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Lee J, Kim WC, Kim HJ, Park H. CyberKnife based fractionated stereotactic radiotherapy as an upfront treatment for cerebral arteriovenous malformation. J Clin Neurosci 2023; 117:40-45. [PMID: 37757652 DOI: 10.1016/j.jocn.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/10/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND To explore the therapeutic outcomes of CyberKnife based fractionated stereotactic radiotherapy (CKFRT) for patients with cerebral arteriovenous malformations (AVM). METHODS Between January 2008 and October 2020, 45 patients underwent CKFRT for cerebral AVMs as a first treatment. The delineation of AVM targets included AVM nidus. The mean target volume was 4.07 cm3, and 9 lesions (20%) were larger than 10.0 cm3. The mean marginal dose was 24 Gy (range, 20-35 Gy). CKFRT was delivered in median 3 fractions (range, 2 ∼ 5 fractions). AVM obliteration following CKFRT was confirmed by magnetic resonance imaging or angiography. RESULTS During a median follow-up of 47 (5-148) months, complete obliteration and partial obliteration of AVM after CKFRT were obtained in 23 (51%) and 13 (29%) patients, respectively. Median time to complete obliteration was 39 (15-63) months. The cumulative probability of complete obliteration rate at 3 years was 47%. Complete obliteration rate of AVM was associated with Radiosurgery-based AVM score, which was consisted of AVM volume, patients age, and AVM location. One (2%) patient had hemorrhage during the follow-up period. CONCLUSIONS CKFRT is an effective primary treatment for patients with cerebral AVMs with a low hemorrhage risk.
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Affiliation(s)
- Jeongshim Lee
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, South Korea.
| | - Woo Chul Kim
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, South Korea
| | - Hun Jung Kim
- Department of Radiation Oncology, Inha University Hospital, Inha University School of Medicine, Incheon, South Korea
| | - Hyeonseon Park
- Department of Neurosurgery, Inha University Hospital, Inha University School of Medicine, Incheon, South Korea.
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Linac-based stereotactic radiosurgery for brain arteriovenous malformations. Radiat Oncol 2022; 17:161. [PMID: 36175931 PMCID: PMC9520913 DOI: 10.1186/s13014-022-02130-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Linac stereotactic radiosurgery (SRS) is gaining popularity as a form of radiation treatment for cerebral arteriovenous malformations (AVMs) since the theory of combined radiosurgical and endovascular treatment poses much uncertainty and due to significant technical progress for SRS. This study focuses on how to evaluate obliteration and re-bleeding rates, and to determine factors and adverse effects influencing obliteration after linac-based SRS for cerebral AVMs. MATERIAL AND METHODS From a statistical record of 71 patients, 31 had partial embolisation, five surgery and 29 had no prior treatment. Using Kaplan-Meier survival and life table analyses, actuarial obliteration and annual bleeding hazard rates were calculated after SRS. RESULTS After a follow up of 1, 2 and 3 years the actual obliteration rates were 22, 59 and 66%, respectively whereby it was noted that prior embolization had no effect on the obliteration rate. Annual bleeding hazard rates were further analyzed after stereotactic radiosurgery to be 2.1% and 1.4% for the first and second year respectively. Asymptomatic abnormalities were detected after imaging in 33.9% of patients. A dose of less than 18 Gy significantly reduced the obliteration probability. CONCLUSION SRS is a therapeutic option for intracerebral AVM. In general, there is a low rate of morbidity and a high probability of nidus obliteration.
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LINAC stereotactic radiosurgery for brain arteriovenous malformations: An updated single centre analysis of outcomes. J Clin Neurosci 2022; 102:54-59. [PMID: 35728395 DOI: 10.1016/j.jocn.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 06/03/2022] [Accepted: 06/05/2022] [Indexed: 10/18/2022]
Abstract
Arteriovenous malformations (AVM) of the brain are congenital, high pressure vascular malformations, which are at risk of haemorrhage. Stereotactic radiosurgery (SRS) can obliterate the nidus by delivering a precise high dose of ionising radiation in a single fraction. This paper updates long term AVM obliteration rates, time to obliteration and retreatment outcomes in LINAC delivered SRS treatment at the Royal Adelaide Hospital. A retrospective review of a prospectively maintained AVM SRS database supplemented by clinical case notes, patient correspondence and electronic medical records was performed. 89 AVMs received primary SRS treatment for which the crude obliteration rate was 61% (68% for 79 patients with adequate follow up). Higher marginal dose, smaller nidus size and lower Pollock-Flickinger (PF) score were significantly associated with AVM obliteration. The crude obliteration rates for patients with adequate follow-up and AVM diameter < 3 cm vs ≥ 3 cm were 76% vs 48%, respectively, and 93% with PF score < 1.0. Median time to obliteration was 36 months. Higher dose and lower PF score were associated with earlier obliteration. The crude obliteration rate after second SRS was 56% (9/16 patients) and no significant associations were found. These obliteration rates after primary and retreatment LINAC SRS are comparable to other studies. Marginal dose and PF score were the main predictors of obliteration overall as well as early (<36 months) obliteration.
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Greve T, Ehret F, Hofmann T, Thorsteinsdottir J, Dorn F, Švigelj V, Resman-Gašperšič A, Tonn JC, Schichor C, Muacevic A. Magnetic Resonance Imaging-Based Robotic Radiosurgery of Arteriovenous Malformations. Front Oncol 2021; 10:608750. [PMID: 33767974 PMCID: PMC7986716 DOI: 10.3389/fonc.2020.608750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/21/2020] [Indexed: 11/19/2022] Open
Abstract
Objective CyberKnife offers CT- and MRI-based treatment planning without the need for stereotactically acquired DSA. The literature on CyberKnife treatment of cerebral AVMs is sparse. Here, a large series focusing on cerebral AVMs treated by the frameless CyberKnife stereotactic radiosurgery (SRS) system was analyzed. Methods In this retrospective study, patients with cerebral AVMs treated by CyberKnife SRS between 2005 and 2019 were included. Planning was MRI- and CT-based. Conventional DSA was not coregistered to the MRI and CT scans used for treatment planning and was only used as an adjunct. Obliteration dynamics and clinical outcome were analyzed. Results 215 patients were included. 53.0% received SRS as first treatment; the rest underwent previous surgery, embolization, SRS, or a combination. Most AVMs were classified as Spetzler-Martin grade I to III (54.9%). Hemorrhage before treatment occurred in 46.0%. Patients suffered from headache (28.8%), and seizures (14.0%) in the majority of cases. The median SRS dose was 18 Gy and the median target volume was 2.4 cm³. New neurological deficits occurred in 5.1% after SRS, with all but one patient recovering. The yearly post-SRS hemorrhage incidence was 1.3%. In 152 patients who were followed-up for at least three years, 47.4% showed complete AVM obliteration within this period. Cox regression analysis revealed Spetzler-Martin grade (P = 0.006) to be the only independent predictor of complete obliteration. Conclusions Although data on radiotherapy of AVMs is available, this is one of the largest series, focusing exclusively on CyberKnife treatment. Safety and efficacy compared favorably to frame-based systems. Non-invasive treatment planning, with a frameless SRS robotic system might provide higher patient comfort, a less invasive treatment option, and lower radiation exposure.
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Affiliation(s)
- Tobias Greve
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
| | - Felix Ehret
- European Cyberknife Center Munich-Grosshadern, Munich, Germany
| | - Theresa Hofmann
- European Cyberknife Center Munich-Grosshadern, Munich, Germany
| | | | - Franziska Dorn
- Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Viktor Švigelj
- Division of Neurology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | | | - Christian Schichor
- Department of Neurosurgery, University Hospital, LMU Munich, Munich, Germany
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Xu MC, Khattab MH, Luo G, Sherry AD, Morales-Paliza M, Chaballout BH, Anderson JL, Attia A, Cmelak AJ. Effects of cone versus multi-leaf collimation on dosimetry and neurotoxicity in patients with small arteriovenous malformations treated by stereotactic radiosurgery. JOURNAL OF RADIOSURGERY AND SBRT 2021; 7:287-294. [PMID: 34631230 PMCID: PMC8492055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 02/15/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE/OBJECTIVE Linear accelerator (LINAC) based stereotactic radiosurgery (SRS) for arteriovenous malformations (AVMs) is delivered with cone or multileaf collimators (MLCs), and favorable dosimetry is associated with reduced radionecrosis in normal brain tissue. This study aims to determine whether cones or MLCs has better dosimetric characteristics, to predict differences in toxicity. METHODS All patients treated for AVMs using LINAC SRS from 2003-2017 were examined retrospectively. Demographic data, volumes of normal tissue exposed to 12Gy (V12Gy[cc]) and 4Gy (V4Gy[cc]), maximal dose, and dose gradient were analyzed. Univariate and multivariate analyses were used to evaluate relationships between collimator type, dosimetric parameters, and toxicity. Propensity score matching was used to adjust for AVM size. RESULTS Compared to MLC, cones were independently associated with reduced V12Gy[cc] after propensity score matching (p=0.008) and reduced neurotoxicity (p=0.016). Higher V12Gy[cc] (p=0.0008) and V4Gy[cc] (p=0.002) were associated with increased neurotoxicity. CONCLUSIONS Treating AVMs with cone-based SRS over MLC-based SRS may improve dosimetry and reduce toxicities.
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Affiliation(s)
- Mark C Xu
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Manuel Morales-Paliza
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Basil H. Chaballout
- University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | | | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
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Gutierrez-Aceves GA, Rodriguez-Camacho A, Celis-Lopez MA, Moreno-Jimenez S, Herrera-Gonzalez JA. Frameless radiosurgical third ventriculostomy: Technical report. Surg Neurol Int 2020; 11:398. [PMID: 33282458 PMCID: PMC7710479 DOI: 10.25259/sni_247_2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/23/2020] [Indexed: 11/28/2022] Open
Abstract
Background: We describe the technical report and results of the first image-guided, linear accelerator, frameless radiosurgical third ventriculostomy. Methods: We report a 20 years old man, with diplopia, balance disturbances, and limitation for gaze supraversion. Magnetic resonance imaging resonance imaging of the brain and cranial computed tomography showed showed a left thalamic-midbrain lesion that caused partial compression of the Silvio aqueduct and mild ventricular dilatation. The biopsy revealed the diagnosis of pleomorphic xanthoastrocytoma. Before radical treatment of the tumor with fractionated stereotactic radiotherapy, the patient underwent to frameless radiosurgical third ventriculostomy, on the TrueBeam STX® platform with the ExacTrac localization system. The target used was the one defined on the floor of the third ventricle, at the midpoint between the mammillary bodies and the infundibular recess. The prescription dose was 120 Gy, given using a monoisocentric technique of multiple noncoplanar circular arches. The geometric arrangement of the plan consisted of 15 arches, with a 4 mm cone, distributed over a 110° table. Results: There was symptomatic and image improvement two days after radiosurgery. On CT, a reduction in ventricular dilation was observed with a reduction in the Evans index from 0.39 (initial CT) to 0.29 (CT at 15 days). In 3.0T magnetic resonance image at 3 months, we showed the third ventriculostomy. There have been no treatment failures or complications. Conclusion: It is possible to effectively perform the frameless radiosurgical third ventriculostomy without associated morbidity in the short term.
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Affiliation(s)
| | - Alejandro Rodriguez-Camacho
- Radio Neurosurgery Unit, National Institute of Neurology and Neurosurgery "Dr. Manuel Velasco Suarez", Mexico City, Mexico
| | - Miguel Angel Celis-Lopez
- Radio Neurosurgery Unit, National Institute of Neurology and Neurosurgery "Dr. Manuel Velasco Suarez", Mexico City, Mexico
| | - Sergio Moreno-Jimenez
- Radio Neurosurgery Unit, National Institute of Neurology and Neurosurgery "Dr. Manuel Velasco Suarez", Mexico City, Mexico
| | - Jose Alfredo Herrera-Gonzalez
- Radio Neurosurgery Unit, National Institute of Neurology and Neurosurgery "Dr. Manuel Velasco Suarez", Mexico City, Mexico
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Liu EK, Silverman JS, Sulman EP. Stereotactic Radiation for Treating Primary and Metastatic Neoplasms of the Spinal Cord. Front Oncol 2020; 10:907. [PMID: 32582555 PMCID: PMC7295942 DOI: 10.3389/fonc.2020.00907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/11/2020] [Indexed: 12/14/2022] Open
Abstract
Stereotactic radiation treatment can be used to treat spinal cord neoplasms in patients with either unresectable lesions or residual disease after surgical resection. While treatment guidelines have been suggested for epidural lesions, the utility of stereotactic radiation for intradural and intramedullary malignancies is still debated. Prior reports have suggested that stereotactic radiation approaches can be used for effective tumor control and symptom management. Treatment-related toxicity has been documented in rare subsets of patients, though the incidences of injury are not directly correlated with higher radiation doses. Further studies are needed to assess the factors that influence the risk of radiation-induced myelopathy when treating spinal cord neoplasms with stereotactic radiation, which can include, but may not be limited to, maximum dose, dose-fractionation, irradiated volume, tumor location, histology and treatment history. This review will discuss evidence for current treatment approaches.
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Affiliation(s)
- Elisa K Liu
- Departments of Radiation Oncology, NYU Grossman School of Medicine, New York, NY, United States
| | - Joshua S Silverman
- Departments of Radiation Oncology, NYU Grossman School of Medicine, New York, NY, United States.,Departments of Neurosurgery, NYU Grossman School of Medicine, New York, NY, United States
| | - Erik P Sulman
- Departments of Radiation Oncology, NYU Grossman School of Medicine, New York, NY, United States.,Brain and Spine Tumor Center, Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, NY, United States
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Chagoya G, Hardigan AA, Fox BM, Laskay N, Salehani AA, Rotman LE, Elsayed GA, Bernstock JD, Omar NB, Tabibian BE, Ilyas A, Hackney J, Fisher WS. Cerebellar Arteriovenous Malformation Rupture Despite Apparent Angiographic Obliteration. World Neurosurg 2019; 134:25-32. [PMID: 31629928 DOI: 10.1016/j.wneu.2019.10.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Arteriovenous malformations (AVMs) can occur in all regions of the brain and spinal cord, with clinical consequences and risks varying by location. Delayed AVM rupture despite digital subtraction angiography-confirmed obliteration post-radiation is exceedingly rare. CASE DESCRIPTION To our knowledge, we present the first documented case of delayed hemorrhage associated with a cerebellar AVM 5 years after linear accelerator-based radiation in a man aged 31 years despite apparent angiographic obliteration. CONCLUSIONS Intracranial hemorrhage after radiosurgery in digital subtraction angiography-confirmed obliterated AVMs is rare, with limited understanding of risk factors, appropriate preventative management, and mechanisms of occurrence. This case serves to demonstrate the need for greater awareness of this rare complication, as well as the need for appropriate surveillance and management strategies.
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Affiliation(s)
- Gustavo Chagoya
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Andrew A Hardigan
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama; Department Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brandon M Fox
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama; Department Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nicholas Laskay
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Arsalaan A Salehani
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lauren E Rotman
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Galal A Elsayed
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nidal B Omar
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - B Ethan Tabibian
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James Hackney
- Department Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Winfield S Fisher
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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