransferase METTL3 affects the phenotype of cerebral arteriovenous malformation via modulating Notch signaling pathway. J Biomed Sci 2020; 27:62. [PMID: 32384926 PMCID: PMC7210675 DOI: 10.1186/s12929-020-00655-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/23/2020] [Indexed: 02/10/2023] Open
Abstract
Background Cerebral arteriovenous malformation (AVM) is a serious life-threatening congenital cerebrovascular disease. Specific anatomical features, such as nidus size, location, and venous drainage, have been validated to affect treatment outcomes. Until recently, molecular biomarkers and corresponding molecular mechanism related to anatomical features and treatment outcomes remain unknown. Methods RNA N6-methyladenosine (m6A) Methyltransferase METTL3 was identified as a differentially expressed gene in groups with different lesion sizes by analyzing the transcriptome sequencing (RNA-seq) data. Tube formation and wound healing assays were performed to investigate the effect of METTL3 on angiogenesis. In addition, Methylated RNA Immunoprecipitation Sequencing technology (MeRIP-seq) was performed to screen downstream targets of METTL3 in endothelial cells and to fully clarify the specific underlying molecular mechanisms affecting the phenotype of cerebral AVM. Results In the current study, we found that the expression level of METTL3 was reduced in the larger pathological tissues of cerebral AVMs. Moreover, knockdown of METTL3 significantly affected angiogenesis of the human endothelial cells. Mechanistically, down-regulation of METTL3 reduced the level of heterodimeric Notch E3 ubiquitin ligase formed by DTX1 and DTX3L, thereby continuously activating the Notch signaling pathway. Ultimately, the up-regulated downstream genes of Notch signaling pathway dramatically affected the angiogenesis of endothelial cells. In addition, we demonstrated that blocking Notch pathway with DAPT could restore the phenotype of METTL3 deficient endothelial cells. Conclusions Our findings revealed the mechanism by which m6A modification regulated the angiogenesis and might provide potential biomarkers to predict the outcome of treatment, as well as provide suitable pharmacological targets for preventing the formation and progression of cerebral AVM.
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Affiliation(s)
- Lin-Jian Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Yimeng Xue
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Ran Huo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Zihan Yan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hongyuan Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hao Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jia Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qian Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China. .,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China. .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
| | - Ji-Zong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.119 South 4th Ring West Road, Fengtai District, Beijing, 100070, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China. .,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, 100049, China. .,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China. .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
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Tailor C, Ashby WS, Gorassini DR, Lownie SP, Walsh K, Pelz D, Hammond RR. Embolized cerebral arteriovenous malformations: a multivariate analysis of 101 excised specimens. J Neurosurg 2020; 132:1140-1146. [PMID: 30875685 DOI: 10.3171/2018.12.jns182244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 12/12/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Endovascular approaches have evolved from a technique practiced at very few centers to a widely available option in the management of arteriovenous malformations (AVMs) of the central nervous system. Embolization can be employed as definitive therapy or as an adjunct to surgical excision. A wide variety of embolic agents have been successfully developed and used in the clinical setting. In addition to facilitating vascular occlusion, embolic agents induce a number of reactive and destructive changes in vessel walls and the surrounding tissue. However, studies examining the pathological changes induced by different embolic agents and varying times of exposure are scarce. The goal of the present study was to compare embolic agents and time of exposure on the pathology in excised specimens. METHODS The records of the Department of Pathology at the London Health Sciences Centre were searched for embolized AVMs for the 35-year period 1980-2015. All cases were reevaluated for clinical and technical variables and standardized histopathological findings. Cases were grouped by embolic agent, volume of agent used, and time to excision. RESULTS A total of 101 specimens were identified. Embolic agents were invariably associated with a range of pathological findings, some of which may affect the integrity of vessel walls or the reestablishment of flow, thrombosis, acute and chronic inflammatory changes, angionecrosis, extravasation, and recanalization. The type of embolic agent did not predict differences in the incidence or severity of histopathological changes. Larger volumes of embolic agent were associated with a greater proportion of vessels containing embolic material. AVMs excised early (< 1 week postembolization) contained more acute vasculitis, while those excised later (≥ 1 week postembolization) were more likely to exhibit recanalization and foreign body giant cell infiltrates. CONCLUSIONS Embolic agents induce a predictable range and temporal progression of pathological changes in cerebral AVMs. The embolic agents studied are indistinguishable in terms of the range and frequency of pathological reactions induced. Greater volumes of embolic agent are associated with more abundant agent within the lesion, but the proportion of vessels and vascular cross-sectional areas containing agent is small. Several changes are significantly associated with time postembolization. Acute vasculitis is a more common finding in the 1st week, while recanalization and foreign body-type granulomatous inflammation are more common at 1 week and beyond.
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Affiliation(s)
| | | | - Donald R Gorassini
- 3Department of Social Sciences, King's University College, Western University, London, Ontario, Canada
| | | | | | - David Pelz
- 4Clinical Neurological Sciences, and
- 5Medical Imaging, London Health Sciences Centre, Western University, London; and
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73
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Maor GS, Faden MS, Brown R. Prevalence, risk factors and pregnancy outcomes of women with vascular brain lesions in pregnancy. Arch Gynecol Obstet 2020; 301:665-670. [PMID: 32060681 DOI: 10.1007/s00404-020-05451-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 01/23/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Vascular brain lesions (VBL) occur in up to 4.0% of the general population. With the increasing availability and use of sophisticated imaging techniques, there are more patients being diagnosed with asymptomatic intracranial AVMs and cavernous hemangiomas. OBJECTIVES Here we evaluate the association between VBL in pregnancy and the maternal and fetal outcomes. STUDY DESIGN The study cohort was identified by isolating all pregnancies from the nationwide inpatient sample (NIS), from the healthcare cost and utilization project (HCUP) over a five-year period. Within this cohort, cases with an arteriovenous malformation (AVM) or cerebral vascular malformations (CVM) were identified and their prevalence was calculated. Baseline demographic characteristics were compared and the odds ratios for various complications and outcomes were calculated. RESULTS Amongst 4,012,396 deliveries, VBL were identified in 214 cases: a prevalence of 5.33 cases per 100,000 deliveries. Majority of VBL cases were identified in women between 25 and 35 years of age, but the proportion of women aged 35 and older was greater amongst those patients with VBL. 74% of cases were of Caucasian race and more cases with VBL had a private insurance payer (62.1%). Seizure disorders were present in 63.6% of the cases with VBL. Whilst VBL are not associated with unfavorable obstetrical complications, they are more likely to be delivered by caesarean section (CS) - 79% of VBL cases were delivered by CS compared to 33% of the patients without VBL (OR 7.03 CI 95% 4.98-9.92). Instrumental delivery was performed in 10.3% of the vaginal deliveries for index cases. Index cases were less prone to fetal growth restriction. VBL accounted for 8.4% of 166 cases of intracranial bleeding occurring during the antepartum period within the entire pregnant population. CONCLUSIONS Presence of VBL does not appear to carry additional risk to mother or fetus during pregnancy.
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Affiliation(s)
- Gil Shechter Maor
- Department of Obstetrics and Gynecology, Royal Victoria Hospital, McGill University, Montreal, QC, Canada. .,Department of Obstetric and Gynecology, Meir Medical Center, 59 Tcharnichovsky st., Kfar Saba, Israel.
| | - Majed S Faden
- Department of Obstetrics and Gynecology, Royal Victoria Hospital, McGill University, Montreal, QC, Canada.,Department of Maternal Fetal Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Richard Brown
- Department of Obstetrics and Gynecology, Royal Victoria Hospital, McGill University, Montreal, QC, Canada
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74
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Vassallo R, Rankin A, Lownie SP, Fukuda H, Kasuya H, Lo BWY, Peters T, Xiao Y. Determining blood flow direction from short neurovascular surgical microscope videos. Healthc Technol Lett 2020; 6:191-196. [PMID: 32038856 PMCID: PMC6952245 DOI: 10.1049/htl.2019.0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/02/2019] [Indexed: 11/25/2022] Open
Abstract
Neurovascular surgery aims to repair diseased or damaged blood vessels in the brain or spine. There are numerous procedures that fall under this category, and in all of them, the direction of blood flow through these vessels is crucial information. Current methods to determine this information intraoperatively include static pre-operative images combined with augmented reality, Doppler ultrasound, and injectable fluorescent dyes. Each of these systems has inherent limitations. This study includes the proposal and preliminary validation of a technique to identify the direction of blood flow through vessels using only video segments of a few seconds acquired from routinely used surgical microscopes. The video is enhanced to reveal subtle colour fluctuations related to blood pulsation, and these rhythmic signals are further analysed in Fourier space to reveal the direction of blood flow. The proposed method was validated using a novel physical phantom and retrospective analysis of surgical videos and demonstrated high accuracy in identifying the direction of blood flow.
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Affiliation(s)
- Reid Vassallo
- Robarts Research Institute, Western University, London, Canada.,School of Biomedical Engineering, Western University, London, Canada
| | - Adam Rankin
- Robarts Research Institute, Western University, London, Canada
| | - Stephen P Lownie
- Department of Clinical Neurological Sciences, Western University, London, Canada
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kochi University Hospital, Kochi, Japan
| | - Hidetoshi Kasuya
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Benjamin W Y Lo
- Department of Neurosurgery and Neurointensive Care, Lenox Hill Hospital, New York City, USA
| | - Terry Peters
- Robarts Research Institute, Western University, London, Canada.,School of Biomedical Engineering, Western University, London, Canada
| | - Yiming Xiao
- Robarts Research Institute, Western University, London, Canada
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75
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Graffeo CS, Link MJ, Stafford SL, Garces YI, Foote RL, Pollock BE. More II It than Meets the Eye: Outcomes After Single-Fraction Stereotactic Radiosurgery in a Case Series of Low-Grade Arteriovenous Malformations. Oper Neurosurg (Hagerstown) 2020; 18:136-144. [PMID: 31250901 DOI: 10.1093/ons/opz153] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/21/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Surgical resection is typically cited as the optimal treatment of patients with Spetzler-Martin Grade I-II arteriovenous malformation (AVM). OBJECTIVE To report our experience with single-fraction stereotactic radiosurgery (SRS) for Spetzler-Martin Grade I-II AVM. METHODS A prospectively maintained registry was reviewed for patients with nonsyndromic Spetzler-Martin Grade I-II AVM having SRS from 1990 to 2011. Patients with <24 mo of follow-up or prior radiotherapy/SRS were excluded, resulting in a study population of 173 patients. Actuarial analysis was performed using the Kaplan-Meier method, and Cox proportional hazards modeling was performed with excellent outcomes (obliteration without new deficits) as the dependent variable. RESULTS Median post-SRS follow-up was 68 mo (range, 24-275). AVM obliteration was achieved in 132 (76%) after initial SRS. Eleven additional patients achieved obliteration after repeat SRS for an overall obliteration rate of 83%. The rate of obliteration was 60% at 4 yr and 78% at 8 yr. Post-SRS hemorrhage occurred in 7 patients (4%), resulting in 3 minor deficits (2%) and 1 death (<1%). Radiation-induced complications occurred in 5 patients (3%), resulting in minor deficits only. One hundred and thirty-seven patients (79%) had excellent outcomes at last follow-up. CONCLUSION SRS is a safe and effective treatment for patients with Spetzler-Martin Grade I-II AVM. Selection bias is likely a contributing factor to explain the superior outcomes generally noted in reported series of microsurgery for patients with low grade AVM.
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Affiliation(s)
- Christopher S Graffeo
- Department of Neurological Surgery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Michael J Link
- Department of Neurological Surgery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.,Department of Otorhinolaryngology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Scott L Stafford
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Yolanda I Garces
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.,Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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76
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Hasegawa H, Yamamoto M, Shin M, Barfod BE. Gamma Knife Radiosurgery For Brain Vascular Malformations: Current Evidence And Future Tasks. Ther Clin Risk Manag 2019; 15:1351-1367. [PMID: 31819462 PMCID: PMC6874113 DOI: 10.2147/tcrm.s200813] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/22/2019] [Indexed: 12/25/2022] Open
Abstract
Gamma Knife radiosurgery (GKRS) has long been used for treating brain vascular malformations, including arteriovenous malformations (AVMs), dural arteriovenous fistulas (DAVFs), and cavernous malformations (CMs). Herein, current evidence and controversies regarding the role of stereotactic radiosurgery for vascular malformations are described. 1) It has already been established that GKRS achieves 70–85% obliteration rates after a 3–5-year latency period for small to medium-sized AVMs. However, late radiation-induced adverse events (RAEs) including cyst formation, encapsulated hematoma, and tumorigenesis have recently been recognized, and the associated risks, clinical courses, and outcomes are under investigation. SRS-based therapeutic strategies for relatively large AVMs, including staged GKRS and a combination of GKRS and embolization, continue to be developed, though their advantages and disadvantages warrant further investigation. The role of GKRS in managing unruptured AVMs remains controversial since a prospective trial showed no benefit of treatment, necessitating further consideration of this issue. 2) Regarding DAVFs, GKRS achieves 41–90% obliteration rates at the second post-GKRS year with a hemorrhage rate below 5%. Debate continues as to whether GKRS might serve as a first-line solo therapeutic modality given its latency period. Although the post-GKRS outcomes are thought to differ among lesion locations, further outcome analyses regarding DAVF locations are required. 3) GKRS is generally accepted as an alternative for small or medium-sized CMs in which surgery is considered to be too risky. The reported hemorrhage rates ranged from 0.5–5% after GKRS. Higher dose treatments (>15 Gy) were performed during the learning curve, while, with the current standard treatment, a dose range of 12–15 Gy is generally selected, and has resulted in acceptable complication rates (< 5%). Nevertheless, further elucidation of long-term outcomes is essential.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Bierta E Barfod
- Katsuta Hospital Mito Gamma House, Hitachinaka, Ibaraki, Japan
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Tzikoulis V, Gkantaifi A, Alongi F, Tsoukalas N, Saraireh HH, Charalampakis N, Tzikoulis G, Andreou E, Tsapakidis K, Kardamakis D, Tsanadis K, Kyrgias G, Tolia M. Benign Intracranial Lesions - Radiotherapy: An Overview of Treatment Options, Indications and Therapeutic Results. Rev Recent Clin Trials 2019; 15:93-121. [PMID: 31713498 DOI: 10.2174/1574887114666191111100635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 10/14/2019] [Accepted: 10/26/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Radiation Therapy (RT) is an established treatment option for benign intracranial lesions. The aim of this study is to display an update on the role of RT concerning the most frequent benign brain lesions and tumors. METHODS Published articles about RT and meningiomas, Vestibular Schwannomas (VSs), Pituitary Adenomas (PAs), Arteriovenous Malformations (AVMs) and craniopharyngiomas were reviewed and extracted data were used. RESULTS In meningiomas RT is applied as an adjuvant therapy, in case of patientrefusing surgery or in unresectable tumors. The available techniques are External Beam RT (EBRT) and stereotactic ones such as Stereotactic Radiosurgery (SRS), Fractionated Stereotactic RT (FSRT), Intensity Modulated RT (IMRT) and proton-beam therapy. The same indications are considered in PAs, in which SRS and FSRT achieve excellent tumor control rate (92-100%), acceptable hormone remission rates (>50%) and decreased Adverse Radiation Effects (AREs). Upon tumor growth or neurological deterioration, RT emerges as alone or adjuvant treatment against VSs, with SRS, FSRT, EBRT or protonbeam therapy presenting excellent tumor control growth (>90%), facial nerve (84-100%), trigeminal nerve (74-99%) and hearing (>50%) preservation. SRS poses an effective treatment modality of certain AVMs, demonstrating a 3-year obliteration rate of 80%. Lastly, a combination of microsurgery and RT presents equal local control and 5-year survival rate (>90%) but improved toxicity profile compared to total resection in case of craniopharyngiomas. CONCLUSION RT comprises an effective treatment modality of benign brain and intracranial lesions. By minimizing its AREs with optimal use, RT projects as a potent tool against such diseases.
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Affiliation(s)
- Vasileios Tzikoulis
- School of Health Sciences, Faculty of Medicine, Biopolis, University of Thessaly, Larisa, 41500, Greece
| | - Areti Gkantaifi
- Radiotherapy Department, Interbalkan Medical Center, Thessaloniki, Greece
| | - Filippo Alongi
- Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Nikolaos Tsoukalas
- Oncology Department, Veterans Hospital (NIMTS), 10-12 Monis Petraki Str., 115 21, Athens, Greece
| | - Haytham Hamed Saraireh
- Radiation Oncology Department, Jordanian Royal Medical Services, King Hussein Medical Center, King Abdullah II St 230, Amman, Jordan
| | | | - Georgios Tzikoulis
- Department of Biochemistry and Biotechnology, University of Thessaly, Biopolis, 41500, Larisa, Greece
| | - Emmanouil Andreou
- School of Health Sciences, Faculty of Medicine, Biopolis, University of Thessaly, Larisa, 41500, Greece
| | - Konstantinos Tsapakidis
- Department of Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larisa, Greece
| | - Dimitrios Kardamakis
- Department of Radiation Oncology, Medical School, University of Patras, 265 04, Patra, Greece
| | - Konstantinos Tsanadis
- Department of Radiotherapy/Radiation Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larisa, Biopolis, 41500 Larisa, Greece
| | - George Kyrgias
- Department of Radiotherapy/Radiation Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larisa, Biopolis, 41500 Larisa, Greece
| | - Maria Tolia
- Department of Radiotherapy/Radiation Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larisa, Biopolis, 41500 Larisa, Greece
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Schuss P, Hadjiathanasiou A, Ilic I, Brandecker S, Güresir Á, Vatter H, Güresir E. Risk of Rebleeding in Patients Suffering From Ruptured Brain Arteriovenous Malformations Undergoing Subacute Treatment: A Single-Center Series and Systematic Review of the Literature. World Neurosurg 2019; 134:e610-e615. [PMID: 31678312 DOI: 10.1016/j.wneu.2019.10.148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION The optimal timing for treatment of ruptured brain arteriovenous malformation (BAVM) is still controversial. The present study aims to determine safety of subacute BAVM management in clinically stable patients by identifying the rate of rebleeding. METHODS Patients presenting from 2000 to 2018 with ruptured BAVM who were scheduled for BAVM treatment at least 4 weeks after initial hemorrhage were included in the present study. After neurological rehabilitation of the patient and decreased hemorrhage-induced brain swelling, subacute treatment for the ruptured BAVM was carried out. Primary outcome of the present series was defined as treatment failure resulting from rehemorrhage caused by the ruptured BAVM in patients previously labeled eligible for subacute BAVM treatment. Additionally, we performed a systematic review of the contemporary peer-reviewed literature concerning treatment strategy in patients with ruptured BAVM. RESULTS Fifty-five patients suffering from ruptured BAVM were considered eligible for subacute BAVM treatment at our institution. No patient suffered from early rebleeding before definitive BAVM treatment in our institutional group. Our own patient data were then pooled with data from the literature, resulting in 166 patients suffering from ruptured BAVM who underwent subacute BAVM treatment. Of these, 1 patient (0.6%) suffered from rehemorrhage during the recovery period 130 days after initial BAVM rupture. CONCLUSIONS The present series and systematic review revealed a rehemorrhage rate of 0.6% in patients suffering from ruptured BAVM who underwent subacute treatment. Therefore, subacute treatment of patients with ruptured BAVM seems safe after application of rigorous treatment algorithms to sort out patients with higher risk for rehemorrhage.
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Affiliation(s)
- Patrick Schuss
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany.
| | | | - Inja Ilic
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Simon Brandecker
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Ági Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
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Klostranec JM, Chen L, Mathur S, McDonald J, Faughnan ME, Ratjen F, Krings T. A theory for polymicrogyria and brain arteriovenous malformations in HHT. Neurology 2019; 92:34-42. [PMID: 30584075 DOI: 10.1212/wnl.0000000000006686] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 08/14/2018] [Indexed: 01/11/2023] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT) is generally considered a disorder of endothelial dysfunction, characterized by the development of multiple systemic arteriovenous malformations (AVMs), including within the brain. However, there have recently been a number of reports correlating HHT with malformations of cortical development, of which polymicrogyria is the most common type. Here we present 7 new cases demonstrating polymicrogyria in HHT, 6 of which demonstrate a brain AVM (bAVM) in close spatial proximity, with the aim of providing a common origin for the association. Upon reviewing patient genetics and imaging data and comparing with previously reported findings, we form 2 new conclusions: (1) polymicrogyria in HHT appears exclusively associated with a subset of mutations in the transmembrane protein endoglin that is involved with blood flow-related mechanotransduction signaling during angiogenesis and (2) the polymicrogyria is characteristically unilateral, typically focal, and correlates with vascular regions experiencing low fluid shear stress during corticogenesis in utero. Integrating these with findings in the literature from genetics and molecular biology experiments, we propose a theory suggesting haploinsufficient endoglin mutations, especially those that are dominant-negative, may predispose focal, aberrant hypersprouting angiogenesis during corticogenesis that leads to the production of polymicrogyria. This hypoxic insult may further serve as the revealing trigger for later development of a spatially coincident bAVM. This hypothesis suggests an essential role for endoglin-mediated hemodynamic mechanotransduction in normal corticogenesis.
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Affiliation(s)
- Jesse M Klostranec
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Long Chen
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Shobhit Mathur
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Jamie McDonald
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Marie E Faughnan
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Felix Ratjen
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada
| | - Timo Krings
- From the Department of Medical Imaging (J.M.K., L.C., S.M., T.K.), Division of Respirology (M.E.F.) and Department of Paediatrics (F.R.), Department of Medicine, and Division of Neurosurgery (T.K.), Department of Surgery, University of Toronto; Division of Neuroradiology (J.M.K., L.C., S.M., T.K.), Toronto Western Hospital, University Health Network, Canada; Departments of Radiology and Pathology (J.M.), University of Utah School of Medicine, Salt Lake City; Toronto HHT Centre, Division of Respirology, Department of Medicine, and Li Ka Shing Knowledge Institute (M.E.F.), St. Michael's Hospital, Toronto; and Division of Respiratory Medicine (F.R.), the Hospital for Sick Children, Toronto, Canada.
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Biondetti E, Rojas-Villabona A, Sokolska M, Pizzini FB, Jäger HR, Thomas DL, Shmueli K. Investigating the oxygenation of brain arteriovenous malformations using quantitative susceptibility mapping. Neuroimage 2019; 199:440-453. [DOI: 10.1016/j.neuroimage.2019.05.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/23/2019] [Accepted: 05/06/2019] [Indexed: 02/07/2023] Open
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Feghali J, Huang J. Updates in arteriovenous malformation management: the post-ARUBA era. Stroke Vasc Neurol 2019; 5:34-39. [PMID: 32411406 PMCID: PMC7213498 DOI: 10.1136/svn-2019-000248] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 05/31/2019] [Accepted: 09/03/2019] [Indexed: 11/04/2022] Open
Abstract
Brain arteriovenous malformations (AVMs) are complex and heterogeneous lesions that can rupture, causing significant morbidity and mortality. While ruptured lesions are usually treated, the management of unruptured AVMs remains unclear. A Randomized trial of Unruptured Brain Arteriovenous Malformations (ARUBA) was the first trial conducted to compare the effects of medical and interventional therapy. Although it concluded that medical therapy was superior in preventing stroke and death over a follow-up period of 33 months, the findings were met with intense criticism regarding several aspects of study design, progression, and analysis/conclusion. Namely, the increased use of stand-alone embolisation relative to microsurgery in a cohort with predominantly low-grade lesions combined with a short follow-up period amplified treatment risk. Subsequently, several observational studies were conducted on ARUBA-eligible patients to investigate the safety and efficacy of microsurgery, radiosurgery, and endovascular embolisation over longer follow-up periods. These reports showed that favourable safety profiles and cure rates can be achieved with appropriate patient selection and judicious use of different treatment modalities in multidisciplinary centres. Since large prospective randomised trials on AVMs may not be feasible, it is important to make use of practice-based data beyond the flawed ARUBA study to optimise patients' lifetime outcomes.
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Affiliation(s)
- James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Zaki Ghali MG, Kan P, Britz GW. Curative Embolization of Arteriovenous Malformations. World Neurosurg 2019; 129:467-486. [DOI: 10.1016/j.wneu.2019.01.166] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
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83
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Hu J, Albadawi H, Oklu R, Chong BW, Deipolyi AR, Sheth RA, Khademhosseini A. Advances in Biomaterials and Technologies for Vascular Embolization. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2019; 31:e1901071. [PMID: 31168915 PMCID: PMC7014563 DOI: 10.1002/adma.201901071] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/24/2019] [Indexed: 05/03/2023]
Abstract
Minimally invasive transcatheter embolization is a common nonsurgical procedure in interventional radiology used for the deliberate occlusion of blood vessels for the treatment of diseased or injured vasculature. A wide variety of embolic agents including metallic coils, calibrated microspheres, and liquids are available for clinical practice. Additionally, advances in biomaterials, such as shape-memory foams, biodegradable polymers, and in situ gelling solutions have led to the development of novel preclinical embolic agents. The aim here is to provide a comprehensive overview of current and emerging technologies in endovascular embolization with respect to devices, materials, mechanisms, and design guidelines. Limitations and challenges in embolic materials are also discussed to promote advancement in the field.
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Affiliation(s)
- Jingjie Hu
- Division of Vascular & Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
| | - Hassan Albadawi
- Division of Vascular & Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
| | - Rahmi Oklu
- Division of Vascular & Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
| | - Brian W Chong
- Departments of Radiology and Neurological Surgery, Mayo Clinic, 13400 East Shea Blvd., Scottsdale, Arizona 85259, USA
| | - Amy R. Deipolyi
- Department of Interventional Radiology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical Center, 1275 York Avenue, New York, New York 10065, USA
| | - Rahul A. Sheth
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77054, USA
| | - Ali Khademhosseini
- Department of Bioengineering, Department of Radiological Sciences, Department of Chemical and Biomolecular Engineering, Center for Minimally Invasive Therapeutics, California Nanosystems Institute, University of California, 410 Westwood Plaza, Los Angeles, California 90095, USA
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84
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Sappenfield EC, Jha RT, Agazzi S, Ros S. Cerebral arteriovenous malformation rupture in pregnancy. BMJ Case Rep 2019; 12:e225811. [PMID: 31340940 PMCID: PMC6663161 DOI: 10.1136/bcr-2018-225811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2019] [Indexed: 11/04/2022] Open
Abstract
A 30-year-old nulliparous woman at 38 5/7 weeks of gestation developed a sudden, severe headache at work and subsequent loss of consciousness. She underwent evaluation in the emergency department. CT and CT angiogram head revealed a large intraparenchymal haematoma with intraventricular extension secondary to ruptured cerebral arteriovenous malformation (cAVM). She was intubated and transferred to a tertiary care centre. The patient underwent caesarean section followed by partial embolisation of the cAVM with planned second embolisation and resection 1 week later. Due to drowsiness and headache, the planned repeat embolisation and cAVM resection were performed 3 days earlier. The patient had a full recovery. Emergency medicine physicians and obstetrician-gynaecologists should be familiar with differential diagnosis of sudden headache in pregnancy and signs of a ruptured cAVM to facilitate early diagnosis, multidisciplinary team approach and timely treatment. Early diagnosis and management of ruptured cAVM are important due to associated morbidity and mortality.
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Affiliation(s)
| | - R Tushar Jha
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Siviero Agazzi
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Stephanie Ros
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, USA
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85
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Yao J, Wu X, Zhang D, Wang L, Zhang L, Reynolds EX, Hernandez C, Boström KI, Yao Y. Elevated endothelial Sox2 causes lumen disruption and cerebral arteriovenous malformations. J Clin Invest 2019; 129:3121-3133. [PMID: 31232700 DOI: 10.1172/jci125965] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 04/23/2019] [Indexed: 12/14/2022] Open
Abstract
Lumen integrity in vascularization requires fully differentiated endothelial cells (ECs). Here, we report that endothelial-mesenchymal transitions (EndMTs) emerged in ECs of cerebral arteriovenous malformation (AVMs) and caused disruption of the lumen or lumen disorder. We show that excessive Sry-box 2 (Sox2) signaling was responsible for the EndMTs in cerebral AVMs. EC-specific suppression of Sox2 normalized endothelial differentiation and lumen formation and improved the cerebral AVMs. Epigenetic studies showed that induction of Sox2 altered the cerebral-endothelial transcriptional landscape and identified jumonji domain-containing protein 5 (JMJD5) as a direct target of Sox2. Sox2 interacted with JMJD5 to induce EndMTs in cerebral ECs. Furthermore, we utilized a high-throughput system to identify the β-adrenergic antagonist pronethalol as an inhibitor of Sox2 expression. Treatment with pronethalol stabilized endothelial differentiation and lumen formation, which limited the cerebral AVMs.
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Affiliation(s)
- Jiayi Yao
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Xiuju Wu
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Daoqin Zhang
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Lumin Wang
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Department of Cell Biology and Genetics, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Li Zhang
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Eric X Reynolds
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Carlos Hernandez
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Kristina I Boström
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,The Molecular Biology Institute at UCLA, Los Angeles, California, USA
| | - Yucheng Yao
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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86
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Abstract
Background and Purpose- The management of unruptured brain arteriovenous malformations remains unclear. Using a large cohort to determine risk factors predictive of hemorrhagic presentation of arteriovenous malformations, this study aims to develop a predictive tool that could guide hemorrhage risk stratification. Methods- A database of 789 arteriovenous malformation patients presenting to our institution between 1990 and 2017 was used. A hold-out method of model validation was used, whereby the data was randomly split in half into training and validation data sets. Factors significant at the univariable level in the training data set were used to construct a model based on multivariable logistic regression. Model performance was assessed using receiver operating curves on the training, validation, and complete data sets. The predictors and the complete data set were then used to derive a risk prediction formula and a practical scoring system, where every risk factor was worth 1 point except race, which was worth 2 points (total score varies from 0 to 6). The factors are summarized by R2eD arteriovenous malformation (acronym: R2eD AVM). Results- In 755 patients with complete data, 272 (36%) presented with hemorrhage. From the training data set, a model was derived containing the following risk factors: nonwhite race (odds ratio [OR]=1.8; P=0.02), small nidus size (OR=1.47; P=0.14), deep location (OR=2.3; P<0.01), single arterial feeder (OR=2.24; P<0.01), and exclusive deep venous drainage (OR=2.07; P=0.02). Area under the curve from receiver operating curve analysis was 0.702, 0.698, and 0.685 for the training, validation, and complete data sets, respectively. In the entire study population, the predicted probability of hemorrhagic presentation increased in a stepwise manner from 16% for patients with no risk factors (score of 0) to 78% for patients having all the risk factors (score of 6). Conclusions- The final model derived from this study can be used as a predictive tool that supplements clinical judgment and aids in patient counseling.
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Affiliation(s)
- James Feghali
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wuyang Yang
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Risheng Xu
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jason Liew
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Cameron G McDougall
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Justin M Caplan
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rafael J Tamargo
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Judy Huang
- From the Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Torres-Quinones C, Koch MJ, Raymond SB, Patel A. Left Thalamus Arteriovenous Malformation Secondary to Radiation Therapy of Original Vermian Arteriovenous Malformation: Case Report. J Stroke Cerebrovasc Dis 2019; 28:e53-e59. [PMID: 30975463 DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/04/2019] [Accepted: 03/13/2019] [Indexed: 10/27/2022] Open
Abstract
A 70-year-old gentleman with history of hypothyroidism, hyperlipidemia, hypertension, and right superior cerebellar aneurysm presented to the neurosurgery service in 2008 with vertigo. Diagnostic cerebral angiography performed that year demonstrated a vermian arteriovenous malformations (AVM). The patient underwent stereotactic proton beam radiosurgery, which resulted in a decrease in flow and size of the lesion, and the patient was lost to follow-up. Now at the age of 80, the patient presented with acute gait instability. Cerebral angiogram demonstrated his stable vermian AVM and a new 1.1 cm AVM nidus in the region of the left posterior thalamus. Although AVMs are often described as congenital lesions, there is a growing body of literature suggesting that AVMs can grow, spontaneously regress, and even arise de novo in response to some insult. Understanding what leads to the growth, remodeling, regression, and hemorrhage of AVMs is crucial in order to better direct therapeutic endeavors. We would argue that this patient's AVM is secondary to endothelial cell damage from radiation therapy. Radiation can cause endothelial cell injury and upregulation of factors, such as vascular endothelial growth factor and transforming growth factor beta expression, which are implicated in AVM development pathways. We believe that this patient's new AVM is secondary to entrance radiation dosing affecting the thalamus during radiation therapy for the original vermian AVM.
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Affiliation(s)
- Carlos Torres-Quinones
- Department of Neurosurgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.
| | - Matthew J Koch
- Department of Neurosurgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.
| | - Scott B Raymond
- Department of Neurosurgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.
| | - Aman Patel
- Department of Neurosurgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.
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Abstract
IMPORTANCE Although spontaneous intraparenchymal hemorrhage (IPH) accounts for less than 20% of cases of stroke, it continues to be associated with the highest mortality of all forms of stroke and substantial morbidity rates. OBSERVATIONS Early identification and management of IPH is crucial. Blood pressure control, reversal of associated coagulopathy, care in a dedicated stroke unit, and identification of secondary etiologies are essential to optimizing outcomes. Surgical management of hydrocephalus and space occupying hemorrhage in the posterior fossa are accepted forms of treatment. Modern advances in minimally invasive surgical management of primary, supratentorial IPH are being explored in randomized trials. Hemorrhagic arteriovenous malformations and cavernous malformations are surgically excised if accessible, while hemorrhagic dural arteriovenous fistulas and distal/mycotic aneurysms are often managed with embolization if feasible. CONCLUSIONS AND RELEVANCE IPH remains a considerable source of neurological morbidity and mortality. Rapid identification, medical management, and neurosurgical management, when indicated, are essential to facilitate recovery. There is ongoing evaluation of minimally invasive approaches for evacuation of primary IPH and evolution of surgical and endovascular techniques in the management of lesions leading to secondary IPH.
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Affiliation(s)
- Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Brian T Jankowitz
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert M Friedlander
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Abstract
PURPOSE OF REVIEW Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant inherited disease characterized by telangiectasia and arteriovenous malformations (AVMs). To date, five genetic types of HHT and one combined juvenile polyposis syndrome and HHT are known. Clinical and genetic screening of patients suspected with HHT is recommended to confirm the diagnosis and to prevent complications associated with HHT. The aim of this article is to give an overview of the evidence and to formulate a recommendation for clinicians concerning screening for HHT. RECENT FINDINGS Complications of HHT such as stroke, brain abscess and intracranial hemorrhage are caused by pulmonary and cerebral AVMs (CAVMs) and can often be prevented by screening and treatment when possible. Screening and treatment of these AVMs will result in an increased life expectancy comparable with that of the general population as opposed to unscreened and untreated HHT patients. SUMMARY Screening of HHT patients and their first-degree relatives is recommended to prevent severe complications including stroke, brain abscess and intracranial hemorrhage.
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90
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Kocer N, Kandemirli SG, Dashti R, Kizilkilic O, Hanimoglu H, Sanus GZ, Tunali Y, Tureci E, Islak C, Kaynar MY. Single-stage planning for total cure of grade III-V brain arteriovenous malformations by embolization alone or in combination with microsurgical resection. Neuroradiology 2018; 61:195-205. [PMID: 30488257 DOI: 10.1007/s00234-018-2140-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 11/16/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE There are no established guidelines for treatment of Spetzler-Martin grade III-V brain arteriovenous malformations (bAVMs). The purpose of this study is to report our institutional experience in total obliteration/eradication of grade III-V bAVMs by single-stage planning of embolization combined with microsurgical resection when necessary. METHODS All patients harboring Spetzler-Martin (S-M) grade III-V bAVMs treated with single-stage planning between January 2006 and January 2018 were retrospectively reviewed. This treatment paradigm is applicable only to surgically accessible bAVMs and does not include deep-seated bAVMs. Indications for treatment, clinical presentation, imaging characteristics, and treatment outcomes were analyzed. Outcomes were assessed based on modified Rankin Scale. RESULTS A total of 31 patients were identified. Seventeen patients (54.8%) presented with hemorrhage, 10 (32.3%) with seizures, 3 (9.7%) with headaches, and 1 (3.2%) with progressive neurological deficit. Based on S-M grading system, 25 patients (80.6%) harbored grade III bAVM, 5 patients had grade IV bAVMs (16.1%), and 1 patient (3.2%) had a grade V bAVM. There were no treatment-related complications in 24/31 (77.4%) patients. Of the total of seven patients with complications, four patients had clinical deterioration. The long-term (> 6-month), non-disabling morbidity (mRS ≤ 2) rate was 6.5%. The long-term, disabling morbidity rate was 3.2% with a mortality of 3.2%. Complete angiographic obliteration was achieved in 30/31 (96.8%) patients. CONCLUSION Single-stage treatment strategy can be considered as an alternative to multistage embolization prior to surgery in grade III-V bAVMs. In this study, a high rate of total obliteration with relatively low rates of permanent morbidity and mortality was achieved.
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Affiliation(s)
- Naci Kocer
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey.
| | - Sedat Giray Kandemirli
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey
| | - Reza Dashti
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Osman Kizilkilic
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey
| | - Hakan Hanimoglu
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Galip Zihni Sanus
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Yusuf Tunali
- Department of Anesthesiology and Reanimation, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ercan Tureci
- Department of Anesthesiology and Reanimation, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Civan Islak
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa, 34098, Istanbul, Turkey
| | - Mehmet Yasar Kaynar
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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Burkhardt JK, Lasker GF, Winkler EA, Kim H, Lawton MT. Microsurgical resection of brain arteriovenous malformations in the elderly: outcomes analysis and risk stratification. J Neurosurg 2018; 129:1107-1113. [PMID: 29271715 PMCID: PMC6816804 DOI: 10.3171/2017.6.jns17392] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 06/19/2017] [Indexed: 11/06/2022]
Abstract
As the population ages, the question of how to manage brain arteriovenous malformations in the elderly becomes increasingly relevant. Is resection a reasonable option for these patients? In this study, the authors examined the outcomes of surgical patients 60 years or older and found that favorable outcomes were achieved with careful patient selection. Preoperative grading scales were more predictive of outcomes in patients older than 65 years than in those 60-65 years of age.
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Saad AF, Chaudhari R, Fischbein NJ, Wintermark M. Intracranial Hemorrhage Imaging. Semin Ultrasound CT MR 2018; 39:441-456. [DOI: 10.1053/j.sult.2018.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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93
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Diyora B, Patil S, Bhende B, Nayak N. Cerebral Arteriovenous Malformation Associated with a Cyst. J Neurosci Rural Pract 2018; 9:420-422. [PMID: 30069104 PMCID: PMC6050771 DOI: 10.4103/jnrp.jnrp_534_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
An 11-year-old child presented with chronic occipital headache and vomiting. Computed tomography (CT) scan revealed a cystic mass lesion in the right occipital region. Magnetic resonance imaging brain revealed a cystic mass lesion which was hypointense on T1-weighted images and hyperintense on T2-weighted images. A mural nodule was noted in the inferolateral wall of the lesion. CT angiography revealed small arteriovenous malformations (AVM) related to the lesion. The AVM associated with the cyst was excised. The patient recovered well. Cystic AVM is a rare vascular lesion, and only five such cases have been reported in the past. AVMs should be considered in the differential diagnosis of cystic lesions of the brain, especially when associated with a mural nodule.
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Affiliation(s)
- Batuk Diyora
- Department of Neurosurgery, LTMMC and LTMG Hospital, Mumbai, Maharashtra, India
| | - Swapnil Patil
- Department of Neurosurgery, LTMMC and LTMG Hospital, Mumbai, Maharashtra, India
| | - Bhagyashri Bhende
- Department of Neurosurgery, LTMMC and LTMG Hospital, Mumbai, Maharashtra, India
| | - Naren Nayak
- Department of Neurosurgery, LTMMC and LTMG Hospital, Mumbai, Maharashtra, India
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A Comprehensive Study of Symptomatic Late Radiation-Induced Complications After Radiosurgery for Brain Arteriovenous Malformation: Incidence, Risk Factors, and Clinical Outcomes. World Neurosurg 2018; 116:e556-e565. [DOI: 10.1016/j.wneu.2018.05.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/04/2018] [Accepted: 05/05/2018] [Indexed: 11/20/2022]
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95
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Maekawa H, Terada A, Ishiguro T, Komiyama M, Lenck S, Renieri L, Krings T. Recurrent periventricular hemorrhage in cerebral proliferative angiopathy: Case report. Interv Neuroradiol 2018; 24:713-717. [PMID: 29991310 DOI: 10.1177/1591019918787265] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Cerebral proliferative angiopathy (CPA) is a rare vascular lesion. Bleeding from CPA is uncommon, but the risk of rebleeding is high once it bleeds. We describe a case of CPA with multiple intra- and periventricular hemorrhages during 30-year follow-up. Recurrent bleeding in these areas are common in moyamoya disease. These lesions may share the cause of bleeding: proliferation of the periventricular vessels functioning as collateral pathways. Revascularization surgery for CPA may attenuate the vascular proliferation in the vicinity of the ventricle, which may prevent rebleeding.
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Affiliation(s)
- Hidetsugu Maekawa
- 1 Division of Neuroradiology, Joint Department of Medical Imaging, University Health Network, Toronto Western Hospital, Canada
| | - Aiko Terada
- 2 Department of Neurointervention, Osaka City General Hospital, Japan
| | - Tomoya Ishiguro
- 2 Department of Neurointervention, Osaka City General Hospital, Japan
| | - Masaki Komiyama
- 2 Department of Neurointervention, Osaka City General Hospital, Japan
| | - Stephanie Lenck
- 1 Division of Neuroradiology, Joint Department of Medical Imaging, University Health Network, Toronto Western Hospital, Canada
| | - Leornardo Renieri
- 1 Division of Neuroradiology, Joint Department of Medical Imaging, University Health Network, Toronto Western Hospital, Canada
| | - Timo Krings
- 1 Division of Neuroradiology, Joint Department of Medical Imaging, University Health Network, Toronto Western Hospital, Canada
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96
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Vollherbst DF, Otto R, Do T, Kauczor HU, Bendszus M, Sommer CM, Möhlenbruch MA. Imaging artifacts of Onyx and PHIL on conventional CT, cone-beam CT and MRI in an animal model. Interv Neuroradiol 2018; 24:693-701. [PMID: 29973083 DOI: 10.1177/1591019918782692] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE A frequently reported drawback of ethylene vinyl alcohol copolymer-based liquid embolic agents is the production of artifacts in diagnostic imaging. New embolic agents, such as Precipitating hydrophobic injectable liquid (PHIL; MicroVention, Tustin, CA, USA), are supposed to induce significantly fewer artifacts. The purpose of this study is to assess the degree of artifacts induced by the liquid embolic agents Onyx (Medtronic Neurovascular, Irvine, CA, USA) and PHIL in conventional computed tomography (CT), cone-beam CT and magnetic resonance imaging (MRI) in an experimental in vivo model. MATERIALS AND METHODS In 10 pigs the rete mirabile was embolized with Onyx ( n = 5) or PHIL ( n = 5). After embolization, conventional CT, cone-beam CT and MRI were performed. The degree of artifacts was graded qualitatively (five-point scale; for CT and MRI) and quantitatively (HUs of well-defined regions of interest (ROIs); for CT only). RESULTS Artifacts were significantly more severe for Onyx both in the qualitative (e.g. conventional CT: 2 versus 5 (medians); p = 0.008) and in the quantitative image analysis (e.g. cone-beam CT: standard deviation of a ROI near to the embolic agent cast, 94 HU versus 38 HU (medians); p = 0.008). Neither Onyx nor PHIL produced any apparent artifacts in MRI. CONCLUSION PHIL produces fewer artifacts than Onyx in conventional CT and cone-beam CT in an experimental in vivo model.
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Affiliation(s)
- Dominik F Vollherbst
- 1 Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany.,2 Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ruth Otto
- 1 Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thuy Do
- 2 Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hans U Kauczor
- 2 Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- 1 Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christof M Sommer
- 2 Clinic for Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany.,3 Clinic for Diagnostic and Interventional Radiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Markus A Möhlenbruch
- 1 Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
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97
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Reseland E, Agarwal N, Lunsford LD, Friedlander RM. Commentary: The Continuing Evolution of the Department of Neurological Surgery at the University of Pittsburgh. Neurosurgery 2018; 82:E125-E131. [DOI: 10.1093/neuros/nyy028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/22/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert M Friedlander
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Spontaneous Cystic Arteriovenous Malformation—A Novel Treatment Alternative. J Stroke Cerebrovasc Dis 2018; 27:517-521. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 08/23/2017] [Accepted: 09/21/2017] [Indexed: 11/15/2022] Open
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Feutren T, Huertas A, Salleron J, Anxionnat R, Bracard S, Klein O, Peiffert D, Bernier-Chastagner V. Modern robot-assisted radiosurgery of cerebral angiomas-own experiences, system comparisons, and comprehensive literature overview. Neurosurg Rev 2017; 41:787-797. [PMID: 29105011 DOI: 10.1007/s10143-017-0926-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 10/07/2017] [Accepted: 10/23/2017] [Indexed: 02/05/2023]
Abstract
Cerebral arteriovenous malformations (AVMs) are rare vascular lesions potentially responsible for substantial neurological morbidity and mortality. Over the past four decades, radiosurgery has become a valid therapeutic option for many patients with small intracranial AVMs, but reports describing the use of robotic stereotactic radiosurgery (SRS) are rare. The purposes of this study are to describe the efficacy and toxicity of robotic SRS for AVMs and to review the literature. The reports of 48 consecutive patients treated with SRS were reviewed. A total dose of 18 Gy in a single fraction was prescribed to the 70% isodose line. Efficacy (i.e., total obliteration of the AVM) and toxicity were analyzed. Literature search was performed on Embase and PubMed for the terms "Radiosurgery and AVMs", "Cyberknife and AVMs" and "Radiation therapy and AVMs." The median follow-up was 41 months. The median AVM volume was 2.62 cm3. The incidence of obliteration was 59% at 3 years. Regarding toxicity, 92% of patients remained symptom-free, 66% developed radiogenic edema on MRI, and none developed radionecrosis. Forty-one patients (85%) had embolization prior to SRS. Our study was incorporated in an exhaustive review of 25 trials categorized by SRS technique. In this review, the median follow-up was 60 months. The median nidus volume was 2 cm3. The median overall obliteration rate for SRS was 68% (range 36 to 92). The median embolization rate prior to SRS was 31% (range 8.23 to 90). Compared to other studies, tolerability was excellent and the obliteration rate was acceptable but probably affected by the high embolization rate prior to radiosurgery. Our study suggests that a higher dose is feasible. A larger cohort with a longer follow-up period will be needed to confirm the safety and effectiveness, and subsequently validate different prognosis and predictive scores with this treatment modality to maximize the benefits of this technology for selected patients in the long term.
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Affiliation(s)
- Thomas Feutren
- Department of Radiotherapy, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne, 54519, Vandœuvre-lès-Nancy, France.
| | - Andres Huertas
- Department of Radiotherapy, Hôpital Européen Georges Pompidou, Paris, France
| | - Julia Salleron
- Department of Biostatistics and Data Management, Institut de Cancérologie de Lorraine, Vandœuvre-lès-Nancy, France
| | - René Anxionnat
- Department of Neuroradiology, Hôpital Central CHU de Nancy, Nancy, France
| | - Serge Bracard
- Department of Neuroradiology, Hôpital Central CHU de Nancy, Nancy, France
| | - Olivier Klein
- Department of Neurosurgery, Hôpital Central CHU de Nancy, Nancy, France
| | - Didier Peiffert
- Department of Radiotherapy, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne, 54519, Vandœuvre-lès-Nancy, France
| | - Valérie Bernier-Chastagner
- Department of Radiotherapy, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne, 54519, Vandœuvre-lès-Nancy, France
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Moon JI, Baek HJ, Ryu KH, Park H. A novel non-contrast-enhanced MRA using silent scan for evaluation of brain arteriovenous malformation: A case report and review of literature. Medicine (Baltimore) 2017; 96:e8616. [PMID: 29137094 PMCID: PMC5690787 DOI: 10.1097/md.0000000000008616] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
RATIONALE Brain arteriovenous malformations (AVMs) are congenital vascular abnormalities involving abnormal connections between arteries and veins. In clinical practice, imaging studies help evaluate feeding arteries, niduses, draining venous systems, and coexisting complications in patients with brain AVM. They also have an impact on decision-making regarding clinical management. We applied a novel non-contrast-enhanced MR angiography (MRA) technique, termed "silent MRA," for evaluating an incidental brain AVM. Here, we describe the clinical case with radiological review and highlight the technical background and clinical usefulness of silent MRA. PATIENT CONCERNS A 60-year-old woman underwent neuroimaging study including MRA to evaluate intracranial cause of headache. DIAGNOSES The brain AVM, including its nidus and draining veins, was conspicuously delineated on silent MRA images; these findings correlated well with conventional angiographic findings. INTERVENTIONS The patient did not receive interventional or surgical treatment. OUTCOMES The patient is being followed up regularly at the outpatient department. LESSONS The silent MRA can be a suitable imaging modality for repeated follow-up evaluation for not only brain AVMs but also various intracranial vascular diseases without the use of contrast materials.
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Affiliation(s)
| | | | | | - Hyun Park
- Department of Neurosurgery, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Seongsan-gu, Changwon, Republic of Korea
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