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Koga T, Shin M, Maruyama K, Terahara A, Saito N. Long-term Outcomes of Stereotactic Radiosurgery for Arteriovenous Malformations in the Thalamus. Neurosurgery 2010; 67:398-403. [PMID: 20644425 DOI: 10.1227/01.neu.0000371989.90956.6f] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Arteriovenous malformations (AVMs) in the thalamus carry a high risk of hemorrhage. Although stereotactic radiosurgery (SRS) is widely accepted because of the high surgical morbidity and mortality of these lesions, precise long-term outcomes are largely unknown.
OBJECTIVE
To review our experience with SRS for thalamic AVMs based on the latest follow-up data.
METHODS
Forty-eight patients with thalamic AVMs were treated by SRS using the Leksell Gamma Knife and were followed. Long-term outcomes including the obliteration rate, hemorrhage after treatment, and adverse effects were retrospectively analyzed.
RESULTS
The annual hemorrhage rate before SRS was 14%. The mean follow-up period after SRS was 66 months (range 6–198 months). The actuarial obliteration rate confirmed by angiography was 82% at 5 years after treatment, and the annual hemorrhage rate after SRS was 0.36%. Factors associated with higher obliteration rates were previous hemorrhage (P = .004) and treatment using new planning software (P = .001). Persistent worsening of neurological symptoms was observed in 17% and more frequently seen in patients who were treated using older planning software (P = .04) and a higher margin dose (P = .02). The morbidity rate for patients who received treatment planned using new software with a margin dose not more than 20 Gy was 12%.
CONCLUSION
SRS for thalamic AVMs achieved a high obliteration rate and effectively decreased the risk of hemorrhage, with less morbidity compared with other modalities. Longer follow-up to evaluate the risk of delayed complications and the effort to minimize the morbidity is necessary.
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Affiliation(s)
- Tomoyuki Koga
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Keisuke Maruyama
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Atsuro Terahara
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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52
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Wegner RE, Oysul K, Pollock BE, Sirin S, Kondziolka D, Niranjan A, Lunsford LD, Flickinger JC. A modified radiosurgery-based arteriovenous malformation grading scale and its correlation with outcomes. Int J Radiat Oncol Biol Phys 2010; 79:1147-50. [PMID: 20605347 DOI: 10.1016/j.ijrobp.2009.12.056] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 12/13/2009] [Accepted: 12/14/2009] [Indexed: 11/16/2022]
Abstract
PURPOSE The Pittsburgh radiosurgery-based arteriovenous malformation (AVM) grading scale was developed to predict patient outcomes after radiosurgery and was later modified with location as a two-tiered variable (deep vs. other). The purpose of this study was to test the modified radiosurgery-based AVM score in a separate set of AVM patients managed with radiosurgery. METHODS AND MATERIALS The AVM score is calculated as follows: AVM score = (0.1)(volume, cc) + (0.02)(age, years) + (0.5)(location; frontal/temporal/parietal/occipital/intraventricular/corpus callosum/cerebellar = 0, basal ganglia/thalamus/brainstem = 1). Testing of the modified system was performed on 293 patients having AVM radiosurgery from 1992 to 2004 at the University of Pittsburgh with dose planning based on a combination of stereotactic angiography and MRI. The median patient age was 38 years, the median AVM volume was 3.3 cc, and 57 patients (19%) had deep AVMs. The median modified AVM score was 1.25. The median patient follow-up was 39 months. RESULTS The modified AVM scale correlated with the percentage of patients with AVM obliteration without new deficits (≤1.00, 62%; 1.01-1.50, 51%; 1.51-2.00, 53%; and >2.00, 32%; F = 11.002, R(2) = 0.8117, p = 0.001). Linear regression also showed a statistically significant correlation between outcome and dose prescribed to the margin (F = 25.815, p <0.001). CONCLUSIONS The modified radiosurgery-based AVM grading scale using location as a two-tiered variable correlated with outcomes when tested on a cohort of patients who underwent both angiography and MRI for dose planning. This system can be used to guide choices among observation, endovascular, surgical, and radiosurgical management strategies for individual AVM patients.
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Affiliation(s)
- Rodney E Wegner
- Department of Radiation Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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53
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Skjøth-Rasmussen J, Roed H, Ohlhues L, Jespersen B, Juhler M. Complications Following Linear Accelerator Based Stereotactic Radiation for Cerebral Arteriovenous Malformations. Int J Radiat Oncol Biol Phys 2010; 77:542-7. [PMID: 19796884 DOI: 10.1016/j.ijrobp.2009.05.048] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Revised: 03/14/2009] [Accepted: 05/05/2009] [Indexed: 11/19/2022]
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54
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Pantelis E, Papadakis N, Verigos K, Stathochristopoulou I, Antypas C, Lekas L, Tzouras A, Georgiou E, Salvaras N. Integration of functional MRI and white matter tractography in stereotactic radiosurgery clinical practice. Int J Radiat Oncol Biol Phys 2010; 78:257-67. [PMID: 20421146 DOI: 10.1016/j.ijrobp.2009.10.064] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 10/19/2009] [Accepted: 10/30/2009] [Indexed: 11/25/2022]
Abstract
PURPOSE To study the efficacy of the integration of functional magnetic resonance imaging (fMRI) and diffusion tensor imaging tractography data into stereotactic radiosurgery clinical practice. METHODS AND MATERIALS fMRI and tractography data sets were acquired and fused with corresponding anatomical MR and computed tomography images of patients with arteriovenous malformation (AVM), astrocytoma, brain metastasis, or hemangioma and referred for stereotactic radiosurgery. The acquired data sets were imported into a CyberKnife stereotactic radiosurgery system and used to delineate the target, organs at risk, and nearby functional structures and fiber tracts. Treatment plans with and without the incorporation of the functional structures and the fiber tracts into the optimization process were developed and compared. RESULTS The nearby functional structures and fiber tracts could receive doses of >50% of the maximum dose if they were excluded from the planning process. In the AVM case, the doses received by the Broadmann-17 structure and the optic tract were reduced to 700 cGy from 1,400 cGy and to 1,200 cGy from 2,000 cGy, respectively, upon inclusion into the optimization process. In the metastasis case, the motor cortex received 850 cGy instead of 1,400 cGy; and in the hemangioma case, the pyramidal tracts received 780 cGy instead of 990 cGy. In the astrocytoma case, the dose to the motor cortex bordering the lesion was reduced to 1,900 cGy from 2,100 cGy, and therefore, the biologically equivalent dose in three fractions was delivered instead. CONCLUSIONS Functional structures and fiber tracts could receive high doses if they were not considered during treatment planning. With the aid of fMRI and tractography images, they can be delineated and spared.
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55
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Qian Y. A New Challenge to Estimate the Rupturing Process of ICA Aneurysms. Interv Neuroradiol 2010. [DOI: 10.1177/15910199100160s114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Y Qian
- Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
- Neurosurgery Department, Jikei University School of Medicine, Tokyo, Japan
- Centre for Advanced Biomedical Science, Tokyo, Japan
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56
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KOGA T, SHIN M, SAITO N. Role of Gamma Knife Radiosurgery in Neurosurgery: Past and Future Perspectives. Neurol Med Chir (Tokyo) 2010; 50:737-48. [DOI: 10.2176/nmc.50.737] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Tomoyuki KOGA
- Department of Neurosurgery, The University of Tokyo Hospital
| | - Masahiro SHIN
- Department of Neurosurgery, The University of Tokyo Hospital
| | - Nobuhito SAITO
- Department of Neurosurgery, The University of Tokyo Hospital
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57
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Gamma knife radiosurgery for arteriovenous malformations of basal ganglia, thalamus and brainstem--a retrospective study comparing the results with that for AVMs at other intracranial locations. Acta Neurochir (Wien) 2009; 151:1575-82. [PMID: 19415175 DOI: 10.1007/s00701-009-0335-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2009] [Accepted: 04/01/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The objective of this retrospective study was to study the outcome in patients with basal ganglia, thalamus and brainstem (central/deep) arteriovenous malformations (AVMs) treated with gamma knife radiosurgery (GKS) and to compare the results with that for AVMs at other intracranial locations. METHODS AND RESULTS The results of 53 patients with central AVMs and 255 patients with AVMs at other locations treated with GKS at our center between April 1997 and March 2005 with minimum follow-up of 1 year were analyzed. CENTRAL AVMS: Forty of these 53 AVMs were Spetzler-Martin grade III, 11 were grade IV, and 2 were grade V. The mean AVM volume was 4.3 cm(3) (range 0.1-36.6 cm(3)). The mean marginal dose given was 23.3 Gy (range 16-25 Gy). The mean follow-up was 28 months (range 12-96 months). Check angiograms were advised at 2 years after GKS and yearly thereafter in the presence of residual AVM till 4 years. Presence of a residual AVM on an angiogram at 4 years after radiosurgery was considered as radiosurgical failure. Complete obliteration of the AVM was documented in 14 (74%) of the 19 patients with complete angiographic follow-up. Significantly lower obliteration rates (37% vs. 100%) were seen in larger AVMs (>3 cm(3)) and AVMs of higher (IV and V) Spetzler-Martin grades (28% vs. 100%). The 3- and 4-year actuarial rates of nidus obliteration were 68% and 74%, respectively. Eight patients (15%) developed radiation edema with a statistically significantly higher incidence in patients with AVM volume >3 cm(3) and in patients with Spetzler-Martin grade IV and V AVMs. Five patients (9.4%) had hemorrhage in the period of latency. COMPARISON OF RESULTS WITH AVMS AT OTHER LOCATIONS: Patients with central AVMs presented at a younger age (mean age 22.7 years vs. 29 years), with a very high proportion (81% vs. 63%) presenting with hemorrhage. Significantly higher incidence of radiation edema (15% vs. 5%) and lower obliteration rates (74% vs. 93%) were seen in patients with central AVMs. CONCLUSIONS GKS is an effective modality of treatment for central AVMs, though relatively lower obliteration rates and higher complication rates are seen compared to AVMs at other locations.
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58
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Beltramello A, Ricciardi GK, Piovan E, Zampieri P, Pasqualin A, Nicolato A, Foroni F, Sala F, Bassi L, Gerosa M. Operative classification of brain arteriovenous malformation. Part two: validation. Interv Neuroradiol 2009; 15:266-74. [PMID: 20465909 DOI: 10.1177/159101990901500303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Accepted: 08/03/2009] [Indexed: 11/15/2022] Open
Abstract
SUMMARY The most important issue when dealing with a patient with a brain AVM is the decision whether to treat or not. Only after this decision has been made, taking into consideration a number of factors depending on both the patient and the specific type of AVM, can the best option for treatment be chosen. An operative classification of brain AVMs, previously adopted in the Department of Neuroradiology and Neurosurgery of Verona (Italy) and published in this journal, was subjected to validation in a consecutive group of 104 patients clinically followed for at least three years after completion of treatment. This classification, slightly modified from the original version concerning the importance of some specific items, allowed us to assess the indication to treat in each case, whatever type of treatment was offered to the patient.
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Affiliation(s)
- A Beltramello
- Neuroradiology Unit, Universitary Hospital of Verona, Italy -
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59
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Sahgal A, Ma L, Chang E, Shiu A, Larson DA, Laperriere N, Yin FF, Tsao M, Menard C, Basran PS, Létourneau D, Heydarian M, Beachey D, Shukla V, Cusimano M, Hodaie M, Zadeh G, Bernstein M, Schwartz M. Advances in technology for intracranial stereotactic radiosurgery. Technol Cancer Res Treat 2009; 8:271-80. [PMID: 19645520 DOI: 10.1177/153303460900800404] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Stereotactic radiosurgery (SRS) refers to a single radiation treatment delivering a high dose to an intra-cranial target localized in three-dimensions by CT and/or MRI imaging. Traditionally, immobilization of the patient's head has been achieved using a rigid stereotactic head frame as the key step in allowing for accurate dose delivery. SRS has been delivered by both Cobalt-60 (Gamma Knife) and linear accelerator (linac) technologies for many decades. The focus of this review is to highlight recent advances and major innovations in SRS technologies relevant to clinical practice and developments allowing for non-invasive frame SRS.
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Affiliation(s)
- Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre, the Princess Margaret Hospital, and the Joey Toby Tanenbaum family Gamma Knife Center, University of Toronto, Toronto, Ontario, Canada.
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60
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Gross BA, Duckworth EAM, Getch CC, Bendok BR, Batjer HH. Challenging traditional beliefs: microsurgery for arteriovenous malformations of the basal ganglia and thalamus. Neurosurgery 2009; 63:393-410; discussion 410-1. [PMID: 18812951 DOI: 10.1227/01.neu.0000316424.47673.03] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Arteriovenous malformations of the basal ganglia and thalamus are often managed with radiosurgery or observation, without consideration of microsurgery. Given the devastating effects of hemorrhage from these lesions, the accumulating evidence that they bleed more frequently than their lobar counterparts should prompt more creative thinking regarding their management. METHODS A review of the endovascular, microsurgical, and radiosurgical literature for arteriovenous malformations of the basal ganglia and thalamus was performed, with close attention to surgical approaches, obliteration rates, and procedure-related complications. RESULTS A complete resection rate of 91% and a mortality rate of 2.4% were found across surgical series of these lesions. These contrast with a 69% rate of complete obliteration and a 5.3% mortality rate (from latency-period hemorrhage) found when compiling results across the radiosurgical literature. CONCLUSION Given an appropriate surgical corridor of access, often afforded by incident hemorrhage, arteriovenous malformations of the basal ganglia and thalamus should be considered for microsurgical extirpation with preoperative embolization. In experienced hands, this approach presents an expeditious and definitive opportunity to eliminate the risk of subsequent hemorrhage and resultant morbidity and mortality.
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Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA
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61
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da Costa L, Wallace MC, ter Brugge KG, O'Kelly C, Willinsky RA, Tymianski M. The Natural History and Predictive Features of Hemorrhage From Brain Arteriovenous Malformations. Stroke 2009; 40:100-5. [PMID: 19008469 DOI: 10.1161/strokeaha.108.524678] [Citation(s) in RCA: 292] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Patients harboring brain arteriovenous malformations (bAVMs) are at a lifelong risk for hemorrhagic strokes, but the natural history is poorly understood. We examined the impact of demographic and angiographic features on the likelihood of future hemorrhage.
Methods—
A prospectively accrued database of bAVM patients maintained at the Toronto Western Hospital was analyzed; 678 consecutive, prospectively enrolled bAVM patients were followed for 1931.7 patient-years. The rate of hemorrhage over long-term follow-up was recorded. The impact of baseline clinical and radiographic features and partial treatment on time to hemorrhage were analyzed using survival analysis. Neurological outcome after hemorrhage was assessed using the Glasgow Outcome Score.
Results—
Hemorrhage rates were 4.61% per year for the entire cohort (n=678), 7.48% per year for bAVMs with initial hemorrhagic presentation (n=258), 4.16% per year for initial seizure presentation (n=260), 3.99% per year for patients not harboring aneurysms (n=556), 6.93% per year for patients with associated aneurysms (n=122), and 5.42% per year for bAVMs with deep venous drainage (n=365). Hemorrhagic presentation was a significant independent predictor of future hemorrhage (HR, 2.15;
P
<0.01), whereas associated aneurysms (HR, 1.59;
P
=0.07) and deep venous drainage (HR, 1.59;
P
=0.07) showed a trend toward significance. Hemorrhage risk was unchanged in patients who underwent partial arteriovenous malformation embolization (n=211; HR, 0.875;
P
=0.32).
Conclusion—
Brain arteriovenous malformations presenting with hemorrhage, with deep venous drainage, or associated aneurysms have ≈2-fold greater likelihood of a future hemorrhage. Partial treatment by embolization does not alter these risks. This natural history should be taken into account in the treatment strategy.
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Affiliation(s)
- Leodante da Costa
- From University Health Network (L.d.C., M.C.W., K.G.t.B., C.O., R.A.W., M.T.), Neurovascular Therapeutics Program, Toronto Western Hospital (M.C.W., K.G.t.B, R.A.W., M.T.), Division of Neurosurgery, Toronto Western Hospital (M.C.W., M.T.), Division of Radiology, University of Toronto (K.G.t.B., R.A.W.), Department of Surgery, University of Toronto (L.d.C., M.C.W., M.T.)
| | - M. Christopher Wallace
- From University Health Network (L.d.C., M.C.W., K.G.t.B., C.O., R.A.W., M.T.), Neurovascular Therapeutics Program, Toronto Western Hospital (M.C.W., K.G.t.B, R.A.W., M.T.), Division of Neurosurgery, Toronto Western Hospital (M.C.W., M.T.), Division of Radiology, University of Toronto (K.G.t.B., R.A.W.), Department of Surgery, University of Toronto (L.d.C., M.C.W., M.T.)
| | - Karel G. ter Brugge
- From University Health Network (L.d.C., M.C.W., K.G.t.B., C.O., R.A.W., M.T.), Neurovascular Therapeutics Program, Toronto Western Hospital (M.C.W., K.G.t.B, R.A.W., M.T.), Division of Neurosurgery, Toronto Western Hospital (M.C.W., M.T.), Division of Radiology, University of Toronto (K.G.t.B., R.A.W.), Department of Surgery, University of Toronto (L.d.C., M.C.W., M.T.)
| | - Cian O'Kelly
- From University Health Network (L.d.C., M.C.W., K.G.t.B., C.O., R.A.W., M.T.), Neurovascular Therapeutics Program, Toronto Western Hospital (M.C.W., K.G.t.B, R.A.W., M.T.), Division of Neurosurgery, Toronto Western Hospital (M.C.W., M.T.), Division of Radiology, University of Toronto (K.G.t.B., R.A.W.), Department of Surgery, University of Toronto (L.d.C., M.C.W., M.T.)
| | - Robert A. Willinsky
- From University Health Network (L.d.C., M.C.W., K.G.t.B., C.O., R.A.W., M.T.), Neurovascular Therapeutics Program, Toronto Western Hospital (M.C.W., K.G.t.B, R.A.W., M.T.), Division of Neurosurgery, Toronto Western Hospital (M.C.W., M.T.), Division of Radiology, University of Toronto (K.G.t.B., R.A.W.), Department of Surgery, University of Toronto (L.d.C., M.C.W., M.T.)
| | - Michael Tymianski
- From University Health Network (L.d.C., M.C.W., K.G.t.B., C.O., R.A.W., M.T.), Neurovascular Therapeutics Program, Toronto Western Hospital (M.C.W., K.G.t.B, R.A.W., M.T.), Division of Neurosurgery, Toronto Western Hospital (M.C.W., M.T.), Division of Radiology, University of Toronto (K.G.t.B., R.A.W.), Department of Surgery, University of Toronto (L.d.C., M.C.W., M.T.)
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62
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Combined management of intracranial arteriovenous malformations with embolization and Gamma Knife radiosurgery: comparative evaluation of the long-term results. ACTA ACUST UNITED AC 2009; 71:43-52; discussion 52-3. [DOI: 10.1016/j.surneu.2007.11.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Accepted: 11/27/2007] [Indexed: 11/15/2022]
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63
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The basal ganglia. Clin Neuroradiol 2008. [DOI: 10.1017/cbo9780511551925.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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64
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Pollock BE, Flickinger JC. MODIFICATION OF THE RADIOSURGERY-BASED ARTERIOVENOUS MALFORMATION GRADING SYSTEM. Neurosurgery 2008; 63:239-43; discussion 243. [DOI: 10.1227/01.neu.0000315861.24920.92] [Citation(s) in RCA: 166] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Bruce E. Pollock
- Departments of Neurological Surgery and Radiation Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - John C. Flickinger
- Departments of Radiation Oncology and Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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65
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Duckworth EA, Gross B, Batjer HH. Thalamic and Basal Ganglia Arteriovenous Malformations: Redefining “Inoperable”. Oper Neurosurg (Hagerstown) 2008. [DOI: 10.1227/01.neu.0000320137.55446.db] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Deep Arteriovenous Malformations of the basal ganglia and thalamus have an aggressive natural history and present a therapeutic challenge. More often than not, these lesions are deemed “inoperable” and are treated expectantly or with stereotactic radiosurgery. In some cases, clinical details combined with an opportune route of access dictate surgical resection. History of hemorrhage, small lesion size, and deep venous drainage each add to the aggressive natural history of these malformations. Interestingly, these same factors can point toward surgery. We present a discussion of the microsurgical techniques involved in managing these lesions, with an emphasis on situations that allow these lesions to be approached surgically.
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Affiliation(s)
| | - Bradley Gross
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | - H. Hunt Batjer
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
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66
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Maruyama K, Kamada K, Ota T, Koga T, Itoh D, Ino K, Aoki S, Tago M, Masutani Y, Shin M, Saito N. Tolerance of pyramidal tract to gamma knife radiosurgery based on diffusion-tensor tractography. Int J Radiat Oncol Biol Phys 2007; 70:1330-5. [PMID: 17935904 DOI: 10.1016/j.ijrobp.2007.08.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2007] [Revised: 08/10/2007] [Accepted: 08/10/2007] [Indexed: 11/26/2022]
Abstract
PURPOSE To minimize the morbidity of radiosurgery for critically located lesions, we integrated diffusion-tensor tractography into treatment planning for gamma-knife radiosurgery. We calculated the refined tolerance of the pyramidal tract (PT) after prospective application of the technique to additional patients. METHODS AND MATERIALS The relationship between the dosimetry during treatment planning and the development of subsequent motor complications was investigated in 24 patients, 9 studied retrospectively and 15 studied prospectively. The maximal dose to the PT and the volumes of the PT that received > or = 20 Gy (20-Gy volume) and > or = 25 Gy (25-Gy volume) were calculated. Univariate logistic regression analyses were used to produce dose-response curves. Differences in the tolerable dose according to the PT location were calculated. RESULTS Univariate logistic regression analysis of the motor complications revealed a significant independent correlation with the maximal dose to the PT and the 20- and 25-Gy volumes. The maximal dose to the PT with a 5% risk of motor complications was 23 Gy compared with 15 Gy in our previous report. The risk of motor complications was significantly greater in the internal capsule than in the corona radiata for the 20- and 25-Gy volumes in generalized Wilcoxon tests (p = 0.031), although no significant difference was observed for the maximal dose. CONCLUSION The tolerable dose of the PT was greater than that previously reported. The internal capsule was more sensitive to high-dose irradiation over a wide area of the PT, probably owing to the dense concentration of motor fibers.
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Affiliation(s)
- Keisuke Maruyama
- Department of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan.
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67
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Jahan R, Solberg TD, Lee D, Medin P, Tateshima S, De Salles A, Sayre J, Vinters HV, Viñuela F. An Arteriovenous Malformation Model for Stereotactic Radiosurgery Research. Neurosurgery 2007; 61:152-9; discussion 159. [PMID: 17621031 DOI: 10.1227/01.neu.0000279736.07683.1e] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
To introduce the utilization of a swine arteriovenous malformation (AVM) model for stereotactic radiosurgery research and to describe the morphological changes in the vessels after radiation.
METHODS
The model was created in six animals by creation of a right-sided carotid-jugular fistula. Pre- and postsurgical hemodynamic evaluation was performed. The left rete was radiated in four animals; two animals were not radiated. All animals were sacrificed 4 months after surgery, and the bilateral retia were obtained at autopsy.
RESULTS
There were no procedure-related complications. A pressure gradient of 20 mmHg across the nidus was obtained after surgery. The peak velocity in the arterial feeder increased from 18.5 to 83 cm/s. Microscopic examination of the control animals showed intimal hyperplasia and disrupted internal elastic lamina, similar to human AVMs. The radiated retia showed more prominent intimal hyperplasia. This was confirmed by histometric studies showing greater luminal occlusion in radiated specimens. Adventitial fibrosis was prominent in the radiated retia and was absent in the control animals. Immunohistochemical studies showed proliferating smooth muscle cells in the intima. The adventitial fibrosis consisted of smooth muscle cells surrounded by collagen Type IV extracellular matrix.
CONCLUSION
The nidus component and high-flow vasculopathy make this an attractive model for stereotactic radiosurgery research. Histology of the radiated models is similar to those described in radiated human AVMs. Further studies of the model are warranted to gain a better understanding of the cellular and molecular events in AVM vessels after stereotactic radiosurgery.
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Affiliation(s)
- Reza Jahan
- Division of Interventional Neuroradiology, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California 90095, USA.
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Machado A, Rezai AR, Kopell BH, Gross RE, Sharan AD, Benabid AL. Deep brain stimulation for Parkinson's disease: surgical technique and perioperative management. Mov Disord 2006; 21 Suppl 14:S247-58. [PMID: 16810722 DOI: 10.1002/mds.20959] [Citation(s) in RCA: 204] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Deep brain stimulation (DBS) is a widely accepted therapy for medically refractory Parkinson's disease (PD). Both globus pallidus internus (GPi) and subthalamic nucleus (STN) stimulation are safe and effective in improving the symptoms of PD and reducing dyskinesias. STN DBS is the most commonly performed surgery for PD as compared to GPi DBS. Ventral intermediate nucleus (Vim) DBS is infrequently used as an alternative for tremor predominant PD patients. Patient selection is critical in achieving good outcomes. Differential diagnosis should be emphasized as well as neurological and nonneurological comorbidities. Good response to a levodopa challenge is an important predictor of favorable long-term outcomes. The DBS surgery is typically performed in an awake patient and involves stereotactic frame application, CT/MRI imaging, anatomical targeting, physiological confirmation, and implantation of the DBS lead and pulse generator. Anatomical targeting consists of direct visualization of the target in MR images, formula-derived coordinates based on the anterior and posterior commissures, and reformatted anatomical stereotactic atlases. Physiological verification is achieved most commonly via microelectrode recording followed by implantation of the DBS lead and intraoperative test stimulation to assess benefits and side effects. The various aspects of DBS surgery will be presented.
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Affiliation(s)
- Andre Machado
- Center for Neurological Restoration, Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Zabel-du Bois A, Milker-Zabel S, Huber P, Schlegel W, Debus J. Stereotactic linac-based radiosurgery in the treatment of cerebral arteriovenous malformations located deep, involving corpus callosum, motor cortex, or brainstem. Int J Radiat Oncol Biol Phys 2006; 64:1044-8. [PMID: 16373080 DOI: 10.1016/j.ijrobp.2005.09.024] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Revised: 09/21/2005] [Accepted: 09/27/2005] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate patient outcome and obliteration rates after radiosurgery (RS) for cerebral arteriovenous malformations (AVM) located deep, in the motor cortex or brainstem and those involving corpus callosum. METHODS AND MATERIALS This analysis is based on 65 patients. AVM classification according to Spetzler-Martin was 13 patients Grade 2, 39 Grade 3, 12 Grade 4, and 1 Grade 5. Median RS-based AVM score was 1.69. Median single dose was 18 Gy. Mean treatment volume was 5.2 cc (range, 0.2-26.5 cc). Forty patients (62%) experienced intracranial hemorrhage before RS. Median follow-up was 3.0 years. RESULTS Actuarial complete obliteration rate (CO) was 50% and 65% after 3 and 5 years, respectively. CO was significantly higher in AVM <3 cm (p < 0.02) and after doses >18 Gy (p < 0.009). Annual bleeding risk after RS was 4.7%, 3.4%, and 2.7% after 1, 2, and 3 years, respectively. AVM >3 cm (p < 0.01), AVM volume >4 cc (p < 0.009), and AVM score >1.5 (p < 0.02) showed a significant higher bleeding risk. Neurologic dysfunction improved, completely dissolved, or remained stable in 94% of patients. CONCLUSIONS Surgically inaccessible AVM can be successfully treated using RS with acceptable obliteration rates and low risk for late morbidity. The risk of intracranial hemorrhage is reduced after RS and depends on RS-based AVM score.
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Jahan R, Solberg TD, Lee D, Medin P, Tateshima S, Sayre J, De Salles A, Vinters HV, Vinuela F. Stereotactic Radiosurgery of the Rete Mirabile in Swine: A Longitudinal Study of Histopathological Changes. Neurosurgery 2006; 58:551-8; discussion 551-8. [PMID: 16528197 DOI: 10.1227/01.neu.0000197335.93538.bd] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
Stereotactic radiosurgery is an established, effective treatment for brain arteriovenous malformations. The mechanisms of vessel occlusion in arteriovenous malformations has not been extensively evaluated. To better understand these mechanisms, we report histopathological changes in the swine rete mirabile after stereotactic radiosurgery.
METHODS:
Thirty-five swine were used, 15 as nonradiated controls and 20 as radiated. Two in the control group and five in the radiated group were sacrificed before the study endpoint. Tissue was obtained from 13 nonradiated (4 at 3 mo, 5 at 6 mo, 4 at 9 mo) and 15 radiated swine (2 at 3 mo, 3 at 6 mo, 10 at 9 mo) for histological, immunohistochemical, and morphometric analysis.
RESULTS:
Radiated vessels showed increasing intimal hyperplasia over the follow-up period. Histometrical analysis confirmed this with evidence of progressive luminal narrowing over the follow-up period. Immunohistochemical analysis showed intimal cells to be proliferating smooth muscle cells with surrounding extracellular collagen Type IV. Adventitial fibrosis composed of collagen Type IV was also seen with smooth muscle cells interspersed within the collagen matrix. The nonradiated animals showed no intimal hyperplasia or change in the appearance or size of the vessels over the same follow-up period. Adventitial fibrosis was minimal in the nonradiated animals.
CONCLUSION:
The vessels show an intimal response to radiation with progressive occlusion caused by migrating, proliferating smooth muscle cells, a likely source of the extracellular collagen in the intima. Cytokine mediated pathways likely produce these morphological changes. Future studies will be directed toward elucidating these underlying molecular mechanisms.
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Affiliation(s)
- Reza Jahan
- Division of Interventional Neuroradiology, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA.
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