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Sackey FNA, Pinsker NR, Baako BN. Highlights on Cerebral Arteriovenous Malformation Treatment Using Combined Embolization and Stereotactic Radiosurgery: Why Outcomes are Controversial? Cureus 2017; 9:e1266. [PMID: 28652950 PMCID: PMC5481174 DOI: 10.7759/cureus.1266] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 05/22/2017] [Indexed: 11/05/2022] Open
Abstract
Cerebral arteriovenous malformations (AVMs) are abnormal tangling between brain arteries and veins causing an arteriovenous shunt called nidus with an intervening network of vessels from the region of formation and spans through the brain. AVM effect is debilitating to the affected individual due to associated persistent intracerebral hemorrhage, resulting in significant occurrences of seizures and neurological damage. Recent innovative treatments involve a combination of embolization (Embo) procedures followed by stereotactic radiosurgery (SRS), designed to optimize less-invasive practice for the obliteration of the AVMs. Three groups of investigators reported different outcomes based on obliteration rates and adverse events, making the effectiveness of options for therapy, controversial. We have taken the case-oriented-approach to highlight on varying outcomes from various studies and provide insights as to why findings from different operation settings could be so conflicting. We chose 18 articles for systematic analysis based on initial electronic database selection of 40 key papers already identified for inclusion, followed by independent blinding assessment by two co-authors. Our evaluation was based first on our specific inclusion criteria, examining method quality, obliteration rates, serious adverse events (SAEs) and mortality rates. Second, we made a comparison between SRS or embo alone treatments versus combined embo/SRS procedures, relative to AVM sizes, following Spetzler-Martin (SM) method. Third, we considered publications which had concrete statistics with well-defined P-values and clarified outcomes for accurate evaluation. We found that patients with small to medium-sized AVM were susceptible to either embo alone or SRS alone treatments, yielding obliteration rates from 71%-100%. Except for one report, giant sizes AVMs were not amenable to these single treatments, subjecting patients to embo/SRS procedures, which yielded mixed results: One group reported 52%-65% obliteration rates, compared to 23%-28% embo alone treatment. A second group contradicted this apparent beneficial outcome, obtaining obliteration rates of 53% with combined treatment compared to 71% with SRS alone, four-year postoperative. A third group reported there was no difference between single and combined treatments and obtained complete obliteration of 70%-82%, ranging from three-five-years postoperative follow-up. In all the cases analyzed, obliteration rates improved with time. SAEs, such as persistent hemorrhage and permanent neurologic deficits (P-NDs), as well as mortality, were minimal during intraoperative and postoperative follow-ups. The problem of conflicting outcomes in combined treatments of AVM by EMBO/SRS exists. Previous investigators, however, have overlooked to address this issue satisfactorily. Our analysis found that the reported inconsistencies in AVM treatment outcomes are attributable to key factors making therapy unpredictable, which includes: the size of the AVM, nidus localization and accessibility of either Embo or radiation dose applied, certain Embo materials lowering obliteration rates by masking radioactive effect on the nidus during SRS and follow-up timing for obtaining obliteration rates determine the extent of obliteration. We have indicated critical factors which require consideration when planning strategies for treatment of AVM patients and have made suggestions of how to overcome such hurdles.
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Affiliation(s)
- Faustina N A Sackey
- Loeb Health Research Institute at Ottawa Hospital, University of Ottawa, Ontario, Canada
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202
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Affiliation(s)
- Robert A Solomon
- From Columbia University College of Physicians and Surgeons and the Department of Neurological Surgery, New York Presbyterian Hospital, New York
| | - E Sander Connolly
- From Columbia University College of Physicians and Surgeons and the Department of Neurological Surgery, New York Presbyterian Hospital, New York
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203
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Burkhardt JK, Chen X, Winkler EA, Cooke DL, Kim H, Lawton MT. Delayed Venous Drainage in Ruptured Arteriovenous Malformations Based on Quantitative Color-Coded Digital Subtraction Angiography. World Neurosurg 2017; 104:619-627. [PMID: 28457930 DOI: 10.1016/j.wneu.2017.04.120] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 04/17/2017] [Accepted: 04/18/2017] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Clinically applicable hemodynamic risk factors to predict arteriovenous malformation (AVM) rupture are missing in the literature. The aim of this study was to use catheter angiography to identify hemodynamic parameters in ruptured and unruptured AVMs. METHODS Patients with frontal and temporal AVMs and Siemens syngo iFlow color-coding angiography were included in this study (n = 71). Clinical and radiologic data (age, sex, Spetzler-Martin [SM] and supplemented SM grade, and rupture status), and hemodynamic features (contrast mean transit time [MTT] of feeding arteries, draining veins, AVM nidus, and the cerebral circulation time [CCT]) were analyzed. Univariable analysis was performed to compare findings between ruptured and unruptured AVMs. RESULTS In total, 35 ruptured and 36 unruptured AVMs were analyzed. Clinical characteristics and AVM grades were comparable between ruptured and unruptured AVMs. Ipsilateral CCT (5.2 vs. 4.0 seconds; P = 0.035), MTT between Tmax of the ipsilateral internal carotid artery and Tmax of sinus entry of the draining vein (3.2 vs. 2.0 seconds; P < 0.001), and MTT between Tmax at the start of venous outflow and Tmax of sinus entry (1.6 vs. 0.7 seconds; P < 0.0001) were significantly longer in ruptured compared with unruptured AVMs. MTTs of nidus, between the internal carotid and feeding arteries, of the venous sinus passage as well as contralateral CCT and controlled ipsilateral CCT were comparable between both groups. CONCLUSIONS Ruptured AVMs have significantly prolonged venous drainage times compared with unruptured AVMs; this suggests restricted AVM drainage and increased blood pressure within the AVM nidus. Prospective studies are needed to determine the predictive power of these measurements.
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Affiliation(s)
- Jan-Karl Burkhardt
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Xiaolin Chen
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Daniel L Cooke
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA; Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA; Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA.
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204
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Murthy SB, Merkler AE, Omran SS, Gialdini G, Gusdon A, Hartley B, Roh D, Mangat HS, Iadecola C, Navi BB, Kamel H. Outcomes after intracerebral hemorrhage from arteriovenous malformations. Neurology 2017; 88:1882-1888. [PMID: 28424275 DOI: 10.1212/wnl.0000000000003935] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 01/11/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare outcomes after intracerebral hemorrhage (ICH) from cerebral arteriovenous malformation (AVM) rupture and other causes of ICH. METHODS We performed a retrospective population-based study using data from the Nationwide Inpatient Sample. We used standard diagnosis codes to identify ICH cases from 2002 to 2011. Our predictor variable was cerebral AVM. Our primary outcomes were inpatient mortality and home discharge. We used logistic regression to compare outcomes between patients with ICH with and without AVM while adjusting for demographics, comorbidities, and hospital characteristics. In a confirmatory analysis using a prospective cohort of patients hospitalized with ICH at our institution, we additionally adjusted for hematoma characteristics and the Glasgow Coma Scale score. RESULTS Among 619,167 ICH hospitalizations, the 4,485 patients (0.7%, 95% confidence interval [CI] 0.6-0.8) with an AVM were younger and had fewer medical comorbidities than patients without AVM. After adjustment for confounders, patients with AVM had lower odds of death (odds ratio [OR] 0.5, 95% CI 0.4-0.7) and higher odds of home discharge (OR 2.0, 95% CI 1.4-3.0) than patients without AVM. In a confirmatory analysis of 342 patients with ICH at our institution, the 34 patients (9.9%, 95% CI 7.2-13.6) with a ruptured AVM had higher odds of ambulatory independence at discharge (OR 4.4, 95% CI 1.4-13.1) compared to patients without AVM. CONCLUSIONS Patients with ICH due to ruptured AVM have more favorable outcomes than patients with ICH from other causes.
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Affiliation(s)
- Santosh B Murthy
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY.
| | - Alexander E Merkler
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Setareh Salehi Omran
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Gino Gialdini
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Aaron Gusdon
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Benjamin Hartley
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - David Roh
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Halinder S Mangat
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Costantino Iadecola
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Babak B Navi
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
| | - Hooman Kamel
- From the Department of Neurology (S.B.M., A.E.M., S.S.O., A.G., H.S.M., C.I., B.B.N., H.K.), Clinical and Translational Neuroscience Unit (S.B.M., A.E.M., G.G., C.I., B.B.N., H.K.), Feil Family Brain and Mind Research Institute, and Department of Neurological Surgery (B.H., H.S.M.), Weill Cornell Medicine; and Department of Neurology (D.R.), Columbia College of Physicians and Surgeons, New York, NY
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205
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Clement-Colmou K, Roualdes V, Martin SA, Josset S, Desal H, Campion L, Thillays F. Dynamic conformal arc radiosurgery for arteriovenous malformations: Outcome and influence of clinical and dosimetrical data. Radiother Oncol 2017; 123:251-256. [PMID: 28351522 DOI: 10.1016/j.radonc.2017.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/09/2017] [Accepted: 03/10/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess efficacy, toxicity, and their predictive factors for dynamic conformal arc arteriovenous malformations (AVM) stereotactic radiosurgery. METHOD Data concerning 90 consecutive patients were retrospectively studied. Clinical, radiological, dosimetrical data and quality indexes were computed. RESULTS AVM median volume was 1.06cc. Median prescribed dose was 22Gy. Total occlusion was obtained for 69% of patients. Post-radiosurgery annual hemorrhage rate was 2.2%. Predictive factor for total occlusion was delivered dose. Undesirable events occurred for 28% of patients. Predictive factors for adverse events were AVM revealing mode with seizure or headache, age≤28, AVM diameter≥3cm Spetzler-Martin score≥4, V12Gy≥2cc, large target volume and low homogeneity index (p<0.05). Brain parenchymal radiological reactions concerned 23% of patients, and their predictive factors were AVM revelation by seizure, deep localization, AVM diameter≥3cm, Spetzler-Martin score≥4, previous radiosurgery, numerous embolization, target volume, V12Gy and low homogeneity index (p<0.05). CONCLUSION Occlusion rate and toxicities are comparable to other series. Specific attention must be paid on pre-treatment clinical data, and target volume should be as small as possible, without reducing the delivered dose.
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Affiliation(s)
| | | | | | - Stephanie Josset
- Medical Physics, Integrated Center of Oncology, Saint-Herblain, France.
| | - Hubert Desal
- Neuroradiology, Centre Hospitalier Universitaire, Nantes, France.
| | - Loïc Campion
- Statistics, Integrated Center of Oncology, Saint-Herblain, France.
| | - François Thillays
- Radiation Oncology, Integrated Center of Oncology, Saint-Herblain, France.
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206
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Microsurgery for intracranial arteriovenous malformation: Long-term outcomes in 445 patients. PLoS One 2017; 12:e0174325. [PMID: 28323878 PMCID: PMC5360342 DOI: 10.1371/journal.pone.0174325] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 03/07/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The management of intracranial arteriovenous malformations(AVMs) poses challenges to the cerebrovascular specialists. OBJECTIVE To review the long-term outcomes of intracranial AVMs treated with microsurgical resections. METHODS We performed a retrospective review of 445 patients with intracranial AVMs treated in our hospital from January 1st, 2008 to December 31st, 2014. The extracted data included demographic characteristics, clinical presentations, Spetzler-Martin (SM) grades, Supplemented Spetzler-Martin (SM-Supp) Grades, treatment modalities, long-term outcomes, and obliteration rates. Outcome was assessed with a post-operative modified Rankin Scale (mRS) score at the last follow-up visit. RESULTS Of the 445 patients treated with microsurgery, 298 (67.0%) patients initially presented with hemorrhage. Based on the SM grading system, the patients were graded as follows: 83(18.6%) Grade I, 156(35.1%) Grade II, 132(29.7%) Grade III, 61(13.7%) Grade IV and 13(2.9%) Grade V. Overall, 344(77.3%) patients had a favorable outcome (mRS score of 0-2). The favorable outcome for Grade I and II were 92.8% and 85.9%, respectively, sharply reducing to 52.5% in patients with Grade IV and 15.4% in patients with Grade V AVMs. 388(87.2%) patients achieved complete obliteration of the AVMs. 63(14.2%) patients experienced recurrent hemorrhage, and the frequency of rehemorrhage was highest in Grade V patients (77.0%), dropping to 3.6% and 3.8% in patients with Grade I and II lesions, respectively. Permanent neurological deficits occurred in 66(14.8%) patients and death in 35(7.9%) patients. There was no difference of AUROC values between SM grading system and SM-supp grading system (0.726 and 0.734, respectively, p = .715). CONCLUSION The Spetzler-Martin grading system is a simple and effective method to estimate the risk of surgery and to evaluate the prognosis. Microsurgical resection for AVMs depends on the SM grades, and the morbidity-mortality rate increases with an increasing SM grade.
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207
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Morphometric characterization of brain arteriovenous malformations for clinical and radiological studies to identify silent intralesional microhemorrhages. Clin Neuropathol 2017; 35:114-21. [PMID: 27049066 PMCID: PMC4910647 DOI: 10.5414/np300937] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2016] [Indexed: 11/30/2022] Open
Abstract
Abstract. Brain arteriovenous malformations (bAVMs) are vascular lesions that can cause significant morbidity and mortality, particularly when they bleed, i.e., rupture. Determining the risk of rupture for bAVMs is a crucial task to determine the most appropriate approach to patients with bAVM. Furthermore, patients who present with a hemorrhagic event also have a higher risk of subsequent hemorrhage. Determination of the hemorrhage risk and management strategy for incidentally discovered bAVMs still remains a controversial subject. In recent years, we have identified silent intralesional microhemorrhages (SIMs) as a possible risk factor for subsequent hemorrhage in patients with bAVMs. The principal aim of this study was to determine critical histological features that can be correlated with preoperative radioimaging findings, and allow better identification of patients with greater risk of adverse outcome. Here we provide a detailed descriptive analysis of the morphometric assessment of bAVMs in order to provide reproducible methodology that will aid in correlating preoperative radioimaging findings with histological features that may be significantly associated with increased risk of hemorrhage/rupture.
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208
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[Clinical magnetic resonance imaging : Frequent incidental cerebral findings]. Radiologe 2017; 57:251-262. [PMID: 28280860 DOI: 10.1007/s00117-017-0229-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The increasing use of magnetic resonance imaging (MRI) in clinical diagnostics means that patients and physicians are confronted more often with incidental findings. In the literature there are fluctuating data on the incidence of such findings and guidelines concerning the further procedure exist in only very few cases, such as incidental aneurysms and pituitary adenomas. The diagnostic and therapeutic implications which can be derived from incidental findings depend on multiple factors, such as anatomical location, patient age, comorbidity and patient wishes. For this reason it often makes sense to refer patients with incidental findings to an interdisciplinary neurological center at an early stage. In this review frequent incidental cerebral findings, epidemiological data, imaging criteria and, where possible, recommendations for the further procedure are shown.
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209
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Abstract
OBJECTIVE Brain arteriovenous malformation (AVM) rupture results in substantial morbidity and mortality. The goal of AVM treatment is eradication of the AVM, but the risk of treatment must be weighed against the risk of future hemorrhage. CONCLUSION Imaging plays a vital role by providing the information necessary for AVM management. Here, we discuss the background, natural history, clinical presentation, and imaging of AVMs. In addition, we explain advances in techniques for imaging AVMs.
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210
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Ding D, Starke RM, Kano H, Mathieu D, Huang PP, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Kondziolka D, Barnett GH, Dade Lunsford L, Sheehan JP. International multicenter cohort study of pediatric brain arteriovenous malformations. Part 1: Predictors of hemorrhagic presentation. J Neurosurg Pediatr 2017; 19:127-135. [PMID: 27911248 DOI: 10.3171/2016.9.peds16283] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain arteriovenous malformations (AVMs) are the most common cause of spontaneous intracranial hemorrhage in pediatric patients (age < 18 years). Since the cumulative lifetime risk of AVM hemorrhage is considerable in children, an improved understanding of the risk factors influencing hemorrhagic presentation may aid in the management of pediatric AVMs. The aims of this first of a 2-part multicenter, retrospective cohort study are to evaluate the incidence and determine the predictors of hemorrhagic presentation in pediatric AVM patients. METHODS The authors analyzed pooled AVM radiosurgery data from 7 institutions participating in the International Gamma Knife Research Foundation (IGKRF). Patients younger than 18 years at the time of radiosurgery and who had at least 12 months of follow-up were included in the study cohort. Patient and AVM characteristics were compared between unruptured and ruptured pediatric AVMs. RESULTS A total of 357 pediatric patients were eligible for analysis, including 112 patients in the unruptured and 245 patients in the ruptured AVM cohorts (69% incidence of hemorrhagic presentation). The annual hemorrhage rate prior to radiosurgery was 6.3%. Hemorrhagic presentation was significantly more common in deep locations (basal ganglia, thalamus, and brainstem) than in cortical locations (frontal, temporal, parietal, and occipital lobes) (76% vs 62%, p = 0.006). Among the factors found to be significantly associated with hemorrhagic presentation in the multivariate logistic regression analysis, deep venous drainage (OR 3.2, p < 0.001) was the strongest independent predictor, followed by female sex (OR 1.7, p = 0.042) and smaller AVM volume (OR 1.1, p < 0.001). CONCLUSIONS Unruptured and ruptured pediatric AVMs have significantly different patient and nidal features. Pediatric AVM patients who possess 1 or more of these high-risk features may be candidates for relatively more aggressive management strategies.
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Affiliation(s)
- Dale Ding
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
| | - Robert M Starke
- University of Miami, Department of Neurological Surgery, Miami, Florida
| | - Hideyuki Kano
- University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania
| | - David Mathieu
- University of Sherbrooke, Division of Neurosurgery, Sherbrooke, Quebec, Canada; and
| | - Paul P Huang
- New York University Langone Medical Center, Department of Neurosurgery, New York, New York
| | - Caleb Feliciano
- University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico
| | | | - Luis Almodovar
- University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico
| | - Inga S Grills
- Beaumont Health System, Department of Radiation Oncology, Royal Oak, Michigan
| | - Danilo Silva
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Mahmoud Abbassy
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Symeon Missios
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Douglas Kondziolka
- New York University Langone Medical Center, Department of Neurosurgery, New York, New York
| | - Gene H Barnett
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - L Dade Lunsford
- University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
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211
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Starke RM, Ding D, Kano H, Mathieu D, Huang PP, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Kondziolka D, Barnett GH, Dade Lunsford L, Sheehan JP. International multicenter cohort study of pediatric brain arteriovenous malformations. Part 2: Outcomes after stereotactic radiosurgery. J Neurosurg Pediatr 2017; 19:136-148. [PMID: 27911249 DOI: 10.3171/2016.9.peds16284] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Pediatric patients (age < 18 years) harboring brain arteriovenous malformations (AVMs) are burdened with a considerably higher cumulative lifetime risk of hemorrhage than adults. Additionally, the pediatric population was excluded from recent prospective comparisons of intervention versus conservative management for unruptured AVMs. The aims of this multicenter, retrospective cohort study are to analyze the outcomes after stereotactic radiosurgery for unruptured and ruptured pediatric AVMs. METHODS We analyzed and pooled AVM radiosurgery data from 7 participating in the International Gamma Knife Research Foundation. Patients younger than 18 years of age who had at least 12 months of follow-up were included in the study cohort. Favorable outcome was defined as AVM obliteration, no post-radiosurgical hemorrhage, and no permanently symptomatic radiation-induced changes (RIC). The post-radiosurgery outcomes of unruptured versus ruptured pediatric AVMs were compared, and statistical analyses were performed to identify predictive factors. RESULTS The overall pediatric AVM cohort comprised 357 patients with a mean age of 12.6 years (range 2.8-17.9 years). AVMs were previously treated with embolization, resection, and fractionated external beam radiation therapy in 22%, 6%, and 13% of patients, respectively. The mean nidus volume was 3.5 cm3, 77% of AVMs were located in eloquent brain areas, and the Spetzler-Martin grade was III or higher in 59%. The mean radiosurgical margin dose was 21 Gy (range 5-35 Gy), and the mean follow-up was 92 months (range 12-266 months). AVM obliteration was achieved in 63%. During a cumulative latency period of 2748 years, the annual post-radiosurgery hemorrhage rate was 1.4%. Symptomatic and permanent radiation-induced changes occurred in 8% and 3%, respectively. Favorable outcome was achieved in 59%. In the multivariate logistic regression analysis, the absence of prior AVM embolization (p = 0.001) and higher margin dose (p < 0.001) were found to be independent predictors of a favorable outcome. The rates of favorable outcome for patients treated with a margin dose ≥ 22 Gy vs < 22 Gy were 78% (110/141 patients) and 47% (101/216 patients), respectively. A margin dose ≥ 22 Gy yielded a significantly higher probability of a favorable outcome (p < 0.001). The unruptured and ruptured pediatric AVM cohorts included 112 and 245 patients, respectively. Ruptured AVMs had significantly higher rates of obliteration (68% vs 53%, p = 0.005) and favorable outcome (63% vs 51%, p = 0.033), with a trend toward a higher incidence of post-radiosurgery hemorrhage (10% vs 4%, p = 0.07). The annual post-radiosurgery hemorrhage rates were 0.8% for unruptured and 1.6% for ruptured AVMs. CONCLUSIONS Radiosurgery is a reasonable treatment option for pediatric AVMs. Obliteration and favorable outcomes are achieved in the majority of patients. The annual rate of latency period hemorrhage after radiosurgery for both ruptured and unruptured pediatric AVM patients conveys a significant risk until the nidus is obliterated.
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Affiliation(s)
- Robert M Starke
- University of Miami, Department of Neurological Surgery, Miami, Florida
| | - Dale Ding
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
| | - Hideyuki Kano
- University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania
| | - David Mathieu
- University of Sherbrooke, Division of Neurosurgery, Sherbrooke, Quebec, Canada; and
| | - Paul P Huang
- New York University Langone Medical Center, Department of Neurosurgery, New York, New York
| | - Caleb Feliciano
- University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico
| | | | - Luis Almodovar
- University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico
| | - Inga S Grills
- Beaumont Health System, Department of Radiation Oncology, Royal Oak, Michigan
| | - Danilo Silva
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Mahmoud Abbassy
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Symeon Missios
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Douglas Kondziolka
- New York University Langone Medical Center, Department of Neurosurgery, New York, New York
| | - Gene H Barnett
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - L Dade Lunsford
- University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
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212
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Tong X, Wu J, Cao Y, Zhao Y, Wang S. New predictive model for microsurgical outcome of intracranial arteriovenous malformations: study protocol. BMJ Open 2017; 7:e014063. [PMID: 28132013 PMCID: PMC5278248 DOI: 10.1136/bmjopen-2016-014063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Although microsurgical resection is currently the first-line treatment modality for arteriovenous malformations (AVMs), microsurgery of these lesions is complicated due to the fact that they are very heterogeneous vascular anomalies. The Spetzler-Martin grading system and the supplementary grading system have demonstrated excellent performances in predicting the risk of AVM surgery. However, there are currently no predictive models based on multimodal MRI techniques. The purpose of this study is to propose a predictive model based on multimodal MRI techniques to assess the microsurgical risk of intracranial AVMs. METHODS AND ANALYSIS The study consists of 2 parts: the first part is to conduct a single-centre retrospective analysis of 201 eligible patients to create a predictive model of AVM surgery based on multimodal functional MRIs (fMRIs); the second part is to validate the efficacy of the predictive model in a prospective multicentre cohort study of 400 eligible patients. Patient characteristics, AVM features and multimodal fMRI data will be collected. The functional status at pretreatment and 6 months after surgery will be analysed using the modified Rankin Scale (mRS) score. The patients in each part of this study will be dichotomised into 2 groups: those with improved or unchanged functional status (a decreased or unchanged mRS 6 months after surgery) and those with worsened functional status (an increased mRS). The first part will determine the risk factors of worsened functional status after surgery and create a predictive model. The second part will validate the predictive model and then a new AVM grading system will be proposed. ETHICS AND DISSEMINATION The study protocol and informed consent form have been reviewed and approved by the Institutional Review Board of Beijing Tiantan Hospital Affiliated to Capital Medical University (KY2016-031-01). The results of this study will be disseminated through printed media. TRIAL REGISTRATION NUMBER NCT02868008.
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Affiliation(s)
- Xianzeng Tong
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 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 Diseases, Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 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 Diseases, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 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 Diseases, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 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 Diseases, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 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 Diseases, Beijing, China
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213
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Ding D, Starke RM, Sheehan JP. Radiosurgery for the management of cerebral arteriovenous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:69-83. [PMID: 28552160 DOI: 10.1016/b978-0-444-63640-9.00007-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Cerebral arteriovenous malformations (AVMs) are rare, unstable vascular lesions which spontaneously rupture at a rate of approximately 2-4% annually. Stereotactic radiosurgery is a minimally invasive treatment for AVMs, with a favorable risk-to-benefit profile in most patients, with respect to obliteration, hemorrhage, and seizure control. Radiosurgery is ideally suited for small to medium-sized AVMs (diameter <3cm or volume <12cm3) located in deep or eloquent brain regions. Obliteration is ultimately achieved in 70-80% of cases and is directly associated with nidus volume and radiosurgical margin dose. Adverse radiation effects, which appear as T2-weighted hyperintensities on magnetic resonance imaging, develop in 30-40% of patients after AVM radiosurgery, are symptomatic in 10%, and fail to clinically resolve in 2-3%. The risk of AVM hemorrhage may be reduced by radiosurgery, but the hemorrhage risk persists during the latency period between treatment and obliteration. Delayed postradiosurgery cyst formation occurs in 2% of cases and may require surgical treatment. Radiosurgery abolishes or ameliorates seizure activity in the majority of patients with AVM-associated epilepsy and induces de novo seizures in 1-2% of those without preoperative seizures. Strategies for the treatment of large-volume AVMs include neoadjuvant embolization and either dose- or volume-staged radiosurgery.
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Affiliation(s)
- Dale Ding
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
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214
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Gross BA, Moon K, Mcdougall CG. Endovascular management of arteriovenous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:59-68. [PMID: 28552159 DOI: 10.1016/b978-0-444-63640-9.00006-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Arteriovenous malformation (AVM) embolization can serve as a crucial adjunct before surgical resection, a partial approach to target high-risk features, or, rarely, as a curative approach for high-risk, surgically inaccessible lesions. Specifically, embolization is a welcome surgical adjunct to reduce the size of medium to large AVMs, to target perforator supply, and/or to target the deep portion of a nidus. In addition, a crucial role for embolization is the targeting of associated aneurysms, particularly in the setting of a ruptured lesion, regardless of the subsequent therapeutic modality. Rarely, a deep, small ruptured AVM that cannot be accessed surgically may be embolized with intent to cure. This chapter will review patient selection, technical nuances, and published results for AVM embolization. With appropriate patient selection and well-defined goals of embolization, the risk of procedural morbidity can be outweighed by its benefit.
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Affiliation(s)
- Bradley A Gross
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
| | - Karam Moon
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Cameron G Mcdougall
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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216
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Osbun JW, Reynolds MR, Barrow DL. Arteriovenous malformations: epidemiology, clinical presentation, and diagnostic evaluation. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:25-29. [PMID: 28552148 DOI: 10.1016/b978-0-444-63640-9.00003-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Brain arteriovenous malformations (AVMs) represent an uncommon disease of the central nervous system characterized by an arteriovenous shunt in which one or multiple arterial pedicles feed into a vascular nidus, creating early drainage into a venous outflow channel. These lesions are considered to be congenital and can come to clinical attention in a variety of ways such as seizure, intracranial hemorrhage, chronic headache or progressive neurological deficit. We focus on the epidemiology, clinical presentation and diagnostic evaluation in this chapter.
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Affiliation(s)
- Joshua W Osbun
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | | | - Daniel L Barrow
- Department of Neurosurgery, Emory University, Atlanta, GA, USA.
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217
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Can A, Gross BA, Du R. The natural history of cerebral arteriovenous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:15-24. [PMID: 28552137 DOI: 10.1016/b978-0-444-63640-9.00002-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Cerebral arteriovenous malformations (AVMs) are composed of a complex tangle of abnormal arteries and veins and are a significant source of cerebral hemorrhage and consequent morbidity and mortality in young adults, representing a diagnostic and therapeutic challenge. Current natural-history studies of cerebral AVMs report overall annual rates of 1% and 3% for the risk of epilepsy and hemorrhage, respectively. Unruptured AVMs have an annual hemorrhage rate of 2.2% while ruptured lesions have an annual hemorrhage rate of 4.5%. These hemorrhage rates are can change over time, particularly for hemorrhagic lesions, with the rebleed rate ranging from 6% to 15.8% in the first year after rupture across several studies. Besides hemorrhage, other significant risk factors for AVM hemorrhage include deep location, deep venous drainage, associated aneurysms, and pregnancy. Other factors include patient age, sex, and small AVM size, which are not currently considered significant risk factors for AVM hemorrhage. In addition to hemorrhage risk and seizure risk, the natural history of an AVM also encompasses the daily psychologic burden that a patient must endure knowing that he or she possesses an untreated AVM. This chapter reviews the epidemiology, clinical features, and natural history of cerebral AVMs.
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Affiliation(s)
- Anil Can
- Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Bradley A Gross
- Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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218
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Ozpinar A, Mendez G, Abla AA. Epidemiology, genetics, pathophysiology, and prognostic classifications of cerebral arteriovenous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:5-13. [PMID: 28552158 DOI: 10.1016/b978-0-444-63640-9.00001-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Arteriovenous malformations (AVMs) are vascular deformities involving fistula formation of arterial to venous structures without an intervening capillary bed. Such anomalies can prove fatal as the high arterial flow can disrupt the integrity of venous walls, thus leading to dangerous sequelae such as hemorrhage. Diagnosis of these lesions in the central nervous system can often prove challenging as intracranial AVMs represent a heterogeneous vascular pathology with various presentations and symptomatology. The literature suggests that most brain AVMs (bAVMs) are identified following evaluation of the etiology of acute cerebral hemorrhage, or incidentally on imaging associated with seizure or headache workup. Given the low incidence of this disease, most of the data accrued on this pathology comes from single-center experiences. This chapter aims to distill the most important information from these studies as well as examine meta-analyses on bAVMs in order to provide a comprehensive introduction into the natural history, classification, genetic underpinnings of disease, and proposed pathophysiology. While there is yet much to be elucidated about AVMs of the central nervous system, we aim to provide an overview of bAVM etiology, classification, genetics, and pathophysiology inherent to the disease process.
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Affiliation(s)
- Alp Ozpinar
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Gustavo Mendez
- Department of General Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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219
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Starke RM, Kano H, Ding D, Lee JYK, Mathieu D, Whitesell J, Pierce JT, Huang PP, Kondziolka D, Yen CP, Feliciano C, Rodgriguez-Mercado R, Almodovar L, Pieper DR, Grills IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for cerebral arteriovenous malformations: evaluation of long-term outcomes in a multicenter cohort. J Neurosurg 2017; 126:36-44. [DOI: 10.3171/2015.9.jns151311] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE
In this multicenter study, the authors reviewed the results following Gamma Knife radiosurgery (GKRS) of cerebral arteriovenous malformations (AVMs), determined predictors of outcome, and assessed predictive value of commonly used grading scales based upon this large cohort with long-term follow-up.
METHODS
Data from a cohort of 2236 patients undergoing GKRS for cerebral AVMs were compiled from the International Gamma Knife Research Foundation. Favorable outcome was defined as AVM obliteration and no posttreatment hemorrhage or permanent symptomatic radiation-induced complications. Patient and AVM characteristics were assessed to determine predictors of outcome, and commonly used grading scales were assessed.
RESULTS
The mean maximum AVM diameter was 2.3 cm, with a mean volume of 4.3 cm3. A mean margin dose of 20.5 Gy was delivered. Mean follow-up was 7 years (range 1–20 years). Overall obliteration was 64.7%. Post-GRKS hemorrhage occurred in 165 patients (annual risk 1.1%). Radiation-induced imaging changes occurred in 29.2%; 9.7% were symptomatic, and 2.7% had permanent deficits. Favorable outcome was achieved in 60.3% of patients. Patients with prior nidal embolization (OR 2.1, p < 0.001), prior AVM hemorrhage (OR 1.3, p = 0.007), eloquent location (OR 1.3, p = 0.029), higher volume (OR 1.01, p < 0.001), lower margin dose (OR 0.9, p < 0.001), and more isocenters (OR 1.1, p = 0.011) were more likely to have unfavorable outcomes in multivariate analysis. The Spetzler-Martin grade and radiosurgery-based AVM score predicted outcome, but the Virginia Radiosurgery AVM Scale provided the best assessment.
CONCLUSIONS
GKRS for cerebral AVMs achieves obliteration and avoids permanent complications in the majority of patients. Patient, AVM, and treatment parameters can be used to predict long-term outcomes following radiosurgery.
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Affiliation(s)
- Robert M. Starke
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Hideyuki Kano
- 2Department of Neurosurgery, University of Pittsburgh
| | - Dale Ding
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - John Y. K. Lee
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Mathieu
- 4Department of Neurosurgery, University of Sherbrooke, Quebec, Canada
| | - Jamie Whitesell
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John T. Pierce
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul P. Huang
- 5Gamma Knife Center, New York University, New York, New York
| | | | - Chun-Po Yen
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Caleb Feliciano
- 6Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Luis Almodovar
- 6Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | - Daniel R. Pieper
- 7Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Inga S. Grills
- 7Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Danilo Silva
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mahmoud Abbassy
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Symeon Missios
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gene H. Barnett
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Jason P. Sheehan
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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220
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Tong X, Wu J, Cao Y, Zhao Y, Wang S, Zhao J. Microsurgical Outcome of Unruptured Brain Arteriovenous Malformations: A Single-Center Experience. World Neurosurg 2016; 99:644-655. [PMID: 28042014 DOI: 10.1016/j.wneu.2016.12.088] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 12/19/2016] [Accepted: 12/20/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We describe our single-center experience treating unruptured brain arteriovenous malformations (uBAVMs) with microsurgical treatment. METHODS During a 7-year period, 282 patients with uBAVMs were surgically treated at our institution. Patient clinical features, postsurgical complications, arteriovenous malformation obliteration rate, seizure control, and functional outcome were collected and analyzed. Seizure control was evaluated with the Engel classification system. Patient functional outcome was assessed with modified Rankin Scale score. RESULTS Complete obliteration was achieved in 98.2% of cases. Surgical mortality rate was zero, and overall mortality rate was 1.1%. Good functional outcome (modified Rankin Scale score 0-1) was achieved in 86.9% of all patients, including 92.5% of patients with Spetzler-Martin (S-M) grade I and II uBAVMs, 80.6% of patients with S-M grade III uBAVMs, and 62.5% of patients with S-M grade IV and V uBAVMs. Poor outcome was significantly associated with arteriovenous malformation size ≥6 cm, deep venous drainage, eloquent location, and poor seizure control (all P < 0.05). For 177 patients with presurgical seizures, good seizure outcome (Engel class I) was achieved in 124 (70.1%) patients after microsurgical treatment. A short history of seizure occurrence, fewer presurgical seizures, and generalized tonic-clonic seizure type may be predictors of good seizure outcome (all P < 0.05). CONCLUSIONS Good functional outcome can be achieved by microsurgical resection in S-M grade I and II and selected grade III uBAVMs. Surgical resection for high-grade (grade IV and V) uBAVMs is challenging. A high seizure-free rate can be achieved in patients with initial seizure presentation.
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Affiliation(s)
- Xianzeng Tong
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 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 Diseases, Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 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 Diseases, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 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 Diseases, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 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 Diseases, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 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 Diseases, Beijing, China.
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 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 Diseases, Beijing, China
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Yang W, Porras JL, Hung AL, Khalid S, Garzon-Muvdi T, Caplan JM, Braileanu M, Wang JY, Colby GP, Coon AL, Tamargo RJ, Huang J. Risk of hemorrhage in patients over age 60 with arteriovenous malformations (AVMs). J Clin Neurosci 2016; 34:121-127. [DOI: 10.1016/j.jocn.2016.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 05/18/2016] [Indexed: 01/01/2023]
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222
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Ma L, Chen XL, Chen Y, Wu CX, Ma J, Zhao YL. Subsequent haemorrhage in children with untreated brain arteriovenous malformation: Higher risk with unbalanced inflow and outflow angioarchitecture. Eur Radiol 2016; 27:2868-2876. [PMID: 27900505 DOI: 10.1007/s00330-016-4645-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/30/2016] [Accepted: 10/11/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Children with brain arteriovenous malformations (bAVMs) are at risk of life-threatening haemorrhage in their early lives. Our aim was to analyse various angioarchitectural features of bAVM to predict the risk of subsequent haemorrhage during follow-up in children. METHODS We identified all consecutive children admitted to our institution for bAVMs between July 2009 and September 2015. Children with at least 1 month of treatment-free follow-up after diagnosis were included in further analysis. Annual rates of AVM rupture as well as several potential risk factors for subsequent haemorrhage were analysed using Kaplan-Meier analyses and Cox proportional hazards regression models. RESULTS We identified 110 paediatric patients with a mean follow-up period of 2.1 years (range, 1 month-15.4 years). The average annual risk of haemorrhage from untreated AVMs was 4.3 % in children. No generalised venous ectasia in conjunction with fast arteriovenous shunt was predictive of subsequent haemorrhage (RR, 7.55; 95 % CI 1.96-29.06). The annual rupture risk was 11.1 % in bAVMs without generalised venous ectasia but with fast arteriovenous shunt. CONCLUSIONS bAVM angiographic features suggesting unbalanced inflow and outflow might be helpful to identify children at higher risk for future haemorrhage. KEY POINTS • Haemorrhage risk stratification is important for children with untreated brain AVM. • Angiographic features suggesting unbalanced inflow and outflow predict paediatric brain AVM haemorrhage. • Identifying AVMs with high rupture risk help patient selection and tailoring treatment.
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Affiliation(s)
- Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China, 100050.,Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Xiao-Lin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China, 100050.,Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China, 100050.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Chun-Xue Wu
- Department of Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China, 100050
| | - Jun Ma
- Department of Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China, 100050.
| | - Yuan-Li Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili, Dongcheng District, Beijing, People's Republic of China, 100050. .,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China. .,Stroke Center, Beijing Institute for Brain Disorders, Beijing, People's Republic of China. .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, People's Republic of China.
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223
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Shakur SF, Amin-Hanjani S, Abouelleil M, Aletich VA, Charbel FT, Alaraj A. Changes in pulsatility and resistance indices of cerebral arteriovenous malformation feeder arteries after embolization and surgery. Neurol Res 2016; 39:7-12. [DOI: 10.1080/01616412.2016.1258970] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Sophia F. Shakur
- Department of Neurosurgery, University of Illinois at Chicago , Chicago, IL, USA
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois at Chicago , Chicago, IL, USA
| | - Mohamed Abouelleil
- Department of Neurosurgery, University of Illinois at Chicago , Chicago, IL, USA
| | - Victor A. Aletich
- Department of Neurosurgery, University of Illinois at Chicago , Chicago, IL, USA
| | - Fady T. Charbel
- Department of Neurosurgery, University of Illinois at Chicago , Chicago, IL, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago , Chicago, IL, USA
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224
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Knippen S, Putz F, Semrau S, Lambrecht U, Knippen A, Buchfelder M, Schlaffer S, Struffert T, Fietkau R. Predictors for occlusion of cerebral AVMs following radiation therapy : Radiation dose and prior embolization, but not Spetzler-Martin grade. Strahlenther Onkol 2016; 193:185-191. [PMID: 27757503 DOI: 10.1007/s00066-016-1056-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 09/21/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intracranial arteriovenous malformations (AVMs) may show a harmful development. AVMs are treated by surgery, embolization, or radiation therapy. OBJECTIVE This study investigated obliteration rates and side effects in patients with AVMs treated by radiation therapy. METHODS A total of 40 cases treated between 2005 and 2013 were analyzed. Single-dose stereotactic radiosurgery (SRS) was received by 13 patients and 27 received hypofractionated stereotactic radiation therapy (HSRT). In 20 patients, endovascular embolization had been performed prior to irradiation and 24 patients (60 %) had a history of previous intracranial hemorrhage. RESULTS Treatment resulted in complete obliteration (CO) in 23/40 cases and partial obliteration in 8/40. CO was achieved in 85 % of patients receiving SRS compared to 44 % of those receiving HSRT. In the HSRT group, a first indication of an influence of AVM volume on obliteration rate was found. Equivalent 2 Gy fraction doses (EQD2) >70 Gy showed an obliteration rate of 50 %. Prior embolization was significantly associated with a higher portion of CO (p = 0.032). Median latency period (24.2 vs. 26 months) until CO was similar in both groups (SRS vs. HSRT). The rate of intracranial hemorrhage in patients with no prior bleeding events was 0 %. CONCLUSION Excellent obliteration rates were achieved by SRS. Consistent with the literature, this data analysis suggests that the results of HSRT are volume-dependent. Furthermore, regimens with EQD2 doses >70 Gy appear more likely to achieve obliteration than schemes with lower doses. The findings indicate that radiation therapy does not increase the risk of bleeding. Prior embolization may have a good prognostic impact.
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Affiliation(s)
- Stefan Knippen
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany.
| | - Florian Putz
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Ulrike Lambrecht
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Arzu Knippen
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Sven Schlaffer
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Tobias Struffert
- Department of Neuroradiology, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
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225
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Treatment of Cerebral Arteriovenous Malformations with Radiosurgery or Hypofractionated Stereotactic Radiotherapy in a Consecutive Pooled Linear Accelerator Series. World Neurosurg 2016; 94:328-338. [DOI: 10.1016/j.wneu.2016.07.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 07/04/2016] [Accepted: 07/05/2016] [Indexed: 11/23/2022]
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226
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Asadi H, Kok HK, Looby S, Brennan P, O'Hare A, Thornton J. Outcomes and Complications After Endovascular Treatment of Brain Arteriovenous Malformations: A Prognostication Attempt Using Artificial Intelligence. World Neurosurg 2016; 96:562-569.e1. [PMID: 27693769 DOI: 10.1016/j.wneu.2016.09.086] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 09/16/2016] [Accepted: 09/20/2016] [Indexed: 02/05/2023]
Abstract
PURPOSE To identify factors influencing outcome in brain arteriovenous malformations (BAVM) treated with endovascular embolization. We also assessed the feasibility of using machine learning techniques to prognosticate and predict outcome and compared this to conventional statistical analyses. METHODS A retrospective study of patients undergoing endovascular treatment of BAVM during a 22-year period in a national neuroscience center was performed. Clinical presentation, imaging, procedural details, complications, and outcome were recorded. The data was analyzed with artificial intelligence techniques to identify predictors of outcome and assess accuracy in predicting clinical outcome at final follow-up. RESULTS One-hundred ninety-nine patients underwent treatment for BAVM with a mean follow-up duration of 63 months. The commonest clinical presentation was intracranial hemorrhage (56%). During the follow-up period, there were 51 further hemorrhagic events, comprising spontaneous hemorrhage (n = 27) and procedural related hemorrhage (n = 24). All spontaneous events occurred in previously embolized BAVMs remote from the procedure. Complications included ischemic stroke in 10%, symptomatic hemorrhage in 9.8%, and mortality rate of 4.7%. Standard regression analysis model had an accuracy of 43% in predicting final outcome (mortality), with the type of treatment complication identified as the most important predictor. The machine learning model showed superior accuracy of 97.5% in predicting outcome and identified the presence or absence of nidal fistulae as the most important factor. CONCLUSIONS BAVMs can be treated successfully by endovascular techniques or combined with surgery and radiosurgery with an acceptable risk profile. Machine learning techniques can predict final outcome with greater accuracy and may help individualize treatment based on key predicting factors.
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Affiliation(s)
- Hamed Asadi
- Neurointerventional Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland; School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Australia.
| | - Hong Kuan Kok
- Interventional Radiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Seamus Looby
- Neurointerventional Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Paul Brennan
- Neurointerventional Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Alan O'Hare
- Neurointerventional Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - John Thornton
- Neurointerventional Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
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227
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El-Ghanem M, Kass-Hout T, Kass-Hout O, Alderazi YJ, Amuluru K, Al-Mufti F, Prestigiacomo CJ, Gandhi CD. Arteriovenous Malformations in the Pediatric Population: Review of the Existing Literature. INTERVENTIONAL NEUROLOGY 2016; 5:218-225. [PMID: 27781052 DOI: 10.1159/000447605] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Arteriovenous malformations (AVMs) in the pediatric population are relatively rare but reportedly carry a higher rate of rupture than in adults. This could be due to the fact that most pediatric AVMs are only detected after rupture. We aimed to review the current literature regarding the natural history and the clinical outcome after multimodality AVM treatment in the pediatric population, as optimal management for pediatric AVMs remains controversial. A multidisciplinary approach using multimodality therapy if needed has been proved to be beneficial in approaching these lesions in all age groups. Microsurgical resection remains the gold standard for the treatment of all accessible pediatric AVMs. Embolization and radiosurgery should be considered as an adjunctive therapy. Embolization provides a useful adjunct therapy to microsurgery by preventing significant blood loss and to radiosurgery by decreasing the volume of the AVM. Radiosurgery has been described to provide an alternative treatment approach in certain circumstances either as a primary or adjuvant therapy.
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Affiliation(s)
- Mohammad El-Ghanem
- Department of Neurology, Pennsylvania State University, Hershey, Pa, N.Y., USA
| | - Tareq Kass-Hout
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA; Division of Neuro-Endovascular Surgery, Department of Surgery, Rochester Regional Health System, Rochester, N.Y., USA
| | - Omar Kass-Hout
- Department of Neurology, Emory University School of Medicine, Atlanta, Va, N.Y., USA
| | - Yazan J Alderazi
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
| | - Krishna Amuluru
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
| | - Charles J Prestigiacomo
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
| | - Chirag D Gandhi
- Department of Neurosurgery and Neuroscience, Rutgers University School of Medicine, Newark, N.J, N.Y., USA
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228
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Relationship of pulsatility and resistance indices to cerebral arteriovenous malformation angioarchitectural features and hemorrhage. J Clin Neurosci 2016; 33:119-123. [PMID: 27595365 DOI: 10.1016/j.jocn.2016.02.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 02/14/2016] [Indexed: 11/22/2022]
Abstract
The role that hemodynamics plays in the pathophysiology of cerebral arteriovenous malformation (AVM) hemorrhage remains unclear. Here, we examine the relationship of pulsatility and resistance indices to AVM angioarchitectural features and hemorrhage. Records of patients with cerebral AVMs evaluated at our institution between 2007-2014 and with flows obtained before treatment using quantitative magnetic resonance angiography (QMRA) were retrospectively reviewed. Flow volume rate and flow velocity were measured in primary arterial feeders and compared to their contralateral counterparts. Pulsatility index (PI)=[(systolic flow velocity-diastolic flow velocity)/mean flow velocity] and resistance index (RI)=[(systolic flow velocity-diastolic flow velocity)/systolic flow velocity] were calculated for each feeder and compared to the normal contralateral vessel. Relationships between PI, RI and AVM clinical and angioarchitectural features were assessed using linear regression. Seventy-two patients with a total of 101 feeder arteries were included. PI and RI were significantly lower in AVM arterial feeders compared to normal vessels, thereby resulting in significantly higher flow volume rates and flow velocities in feeder vessels. There was no significant association of PI and RI with hemorrhagic presentation, exclusive deep venous drainage, venous stenosis, single draining vein, or deep location. In conclusion, PI and RI can be measured using QMRA and are lower in AVM arterial feeders compared to normal vessels. Although we found no significant correlation between PI, RI, and AVM angioarchitectural characteristics thought to be associated with increased hemorrhage risk, future studies with larger sample sizes may better elucidate this relationship.
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229
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Shakur SF, Liesse K, Amin-Hanjani S, Carlson AP, Aletich VA, Charbel FT, Alaraj A. Relationship of Cerebral Arteriovenous Malformation Hemodynamics to Clinical Presentation, Angioarchitectural Features, and Hemorrhage. Neurosurgery 2016; 63 Suppl 1:136-140. [DOI: 10.1227/neu.0000000000001285] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Sophia F. Shakur
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Kelly Liesse
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Andrew P. Carlson
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Victor A. Aletich
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Fady T. Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
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230
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Tong X, Wu J, Lin F, Cao Y, Zhao Y, Wang S, Zhao J. Risk Factors for Subsequent Hemorrhage in Patients with Cerebellar Arteriovenous Malformations. World Neurosurg 2016; 92:47-57. [DOI: 10.1016/j.wneu.2016.04.082] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 04/20/2016] [Accepted: 04/22/2016] [Indexed: 11/28/2022]
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231
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Gaab MR. Intracerebral Hemorrhages From Cerebral Arteriovenous Malformations: Prognostic Grading. World Neurosurg 2016; 93:471-3. [PMID: 27404163 DOI: 10.1016/j.wneu.2016.05.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Michael R Gaab
- Neurosurgical Department, Hannover Nordstadt Hospital, Hannover, Germany.
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232
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Ding D, Starke RM, Liu KC, Crowley RW. Cortical plasticity in patients with cerebral arteriovenous malformations. J Clin Neurosci 2016; 22:1857-61. [PMID: 26256067 DOI: 10.1016/j.jocn.2015.06.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/20/2015] [Indexed: 10/22/2022]
Abstract
The aim of this review is to ascertain the evidence for cortical plasticity in arteriovenous malformation (AVM) patients. Chronic hypoperfusion due to vascular steal from cerebral AVM can result in a translocation of eloquent neurological functions to other brain areas, a phenomenon known as cortical plasticity. We performed a systematic literature review of the studies that have evaluated cortical plasticity in AVM patients. A total of 22 studies from 1996 to 2014 were included for the analyses. The evaluation of cortical plasticity was performed prior to AVM intervention in 109 patients, and during or after AVM intervention in 18. The most commonly assessed neurological functions were motor in 85% and language in 11% of the former cohort, and motor in 78% and language, cognition, and memory each in 39% of the latter cohort. Functional MRI was the most frequently used method for evaluating cortical plasticity, and was performed in 63% of the former and 56% of the latter cohort. In conclusion, cortical plasticity appears to be influenced by both AVM pathogenesis and intervention. Given the limited evidence that is currently available for cortical plasticity in AVM patients, further studies are warranted to determine its incidence and impact on long term clinical outcomes.
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Affiliation(s)
- Dale Ding
- Department of Neurosurgery, University of Virginia, Post Office Box 800212, Charlottesville, VA 22908, USA.
| | - Robert M Starke
- Department of Neurosurgery, University of Virginia, Post Office Box 800212, Charlottesville, VA 22908, USA
| | - Kenneth C Liu
- Department of Neurosurgery, University of Virginia, Post Office Box 800212, Charlottesville, VA 22908, USA; Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - R Webster Crowley
- Department of Neurosurgery, University of Virginia, Post Office Box 800212, Charlottesville, VA 22908, USA; Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
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233
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Tong X, Wu J, Lin F, Cao Y, Zhao Y, Wang S, Zhao J. Cerebellar Arteriovenous Malformations: Clinical Feature, Risk of Hemorrhage and Predictors of Posthemorrhage Outcome. World Neurosurg 2016; 92:206-217. [PMID: 27178234 DOI: 10.1016/j.wneu.2016.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/02/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We aimed to summarize the clinical presentation, risk of hemorrhage, and predictors of posthemorrhage outcome in patients with cerebellar arteriovenous malformations (AVMs). METHODS We searched our AVM database at Beijing Tiantan Hospital and identified 225 patients with cerebellar AVMs between the year 2000 and 2015. The clinical presentation and hemorrhage risk were analyzed in all patients. Further analysis of predictors for immediate posthemorrhage outcome was performed in patients with ruptured AVMs. Posthemorrhage modified Rankin Scale (mRS) scores were dichotomized into nonsevere outcome (mRS ≤3) and severe outcome (mRS >3). Univariate and multivariate logistic regression analyses were applied to test the risk factors of hemorrhage and predictors of severe outcome. RESULTS Of the 225 patients, 197 (88%) presented with hemorrhage. Patients with initial hemorrhage were much younger than those with unruptured AVMs (univariate: P = 0.003; multivariate: P = 0.002). Single arterial supply (odds ratio [OR], 2.846; 95% confidence interval [CI], 1.022-7.922) and exclusively deep venous drainage (OR, 3.361; 95% CI, 1.045-10.813) were the other 2 independent risk factors for hemorrhagic presentation. Regarding the neurologic outcome immediately after hemorrhagic presentation, we used 3 models of multivariate logistic regression. Severe neurologic outcome (mRS >3) was associated with eloquent or deep AVM location, associated aneurysm, and the presence of intraventricular hemorrhage (all P < 0.05). CONCLUSION Cerebellar AVMs have an aggressive nature of hemorrhage. Younger age, single feeding artery, and exclusively deep venous drainage were independent risk factors for hemorrhagic presentation. Eloquent location, associated aneurysm, and presence of intraventricular hemorrhage may predict severe immediate posthemorrhage outcome.
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Affiliation(s)
- Xianzeng Tong
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Fuxin Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China.
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China; China National Clinical Research Center for Neurological Diseases, Beijing, P. R. China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, P. R. China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Diseases, Beijing, P. R. China
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234
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Lai LF, Chen JX, Zheng K, He XY, Li XF, Zhang X, Wang QJ, Duan CZ, Chen M. Posterior fossa brain arteriovenous malformations. Clin Neuroradiol 2016; 28:17-24. [DOI: 10.1007/s00062-016-0514-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 04/11/2016] [Indexed: 11/28/2022]
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235
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Hanakita S, Shin M, Koga T, Igaki H, Saito N. Risk Reduction of Cerebral Stroke After Stereotactic Radiosurgery for Small Unruptured Brain Arteriovenous Malformations. Stroke 2016; 47:1247-52. [DOI: 10.1161/strokeaha.116.013132] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/17/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) indicated the superiority of medical management in reducing the risks for strokes and other neurological deficits over observation alone. The aim of our study was to verify the rationale for stereotactic radiosurgery (SRS) for small unruptured arteriovenous malformation.
Methods—
A retrospective review was performed for 292 patients with unruptured arteriovenous malformations referred for SRS. The risks for cerebral hemorrhages were statistically compared before and after SRS.
Results—
Of the 292 patients in whom arteriovenous malformation was found unruptured at initial diagnosis, 17 sustained hemorrhages in the period between the diagnosis and the initial therapeutic intervention (annual bleeding rate, 2.1%; 95% confidence interval [CI], 1.2%–3.4%). Of the remaining 275 patients, 240 were initially treated with SRS, and 16 sustained a hemorrhage after SRS (annual bleeding rate, 1.1%; 95% CI, 0.6%–1.8%), but only 2 sustained a hemorrhage after angiographic obliteration (annual bleeding rate, 0.3%; 95% CI, 0.04%–1.2%). Comparing the risk of hemorrhage between the periods before and after SRS, a 53% risk reduction was achieved after SRS (hazard ratio, 0.47; 95% CI, 0.24–0.94;
P
=0.03), and 85% reduction was achieved after angiographic obliteration (hazard ratio, 0.15; 95% CI, 0.02–0.53;
P
=0.002).
Conclusions—
SRS can significantly reduce the risk of stroke in the patients with small unruptured arteriovenous malformations. To definitively determine the clinical benefits of SRS, a longer follow-up will be necessary. However, based on our results, we can recommend SRS for patients who face a latent risk for stroke from this intractable vascular disease.
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Affiliation(s)
- Shunya Hanakita
- From the Departments of Neurosurgery (S.H., M.S., T.K., N.S.), and Radiology (H.I.), The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiro Shin
- From the Departments of Neurosurgery (S.H., M.S., T.K., N.S.), and Radiology (H.I.), The University of Tokyo Hospital, Tokyo, Japan
| | - Tomoyuki Koga
- From the Departments of Neurosurgery (S.H., M.S., T.K., N.S.), and Radiology (H.I.), The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- From the Departments of Neurosurgery (S.H., M.S., T.K., N.S.), and Radiology (H.I.), The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- From the Departments of Neurosurgery (S.H., M.S., T.K., N.S.), and Radiology (H.I.), The University of Tokyo Hospital, Tokyo, Japan
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236
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Magro E, Gentric JC, Darsaut TE, Ziegler D, Msi, Bojanowski MW, Raymond J. Responses to ARUBA: a systematic review and critical analysis for the design of future arteriovenous malformation trials. J Neurosurg 2016; 126:486-494. [PMID: 27128584 DOI: 10.3171/2015.6.jns15619] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The ARUBA study (A Randomized Trial of Unruptured Brain Arteriovenous Malformations [AVMs]) on unruptured brain AVMs has been the object of comments and editorials. In the present study the authors aim to systematically review critiques, discuss design issues, and propose a framework for future trials. METHODS The authors performed a systematic review of the French and English literature on the ARUBA study published between January 2006 and February 2015. The electronic search, including the Cochrane Library, MEDLINE (PubMed and Ovid), CINAHL, and EMBASE databases, was complemented by hand searching and cross-referencing. The comments were categorized as items related to the design, the conduct, and the analysis and interpretation of the trial. RESULTS Thirty-one articles or letters were identified. The pragmatic design, with heterogeneity of patients and lack of standardization of the treatment arm, were frequently stated concerns. The choice of outcome measures was repeatedly criticized. During the trial, low enrollment rates, selection bias, and premature interruption of enrollment were frequent comments. The short follow-up period, the lack of subgroup analyses, the lack of details on the results of the various treatments, and a contentious interpretation of results were noted at the analysis stage. A fundamental problem was the primary hypothesis testing conservative management. The authors believe that other trials are needed. Future trials could be pragmatic, test interventions stratified at the time of randomization, and look for long-term, hard clinical outcomes in a large number of patients. CONCLUSIONS In the authors' view, the ARUBA trial is a turning point in the history of brain AVM management; future trials should aim at integrating trial methodology and clinical care in the presence of uncertainty.
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Affiliation(s)
- Elsa Magro
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital.,Service de Neurochirurgie, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest; and
| | - Jean-Christophe Gentric
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital.,Groupe d'étude de la Thrombose en Bretagne Occidentale, Brest, France
| | - Tim E Darsaut
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | | | - Msi
- Direction de l'Enseignement et de l'Académie CHUM
- Bibliothèque; and
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital
| | - Jean Raymond
- Department of Radiology, Service of Neuroradiology, CHUM, Notre-Dame Hospital, Montreal, Quebec
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237
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Ding D, Starke RM, Kano H, Lee JYK, Mathieu D, Pierce J, Huang PP, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Kondziolka D, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for Spetzler-Martin Grade III arteriovenous malformations: an international multicenter study. J Neurosurg 2016; 126:859-871. [PMID: 27081906 DOI: 10.3171/2016.1.jns152564] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Because of the angioarchitectural diversity of Spetzler-Martin (SM) Grade III arteriovenous malformations (AVMs), the management of these lesions is incompletely defined. The aims of this multicenter, retrospective cohort study were to evaluate the outcomes after stereotactic radiosurgery (SRS) for SM Grade III AVMs and to determine the factors predicting these outcomes. METHODS The authors analyzed and pooled data from patients with SM Grade III AVMs treated with SRS at 8 institutions participating in the International Gamma Knife Research Foundation. Patients with these AVMs and a minimum follow-up length of 12 months were included in the study cohort. An optimal outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RICs). Data were analyzed by univariate and multivariate regression analyses. RESULTS The SM Grade III AVM cohort comprised 891 patients with a mean age of 34 years at the time of SRS. The mean nidus volume, radiosurgical margin dose, and follow-up length were 4.5 cm3, 20 Gy, and 89 months, respectively. The actuarial obliteration rates at 5 and 10 years were 63% and 78%, respectively. The annual postradiosurgery hemorrhage rate was 1.2%. Symptomatic and permanent RICs were observed in 11% and 4% of the patients, respectively. Optimal outcome was achieved in 56% of the patients and was significantly more frequent in cases of unruptured AVMs (OR 2.3, p < 0.001). The lack of a previous hemorrhage (p = 0.037), absence of previous AVM embolization (p = 0.002), smaller nidus volume (p = 0.014), absence of AVM-associated arterial aneurysms (p = 0.023), and higher margin dose (p < 0.001) were statistically significant independent predictors of optimal outcome in a multivariate analysis. CONCLUSIONS Stereotactic radiosurgery provided better outcomes for patients with small, unruptured SM Grade III AVMs than for large or ruptured SM Grade III nidi. A prospective trial or registry that facilitates a comparison of SRS with conservative AVM management might further clarify the authors' observations for these often high-risk AVMs.
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Affiliation(s)
- Dale Ding
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert M Starke
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, and
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Mathieu
- Division of Neurosurgery, University of Sherbrooke, Centre de recherché du CHUS, Sherbrooke, Quebec, Canada
| | - John Pierce
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul P Huang
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Caleb Feliciano
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Luis Almodovar
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Danilo Silva
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mahmoud Abbassy
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Symeon Missios
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, and
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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238
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Alexander MD, Cooke DL, Hallam DK, Kim H, Hetts SW, Ghodke BV. Less can be more: Targeted embolization of aneurysms associated with arteriovenous malformations unsuitable for surgical resection. Interv Neuroradiol 2016; 22:445-51. [PMID: 27066813 DOI: 10.1177/1591019916641316] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 02/15/2016] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION To mitigate risks of hemorrhage, high-risk features of brain arteriovenous malformations (BAVMs) can be targeted to reduce the risk of rupture. Previous investigation has examined embolization of a pedicle supplying a high-risk feature; this study examines embolization targeted specifically at aneurysms associated with BAVMs. MATERIALS AND METHODS Patients with BAVMs treated at two high-volume neurointerventional services were retrospectively reviewed. Patients treated with intention to occlude only the associated aneurysm itself were analyzed. Demographic and lesion characteristics were identified, as were technical and clinical outcomes. Adverse events were defined as hemorrhage, new seizure, and death. RESULTS Thirty-two patients met inclusion criteria out of 1103 patients treated during the study period. Twenty-seven (84.4%) BAVMs were acutely ruptured, all with the aneurysm identified as the hemorrhage source. Twenty-four (75.0%) lesions involved eloquent territory. There were equal numbers of feeding artery and nidus aneurysms. Follow-up data were available for a total of 101.3 patient-years for a mean follow-up time of 2.9 years. One patient died; the remaining 31 patients had improved functional status at last contact. Annualized rate of hemorrhage after treatment was 1.0%; rate of adverse events after treatment was 3.0%. Excluding time after confirmed occlusion following radiosurgery, annualized rates were 1.4% and 4.8%, respectively. CONCLUSION In inoperable BAVMs, targeted embolization of associated aneurysms can be performed safely and effectively. This should be considered in high-risk lesions prior to radiosurgery or in cases when no other treatment options are available. Such intervention warrants further investigation.
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Affiliation(s)
- Matthew D Alexander
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, USA
| | | | - Helen Kim
- Department of Anesthesia and Perioperative Care, University of California San Francisco, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, USA
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239
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Hermanto Y, Takagi Y, Yoshida K, Ishii A, Kikuchi T, Funaki T, Mineharu Y, Miyamoto S. Histopathological Features of Brain Arteriovenous Malformations in Japanese Patients. Neurol Med Chir (Tokyo) 2016; 56:340-4. [PMID: 27053330 PMCID: PMC4908077 DOI: 10.2176/nmc.oa.2016-0032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Clinical features of high risk brain arteriovenous malformations (BAVMs) are well characterized. However, pathological evidences about the differences that are possessed by high risk patients are still lacking. We reviewed archived routine hematoxylin-eosin specimens from a total of 54 surgical treated BAVMs. The histopathological features in nidus were semi-quantitatively analyzed. We obtained the pathological differences of BAVMs nidus between several clinical features. Among the analyzed pathological features, the significant differences were observed in degree of venous enlargement and intimal hyperplasia. Juvenile, female, diffuse nidus, high Spetzler-Martin grade, and low flow patients had a lesser degree of those parameters compared to adult, male, compact nidus, low Spetzler-Martin grade and high flow patients. High risk profiles of BAVMs patients were well-reflected in the nidus pathology. Therefore, juvenile, female, diffuse nidus, and low flow in Japanese BAVMs patients might have different vascular remodeling process that predispose to higher tendency of hemorrhage.
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Affiliation(s)
- Yulius Hermanto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine
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240
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Shakur SF, Valyi-Nagy T, Amin-Hanjani S, Ya’qoub L, Aletich VA, Charbel FT, Alaraj A. Effects of nidus microarchitecture on cerebral arteriovenous malformation hemodynamics. J Clin Neurosci 2016; 26:70-4. [DOI: 10.1016/j.jocn.2015.10.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 10/11/2015] [Indexed: 10/22/2022]
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241
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Oermann EK, Ding D, Yen CP, Starke RM, Bederson JB, Kondziolka D, Sheehan JP. Effect of Prior Embolization on Cerebral Arteriovenous Malformation Radiosurgery Outcomes: A Case-Control Study. Neurosurgery 2016; 77:406-17; discussion 417. [PMID: 25875580 DOI: 10.1227/neu.0000000000000772] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Embolization before stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations (AVM) has been shown to negatively affect obliteration rates, but its impact on the risks of radiosurgery-induced complications and latency period hemorrhage is poorly defined. OBJECTIVE To determine, in a case-control study, the effect of prior embolization on AVM SRS outcomes. METHODS We evaluated a database of AVM patients who underwent SRS. Propensity score analysis was used to match the case (embolized nidi) and control (nonembolized nidi) cohorts. AVM angioarchitectural complexity was defined as the sum of the number of major feeding arteries and draining veins to the nidus. Multivariate Cox proportional hazards regression analyses were performed on the overall study population to determine independent predictors of obliteration and radiation-induced changes. RESULTS The matching process yielded 242 patients in each cohort. The actuarial obliteration rates were significantly lower in the embolized (31%, 49% at 5, 10 years, respectively) compared with the nonembolized (48%, 64% at 5, 10 years, respectively) cohort (P = .003). In the multivariate analysis for obliteration, lower angioarchitectural complexity (P < .001) and radiologically evident radiation-induced changes (P = .016) were independent predictors, but embolization was not significant (P = .744). In the multivariate analysis for radiologic radiation-induced changes, lack of prior embolization (P = .009) and fewer draining veins (P = .011) were independent predictors. CONCLUSION The effect of prior embolization on AVM obliteration after SRS may be significantly confounded by nidus angioarchitectural complexity. Additionally, embolization could reduce the risk of radiation-induced changes. Thus, combined embolization and SRS may be warranted for appropriately selected nidi.
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Affiliation(s)
- Eric K Oermann
- *Mount Sinai Health System, Department of Neurosurgery, New York City, New York; ‡University of Virginia, Department of Neurosurgery, Charlottesville, Virginia; §New York University Langone Medical Center, Department of Neurosurgery, New York City, New York
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Hanakita S, Shin M, Koga T, Igaki H, Saito N. Outcomes of Volume-Staged Radiosurgery for Cerebral Arteriovenous Malformations Larger Than 20 cm3 with More Than 3 Years of Follow-Up. World Neurosurg 2016; 87:242-9. [DOI: 10.1016/j.wneu.2015.12.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 12/17/2015] [Accepted: 12/18/2015] [Indexed: 11/27/2022]
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243
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Tong X, Wu J, Lin F, Cao Y, Zhao Y, Ning B, Zhao B, Wang L, Zhang S, Wang S, Zhao J. The Effect of Age, Sex, and Lesion Location on Initial Presentation in Patients with Brain Arteriovenous Malformations. World Neurosurg 2016; 87:598-606. [DOI: 10.1016/j.wneu.2015.10.060] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/11/2015] [Accepted: 10/12/2015] [Indexed: 10/22/2022]
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244
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Yang W, Hung AL, Caplan JM, Braileanu M, Wang JY, Colby GP, Coon AL, Tamargo RJ, Huang J. Delayed Hemorrhage After Treatment of Brain Arteriovenous Malformations (AVMs). World Neurosurg 2016; 87:98-109. [DOI: 10.1016/j.wneu.2015.11.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/09/2015] [Accepted: 11/12/2015] [Indexed: 10/22/2022]
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245
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Ding D, Xu Z, Starke RM, Yen CP, Shih HH, Buell TJ, Sheehan JP. Radiosurgery for Cerebral Arteriovenous Malformations with Associated Arterial Aneurysms. World Neurosurg 2016; 87:77-90. [DOI: 10.1016/j.wneu.2015.11.080] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/25/2015] [Accepted: 11/26/2015] [Indexed: 01/08/2023]
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246
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A review on animal models of stroke: An update. Brain Res Bull 2016; 122:35-44. [PMID: 26902651 DOI: 10.1016/j.brainresbull.2016.02.016] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 02/15/2016] [Accepted: 02/17/2016] [Indexed: 01/11/2023]
Abstract
Stroke is one of the major healthcare challenges prevailing across the globe due to its significant rate of mortality and morbidity. Stroke is multifactorial in nature and involves several cellular and molecular signaling cascades that make the pathogenesis complex and treatment difficult. For a deeper understanding of the diverse pathological mechanisms and molecular & cellular cascades during stroke, animal modeling serves as a reliable and an effective tool. This also helps to develop and critically analyse various neuroprotective strategies for the mitigation of this devastating disease. Animal modeling for stroke has been revolutionized with the development of newer and more relevant models or approaches that mimic the clinical setting of stroke to a greater extent. This review analyses experimental models of stroke (ischemic and hemorrhagic) and their reliability in stroke situation. Besides this, the review also stresses upon the use of various preclinical models to understand the pathophysiological mechanisms that operate during stroke and to elucidate new, safe and effective neuroprotective agents to combat this life threatening healthcare concern.
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247
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Using a Machine Learning Approach to Predict Outcomes after Radiosurgery for Cerebral Arteriovenous Malformations. Sci Rep 2016; 6:21161. [PMID: 26856372 PMCID: PMC4746661 DOI: 10.1038/srep21161] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 01/12/2016] [Indexed: 11/08/2022] Open
Abstract
Predictions of patient outcomes after a given therapy are fundamental to medical practice. We employ a machine learning approach towards predicting the outcomes after stereotactic radiosurgery for cerebral arteriovenous malformations (AVMs). Using three prospective databases, a machine learning approach of feature engineering and model optimization was implemented to create the most accurate predictor of AVM outcomes. Existing prognostic systems were scored for purposes of comparison. The final predictor was secondarily validated on an independent site's dataset not utilized for initial construction. Out of 1,810 patients, 1,674 to 1,291 patients depending upon time threshold, with 23 features were included for analysis and divided into training and validation sets. The best predictor had an average area under the curve (AUC) of 0.71 compared to existing clinical systems of 0.63 across all time points. On the heldout dataset, the predictor had an accuracy of around 0.74 at across all time thresholds with a specificity and sensitivity of 62% and 85% respectively. This machine learning approach was able to provide the best possible predictions of AVM radiosurgery outcomes of any method to date, identify a novel radiobiological feature (3D surface dose), and demonstrate a paradigm for further development of prognostic tools in medical care.
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Cohen-Inbar O, Ding D, Chen CJ, Sheehan JP. Stereotactic radiosurgery for deep intracranial arteriovenous malformations, part 1: Brainstem arteriovenous malformations. J Clin Neurosci 2016; 24:30-6. [DOI: 10.1016/j.jocn.2015.11.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 11/21/2015] [Indexed: 11/30/2022]
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249
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Stereotactic radiosurgery for deep intracranial arteriovenous malformations, part 2: Basal ganglia and thalamus arteriovenous malformations. J Clin Neurosci 2016; 24:37-42. [DOI: 10.1016/j.jocn.2015.11.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 11/21/2015] [Indexed: 11/24/2022]
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250
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Waseem A. Cranial Arteriovenous Malformations During Pregnancy: A Multidisciplinary Algorithm for Safe Management. Case Series and Review of the Literature. ACTA ACUST UNITED AC 2016. [DOI: 10.15406/jnsk.2016.04.00122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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