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Maroufi SF, Fallahi MS, Khorasanizadeh M, Waqas M, Sheehan JP. Radiosurgery With Prior Embolization Versus Radiosurgery Alone for Intracranial Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2024; 94:478-496. [PMID: 37796184 DOI: 10.1227/neu.0000000000002699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/02/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The addition of adjuvant embolization to radiosurgery has been proposed as a means of improving treatment outcomes of intracranial arteriovenous malformations (AVMs). However, the relative efficacy and safety of radiosurgery with adjuvant embolization vs radiosurgery alone remain uncertain. Moreover, previous systematic reviews and meta-analyses have included a limited number of studies and did not consider the effects of baseline characteristics, including AVM volume, on the outcomes. This systematic review aimed to evaluate the efficacy of preradiosurgery embolization for intracranial AVMs with consideration to matching status between participants in each treatment group. METHODS A systematic review and meta-analysis were conducted by searching electronic databases, including PubMed, Scopus, and Cochrane Library, up to January 2023. All studies evaluating the utilization of preradiosurgery embolization were included. RESULTS A total of 70 studies (9 matched and 71 unmatched) with a total of 12 088 patients were included. The mean age of the included patients was 32.41 years, and 48.91% of the patients were female. Preradiosurgery embolization was used for larger AVMs and patients with previous hemorrhage ( P < .01, P = .02, respectively). The obliteration rate for preradiosurgery embolization (49.44%) was lower compared with radiosurgery alone (61.42%, odds ratio = 0.56, P < .01), regardless of the matching status of the analyzed studies. Although prior embolization was associated higher rate of cyst formation ( P = .04), it lowered the odds of radiation-induced changes ( P = .04). The risks of minor and major neurological deficits, postradiosurgery hemorrhage, and mortality were comparable between groups. CONCLUSION This study provides evidence that although preradiosurgery embolization is a suitable option to reduce the AVM size for future radiosurgical interventions, it may not be useful for same-sized AVMs eligible for radiosurgery. Utilization of preradiosurgery embolization in suitable lesions for radiosurgery may result in the added cost and burden of an endovascular procedure.
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Affiliation(s)
- Seyed Farzad Maroufi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran , Iran
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran , Iran
| | - Mohammad Sadegh Fallahi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran , Iran
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran , Iran
| | - MirHojjat Khorasanizadeh
- Department of Neurosurgery, Mount Sinai Hospital, Icahn School of Medicine, New York City , New York , USA
| | - Muhammad Waqas
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo , New York , USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
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Beneš V, Bubeníková A, Skalický P, Bradáč O. Treatment of Brain Arteriovenous Malformations. Adv Tech Stand Neurosurg 2024; 49:139-179. [PMID: 38700684 DOI: 10.1007/978-3-031-42398-7_8] [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] [Indexed: 06/01/2024]
Abstract
Brain arteriovenous malformations (AVMs) are a rare entity of vascular anomalies, characteristic of anatomical shunting where arterial blood directly flows into the venous circulation. The main aim of the active treatment policy of brain AVMs is the prevention of haemorrhage. There are well-established treatment strategies that continually improve in their safety and efficacy, primarily due to the advances in imaging modalities, targeted and novel techniques, the development of alternative treatment approaches, and even better experience with the disease itself. There are interesting imaging novelties that may be prospectively applicable in the decision-making and planning of the most effective treatment approach for individual patients with intracranial AVM. Surgery is often considered the first-line treatment; however, each patient should be evaluated individually, and the risks of the active treatment policy should not overcome the benefits of the spontaneous natural history of the disease. All treatment modalities, i.e., surgery, radiosurgery, endovascular embolization, and observation, are justified but need to be meticulously selected for each individual patient in order to deliver the best treatment outcome. This chapter deals with historical and currently applied dogmas, followed by introductions of advances in each available treatment modality of AVM management.
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Affiliation(s)
- Vladimír Beneš
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Adéla Bubeníková
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Neurosurgery, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Petr Skalický
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Neurosurgery, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ondřej Bradáč
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic.
- Department of Neurosurgery, Motol University Hospital, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
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3
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Lauzier DC, Ullman H, Hardi A, Derdeyn C, Cross DT, Moran CJ. Endovascular treatment of dural arteriovenous fistulas involving the vein of Galen: a single-center cohort and meta-analysis. J Neurointerv Surg 2023:jnis-2023-020843. [PMID: 37777258 DOI: 10.1136/jnis-2023-020843] [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: 07/24/2023] [Accepted: 09/13/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Dural arteriovenous fistulas (dAVFs) draining into the vein of Galen (VoG) are complex lesions that often necessitate treatment to minimize the risk of rupture and relieve symptoms. These lesions can be treated with open surgical resection, radiosurgery, or endovascular embolization. Unfortunately, endovascular treatment of dAVFs involving the VoG has not been robustly assessed across large patient cohorts. To meet this need, we performed a retrospective review of dAVFs involving the VoG at our center, and included these in a meta-analysis to identify the safety and efficacy of endovascular embolization, as well as describing current treatment trends for this disease. METHODS Consecutive patients with dAVFs involving the VoG treated at a single center were identified from a prospective database and retrospectively reviewed. A literature search was conducted with defined search criteria, and eligible studies were included alongside our cohort in a meta-analysis. Rates of complete dAVF treatment and clinical complications were pooled across studies with a random effects model and reported with a 95% CI. RESULTS Five dAVFs involving the VoG were treated endovascularly at our center during the study period. In this series, 80% of treatments led to complete occlusion of the fistula while no patients had clinical complications. Onyx was used for all treatments. In our meta-analysis, the overall rate of complete occlusion was 72.0% (95% CI 59.8% to 84.1%) and the overall rate of clinical complications was 10.0% (95% CI 4.7% to 15.3%). CONCLUSIONS Endovascular approaches for dAVFs involving the VoG are technically feasible, but carry a risk of clinical complications. Future work should identify optimal endovascular embolic agents.
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Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Henrik Ullman
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Angela Hardi
- Bernard Becker Medical Library, Washington University School of Medicine, St Louis, Missouri, USA
| | - Colin Derdeyn
- Department of Radiology, University of Iowa Medical Center, Iowa City, Iowa, USA
| | - Dewitte T Cross
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology and Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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Hsieh J, Wei W, Nie JZ, Barnett GH, Mohammadi AM, Stevens G, Vogelbaum M, Angelov L. The impact of opioid administration for post gamma knife radiosurgery frame removal: a prospective quality-improvement study. J Neurooncol 2023; 164:721-728. [PMID: 37749305 DOI: 10.1007/s11060-023-04436-x] [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: 07/05/2023] [Accepted: 08/24/2023] [Indexed: 09/27/2023]
Abstract
PURPOSE In our center, five Gamma Knife proceduralists differed in opioid administration practices prior to Leksell frame removal, providing the opportunity to improve the care of patients with brain metastases by studying whether opioid medications improve pain scores and patient satisfaction during Gamma Knife treatment in a prospective, pseudorandomized fashion. METHODS We prospectively administered a questionnaire to patients undergoing Gamma Knife Radiosurgery for metastases between November, 2017 and July, 2018. Using multivariable methods, we assessed whether opioid pain medication administration influenced the change in pain scores after frame removal, and whether they influenced patient satisfaction on how often their pain was controlled, and their overall satisfaction. RESULTS We included 142 patients. Mean age was 65.2 ± 10.8 years and 52.7% were female. Morphine was the most commonly administered medication. Pain increases were greater around frame removal than placement. Opioids were not associated with any difference in the change in pain scores before and after frame removal, or patient satisfaction. Patients with higher pre-removal pain scores had smaller increases in pain scores after removal; they also had worse pain control and overall satisfaction with their treatment. CONCLUSION Morphine administration prior to frame removal did not improve pain scores or pain control satisfaction. Absence of efficacy may be related to delayed onset of action, and stronger and faster-acting agents should be explored. Pre-removal pain scores were associated with decreased pain control and overall satisfaction, further identifying earlier and stronger pain treatment as a potential area for improvement.
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Affiliation(s)
- Jason Hsieh
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | - Wei Wei
- Department of Quantitative and Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Jeffrey Z Nie
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Alireza M Mohammadi
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Glen Stevens
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Michael Vogelbaum
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Lilyana Angelov
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA.
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Cleveland Clinic, Cleveland, OH, USA.
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA.
- Department of Neurological Surgery, Rose Ella Burkhart Brain Tumor and Neuro-Oncology Center, Cleveland Clinic Lerner College of Medicine, 9500 Euclid Ave CA51, Cleveland, OH, 44195, USA.
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Jiang H, Tang X, Weng R, Ni W, Li Y, Su J, Yang H, Xiao W, Wu H, Gu Y, Mao Y. Long-term outcome of a tailored embolization strategy with Gamma Knife radiosurgery for high-grade brain arteriovenous malformations: a single-center experience. J Neurosurg 2022:1-8. [PMID: 36585868 DOI: 10.3171/2022.11.jns221363] [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: 06/12/2022] [Accepted: 11/17/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The safety and efficacy of embolization with Gamma Knife radiosurgery (GKRS) for high-grade brain arteriovenous malformations (bAVMs) are uncertain. The purpose of this study was to elucidate the long-term outcome of a tailored embolization strategy with GKRS and identify the independent factors associated with bAVM obliteration. METHODS Between January 2014 and January 2017, a consecutive cohort of 159 patients with high-grade bAVMs who underwent embolization with GKRS was enrolled in this prospective single-center cohort study. All patients received a tailored embolization strategy with GKRS. The primary outcome was defined as bAVM obliteration. Secondary outcomes were neurological function and complications. RESULTS After a mean follow-up of 40.4 months, 5 patients were lost to follow-up. One hundred eighteen of the remaining 154 patients had favorable neurological outcomes with complete bAVM obliteration. A decrease in bAVM nidus size was observed in 36 patients. Five patients developed intracranial hemorrhage during the latency period, and 2 patients died. The Kaplan-Meier analysis showed that the obliteration rate increased each year and reached the peak point at approximately 3 years. The multivariate Cox regression analysis of factors affecting bAVM obliteration revealed that postembolization bAVM volume < 10 cm3 (p = 0.02), supratentorial location (p < 0.01), staged embolization prior to GKRS (p < 0.01), and mean Spetzler-Martin (SM) grade (p < 0.01) were independent factors associated with a high obliteration rate. CONCLUSIONS These data suggested that high-grade bAVMs treated using a tailored embolization strategy with GKRS were associated with a favorable clinical outcome and obliteration rate. Postembolization bAVM volume < 10 cm3, supratentorial location, staged embolization prior to GKRS, and low mean SM grade were associated with a high obliteration rate.
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Affiliation(s)
- Hanqiang Jiang
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Xuqun Tang
- 2Department of Neurosurgery, Shanghai Gamma Hospital, Shanghai, China
| | - Ruiyuan Weng
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Wei Ni
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Yanjiang Li
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Jiabin Su
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Heng Yang
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Weiping Xiao
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Hanfeng Wu
- 2Department of Neurosurgery, Shanghai Gamma Hospital, Shanghai, China
| | - Yuxiang Gu
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
| | - Ying Mao
- 1Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai; and
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Kim MJ, Jung HH, Kim YB, Chang JH, Chang JW, Park KY, Chang WS. Comparison of Single-Session, Neoadjuvant, and Adjuvant Embolization Gamma Knife Radiosurgery for Arteriovenous Malformation. Neurosurgery 2022; 92:986-997. [PMID: 36700732 DOI: 10.1227/neu.0000000000002308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 10/14/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The purpose of intracranial arteriovenous malformations (AVMs) treatment is to prevent bleeding or subsequent hemorrhage with complete obliteration. For large, difficult-to-treat AVMs, multimodal approaches including surgery, endovascular embolization, and gamma knife radiosurgery (GKRS) are frequently used. OBJECTIVE To analyze the outcomes of AVMs treated with single-session, neoadjuvant, and adjuvant embolization GKRS. METHODS We retrospectively reviewed a database of 453 patients with AVMs who underwent GKRS between January 2007 and December 2017 at our facility. The obliteration rate, incidence of latent period bleeding, cyst formation, and radiation-induced changes were compared among the 3 groups, neoadjuvant-embolized, adjuvant-embolized, nonembolized group. In addition, the variables predicting AVM obliteration and complications were investigated. RESULTS A total of 228 patients were enrolled in this study. The neoadjuvant-embolized, adjuvant-embolized, and nonembolized groups comprised 29 (12.7%), 19 (8.3%), and 180 (78.9%) patients, respectively. Significant differences were detected among the 3 groups in the history of previous hemorrhage and the presence of aneurysms ( P < .0001). Multivariate Cox regression analyses revealed a significant inverse correlation between neoadjuvant embolization and obliteration occurring 36 months after GKRS (hazard ratio, 0.326; P = .006). CONCLUSION GKRS with either neoadjuvant or adjuvant embolization is a beneficial approach for the treatment of AVMs with highly complex angioarchitectures that are at risk for hemorrhage during the latency period. Embolization before GKRS may be a negative predictive factor for late-stage obliteration (>36 months). To confirm our conclusions, further studies involving a larger number of patients and continuous follow-up are necessary.
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Affiliation(s)
- Myung Ji Kim
- Department of Neurosurgery, Korea University College of Medicine, Korea University Ansan Hospital, Gyeonggi-do, Republic of Korea
| | - Hyun Ho Jung
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Hee Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Woo Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Keun Young Park
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Won Seok Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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Chang H, Silva MA, Weng J, Kovacevic J, Luther E, Starke RM. The impact of embolization on radiosurgery obliteration rates for brain arteriovenous malformations: a systematic review and meta-analysis. Neurosurg Rev 2022; 46:28. [PMID: 36576595 DOI: 10.1007/s10143-022-01935-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 11/25/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022]
Abstract
There exists no consensus in the literature regarding the impact of pre-stereotactic radiosurgery (SRS) embolization on obliteration rates and clinical outcome after radiosurgery treatment of intracranial arteriovenous malformations (AVM). We performed a systematic review of four databases and included studies with at least 10 patients evaluating obliteration rates of intracranial AVMs treated with SRS alone (SRS cohort) and combined pre-SRS embolization followed by SRS (E + SRS cohort). Meta-analytic results were pooled together via random-effects models. A total of 43 studies, with 7103 patients, were included in our analysis. Among our included patients, complete obliteration was achieved in 51.5% (964/1871) of patients in the E + SRS cohort as compared to 61.5% (3217/5231) of patients in the SRS cohort. Meta-analysis of the pooled data revealed that obliteration was significantly lower in the E + SRS cohort (pooled OR = 0.64, 95% CI = 0.54-0.75, p < 0.0001). The use of pre-SRS embolization was significantly associated with lower AVM obliteration rates when compared to treatment with SRS alone. Our analysis seeks to provide a macroscopic insight into the complex interaction between pre-SRS embolization and brain AVM obliteration rates and prognosis. Pre-SRS embolization may still be beneficial in select patients, and further studies are needed to identify patients who benefit from neoadjuvant AVM embolization.
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Affiliation(s)
- Henry Chang
- Department of Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1095 NW 14th Terrace, Miami, FL, USA.
| | - Michael A Silva
- Department of Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1095 NW 14th Terrace, Miami, FL, USA
| | - John Weng
- Florida State University College of Medicine, Tallahassee, FL, USA
| | | | - Evan Luther
- Department of Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1095 NW 14th Terrace, Miami, FL, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1095 NW 14th Terrace, Miami, FL, USA
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Meng X, Gao D, He H, Sun S, Liu A, Jin H, Li Y. A Machine Learning Model Predicts the Outcome of SRS for Residual Arteriovenous malformations after partial embolization- A Real-World Clinical Obstacle. World Neurosurg 2022; 163:e73-e82. [PMID: 35276397 DOI: 10.1016/j.wneu.2022.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To propose a machine learning (ML) model predicting the favorable outcome of stereotactic radiosurgery (SRS) for residual brain arteriovenous malformation (bAVM) after partial embolization. MATERIALS AND METHODS One hundred and thirty bAVM patients who underwent partial embolization followed by SRS were retrospectively reviewed. Patients were randomly split into training datasets (n=100) and testing datasets (n=30). Radiomics and dosimetric features were extracted from pre-SRS treatment images. Feature selection was performed to select appropriate radiomics and dosimetric features. Three ML algorithms were applied to construct models using selected features respectively. A total of 9 models were trained to predict favorable outcomes (obliteration without complication) of bAVMs. The efficacy of these models was evaluated on the testing dataset using mean accuracy (ACC) and area under the receiver operating characteristic curve (AUROC). RESULTS The obliteration rate of this cohort was 70.77% (92/130) with a mean follow-up period of 43.8 (Range 12-108 months) months. Favorable outcomes were achieved in 89 (68.46%) patients. Four radiomics features and 7 dosimetric features were selected for ML model construction. The dosimetric SVM showed the best performance on the training dataset, with an ACC and AUC of 0.74 and 0.78 respectively. The dosimetric SVM model also showed the best performance on the testing dataset where the ACC and AUC were 0.83 and 0.77 respectively. CONCLUSION Dosimetric features are good predictors of prognosis for patients with partially embolized bAVM followed by SRS therapy. The use of ML models is an innovative method for predicting favorable outcomes of partially embolized bAVM followed by SRS therapy.
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Affiliation(s)
- Xiangyu Meng
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dezhi Gao
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongwei He
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shibin Sun
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ali Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Beijing Engineering Research Center, Beijing, China.
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9
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Blakaj DM, Palmer JD, Dibs K, Olausson A, Bourekas EC, Boulter D, Ayan AS, Cochran E, Marras WS, Mageswaran P, Katzir M, Yildiz VO, Grecula J, Arnett A, Raval R, Scharschmidt T, Elder JB, Lonser R, Chakravarti A, Mendel E. Postoperative Stereotactic Body Radiotherapy for Spinal Metastasis and Predictors of Local Control. Neurosurgery 2021; 88:1021-1027. [PMID: 33575784 DOI: 10.1093/neuros/nyaa587] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 11/15/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Spine surgery is indicated for select patients with mechanical instability, pain, and/or malignant epidural spinal cord compression, with or without neurological compromise. Stereotactic body radiotherapy (SBRT) is an option for durable local control (LC) for metastatic spine disease. OBJECTIVE To determine factors associated with LC and progression-free survival (PFS) for patients receiving postoperative stereotactic spine radiosurgery. METHODS We analyzed consecutive patients from 2013 to 2019 treated with surgical intervention followed by SBRT. Surgical interventions included laminectomy and vertebrectomy. SBRT included patients treated with 1 to 5 fractions of radiosurgery. We analyzed LC, PFS, overall survival (OS), and toxicity. Univariate and multivariate analyses were performed. RESULTS A total of 63 patients were treated with a median follow-up of 12.5 mo. Approximately 75% of patients underwent vertebrectomy and 25% underwent laminectomy. One-year cumulative incidence of local failure was 19%. LC was significantly improved for patients receiving radiosurgery ≤40 d from surgery compared to that for patients receiving radiosurgery ≥40 d from surgery, 94% vs 75%, respectively, at 1 yr (P = .03). Patients who received preoperative embolization had improved LC with 1-yr LC of 88% vs 76% for those who did not receive preoperative embolization (P = .037). Significant predictors for LC on multivariate analysis were time from surgery to radiosurgery, higher radiotherapy dose, and preoperative embolization. The 1-yr PFS and OS was 56% and 60%, respectively. CONCLUSION Postoperative radiosurgery has excellent and durable LC for spine metastasis. An important consideration when planning postoperative radiosurgery is minimizing delay from surgery to radiosurgery. Preoperative embolization and higher radiotherapy dose were associated with improved LC warranting further study.
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Affiliation(s)
- Dukagjin M Blakaj
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Khaled Dibs
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Alexander Olausson
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Eric C Bourekas
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Daniel Boulter
- Department of Radiology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ahmet S Ayan
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Eric Cochran
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - William S Marras
- Spine Research Institute, College of Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Prasath Mageswaran
- Spine Research Institute, College of Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Miki Katzir
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Vedat O Yildiz
- Center for Biostatistics, College of Medicine Department of Biomedical Informatics, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John Grecula
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Andrea Arnett
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Raju Raval
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Thomas Scharschmidt
- Department of Orthopedic Surgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - James B Elder
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Russell Lonser
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Arnab Chakravarti
- Department of Radiation Oncology, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ehud Mendel
- Department of Neurosurgery, The James Cancer Hospital at the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Ai X, Xu J. The predictors of clinical outcomes in brainstem arteriovenous malformations after stereotactic radiosurgery. Medicine (Baltimore) 2021; 100:e26203. [PMID: 34087891 PMCID: PMC8183693 DOI: 10.1097/md.0000000000026203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 05/11/2021] [Indexed: 02/05/2023] Open
Abstract
The brainstem arteriovenous malformations (BS-AVMs) have a high morbidity and mortality and stereotactic radiosurgery (SRS) has been widely used to treat BS-AVMs. However, no consensus is reached in the explicit predictors of obliteration for BS-AVMs after SRS.To identify the predictors of clinical outcomes for BS-AVMs treated by SRS, we performed a retrospective observational study of BS-AVMs patients treated by SRS at our institution from 2006 to 2016. The primary outcomes were obliteration of nidus and favorable outcomes (AVM nidus obliteration with mRS score ≤2). For getting the outcomes more accurate, we also pooled the results of previous studies as well as our study by meta-analysis.A total of 26 patients diagnosed with BS-AVMs, with mean volume of 2.6 ml, were treated with SRS. Hemorrhage presentation accounted for 69% of these patients. Overall obliteration rate was 42% with mean follow-up of more than five years and two patients (8%) had a post-SRS hemorrhage. Favorable outcomes were observed in 8 patients (31%). Higher margin dose (>15Gy) was associated with higher obliteration (P = .042) and small volume of nidus was associated with favorable outcomes (P = .036). After pooling the results of 7 studies and present study, non-prior embolization (P = .049) and higher margin dose (P = .04) were associated with higher obliteration rate, in addition, the lower Virginia Radiosurgery AVM Scale (VRAS) was associated with favorable outcomes (P = .02) of BS-AVMs after SRS.In the BS-AVMs patients treated by SRS, higher margin dose (19-24Gy) and non-prior embolization were the independent predictors of higher obliteration rate. In addition, smaller volume of nidus and lower VRAS were the potential predictors of long-term favorable outcomes for these patients.
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Affiliation(s)
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Punyawai P, Radomsutthikul N, Dhanachai M, Kobkitsuksakul C, Hansasuta A. Long-term outcomes of 170 brain arteriovenous malformations treated by frameless image-guided robotic stereotactic radiosurgery: Ramathibodi hospital experience. Medicine (Baltimore) 2021; 100:e25752. [PMID: 34106604 PMCID: PMC8133224 DOI: 10.1097/md.0000000000025752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 04/08/2021] [Indexed: 11/25/2022] Open
Abstract
This study was conducted to report long-term outcomes of the frameless robotic stereotactic radiosurgery (SRS) for brain arteriovenous malformation (AVM) at Ramathibodi Hospital.Retrospective data of patients with brain AVM (bAVM), who underwent CyberKnife SRS (CKSRS) at Ramathibodi Hospital from 2009 to 2014, were examined. Exclusion criteria were insufficient follow-up time (<36 months) or incomplete information. Patients' demographics, clinical presentation, treatment parameters, and results were analyzed. Excellent outcome was defined as AVM obliteration without a new neurological deficit. Risk factors for achieving excellent outcome were assessed.From a total of 277 CKSRS treatments for bAVM during the 6 years, 170 AVMs in 166 patients met the inclusion criteria. One hundred and thirty-nine cases (81.76%) presented with hemorrhages from ruptured bAVMs. Almost two-thirds underwent embolization before radiosurgery. With the median AVM volume of 4.17 mL, three-quarters of the cohort had single-fraction CKSRS, utilizing the median prescribed dose of 15 Gray (Gy). In the multisession group (25.29%), the median prescribed dose and the AVM volume were 27.5 Gy and 22.3 mL, respectively. An overall excellent outcome, at a median follow-up period of 72.45 months, was observed in 99 cases (58.24%). Seven AVMs (4.12%) ruptured after CKSRS but 1 patient suffered a new neurological deficit. Two patients (1.18%) were classified into the poor outcome category but there were no deaths. Negative factors for excellent outcome, by multivariate regression analysis, were the male sex and multisession SRS delivery, but not age, history of AVM rupture, previous embolization, or AVM volume.Despite relatively larger bAVM and utilizing a lower prescribed radiation dose, the excellent outcome was within the reported range from previous literature. This study offers one of the longest follow-ups and the largest cohorts from the frameless image-guided robotic SRS community.
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Affiliation(s)
- Pritsana Punyawai
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan
| | | | - Mantana Dhanachai
- Department of Diagnostic and Therapeutic Radiology, Division of Radiation Oncology
| | - Chai Kobkitsuksakul
- Department of Diagnostic and Therapeutic Radiology, Division of Interventional Neuroradiology
| | - Ake Hansasuta
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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12
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Preradiosurgery embolization in reducing the postoperative hemorrhage rate for patients with cerebral arteriovenous malformations: a systematic review and meta-analysis. Neurosurg Rev 2021; 44:3197-3207. [PMID: 33864525 DOI: 10.1007/s10143-021-01530-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 02/10/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
Few studies have examined the postoperative hemorrhage rate of cerebral arteriovenous malformations (AVMs) treated by embolization prior to stereotactic radiosurgery. The objective of this analysis was to compare the postoperative hemorrhage rate between AVMs treated with and those treated without preradiosurgery embolization. A systematic search of the PubMed and Embase databases was performed with no restriction on the publication period. Based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies with sufficient baseline and outcome data. The analysis was performed using Comprehensive Meta-Analysis (CMA) 2.0. Eleven studies comprising 2591 patients were eligible for analysis. There was no significant difference in the postoperative hemorrhage rate between patients who had undergone embolization followed by SRS and those who had undergone SRS alone (OR 1.140, 95% CI 0.851-1.526, p = 0.38). The obliteration rate was significantly lower in the E + SRS group than in the SRS group (OR 0.586, 95% CI 0.398-0.863, p = 0.007). No significant difference in permanent neurological deficits was identified between patients who had undergone embolization followed by SRS and those who had undergone SRS alone (OR 1.175, 95% CI 0.626-2.206, p = 0.616). Available data suggested that preradiosurgery embolization did not reduce the postoperative hemorrhage rate and resulted in a significantly lower obliteration rate than treatment with SRS alone.
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Efficacy and Safety of Combined Endovascular Embolization and Stereotactic Radiosurgery for Patients with Intracranial Arteriovenous Malformations: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6686167. [PMID: 33954197 PMCID: PMC8060080 DOI: 10.1155/2021/6686167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 03/01/2021] [Accepted: 04/01/2021] [Indexed: 12/03/2022]
Abstract
Whether the use of endovascular embolization could provide additional benefits in patients treated with stereotactic radiosurgery (SRS) for intracranial arteriovenous malformations (IAVMs) remains controversial. The current meta-analysis was conducted to assess the efficacy and safety of SRS with and without prior endovascular embolization in patients with IAVMs. The electronic databases of PubMed, EmBase, and Cochrane Library were systematically searched for eligible studies published from inception to August 12, 2020. The pooled results for obliteration rate, rehemorrhage rate, and permanent neurological deficits were calculated by odds ratios (ORs) with 95% confidence intervals (CIs) using the random-effects model. The sensitivity analysis, subgroup analysis, and publication bias for investigated outcomes were also evaluated. Nineteen studies (two prospective and 17 retrospective studies) involving a total of 3,454 patients with IAVMs were selected for the final meta-analysis. We noted that prior embolization and SRS were associated with a lower obliteration rate compared with SRS alone (OR, 0.57; 95% CI, 0.44–0.74; P < 0.001). However, prior embolization and SRS were not associated with the risk of rehemorrhage (OR, 1.05; 95% CI, 0.81–1.34; P = 0.729) and permanent neurological deficits (OR, 0.80; 95% CI, 0.48–1.33; P = 0.385) compared with SRS alone. The sensitivity analysis suggested that prior embolization might reduce the risk of permanent neurological deficits in patients with IAVMs treated with SRS. The treatment effects of prior embolization in patients with IAVMs could be affected by nidus volume, margin dose, intervention, and follow-up duration. This study found that prior embolization was associated with a reduced risk of obliteration in patients with IAVMs treated with SRS. Moreover, prior embolization might reduce the risk of permanent neurological deficits in patients with IAVMs.
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Meng X, He H, Liu P, Gao D, Chen Y, Sun S, Liu A, Li Y, Jin H. Radiosurgery-Based AVM Scale Is Proposed for Combined Embolization and Gamma Knife Surgery for Brain Arteriovenous Malformations. Front Neurol 2021; 12:647167. [PMID: 33859610 PMCID: PMC8042217 DOI: 10.3389/fneur.2021.647167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/19/2021] [Indexed: 11/28/2022] Open
Abstract
Background and purpose: To evaluate whether a radiosurgery-based arteriovenous malformation (AVM) scale (RBAS) could be used to predict obliteration of brain arteriovenous malformations (bAVMs) supposed for combined endovascular embolization (EMB) and gamma knife surgery (GKS) treatment. Methods: bAVM patients who underwent GKS with or without previous EMB from January 2011 to December 2016 at our institution were retrospectively reviewed. The patients were categorized into a combined treatment group and a GKS group. A 1:1 propensity score matching (PSM) was used to match the two groups. Pre-EMB and pre-GKS RBAS were assessed for every patient. Multivariate analysis was performed to find factors associated with complete obliteration in the combined treatment group. Survival analysis based on sub-groups according to RBAS was performed to compare obliteration rate and find cutoffs for appropriate treatment modalities. Results: A total of 96 patients were involved, and each group comprised 48 patients. There was no difference between the two groups in terms of obliteration rate (75.0 vs. 83.3%, p = 0.174). Pre-EMB RBAS (p = 0.010) and the number of feeding arteries (p = 0.014) were independent factors associated with obliteration rate in the combined treatment group. For the combined treatment patients, sub-group analysis according to pre-EMB RBAS (score <1.0, 1.0-1.5, and >1.5) showed statistical difference in obliteration rate (p = 0.002). Sub-group analysis according to RBAS between the two groups showed that the obliteration rate of the GKS group is significantly higher than the combined group when RBAS >1.5 (47.4 vs. 66.7%, p = 0.036). Conclusions: The RBAS is proposed to be efficient in predicting obliteration of bAVMs supposed to receive combined EMB and GKS treatment. Patients with RBAS >1.5 are inclined to be more suitable for GKS instead of the combined treatment.
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Affiliation(s)
- Xiangyu Meng
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Hongwei He
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dezhi Gao
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shibin Sun
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ali Liu
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxiang Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Engineering Research Center, Beijing, China
| | - Hengwei Jin
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Engineering Research Center, Beijing, China
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