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Tariq R, Siddiqui UA, Bajwa MH, Baig AN, Khan SA, Tariq A, Bakhshi SK. Feasibility of awake craniotomy for brain arteriovenous malformations: A scoping review. World Neurosurg X 2024; 22:100321. [PMID: 38440377 PMCID: PMC10911851 DOI: 10.1016/j.wnsx.2024.100321] [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: 02/28/2023] [Accepted: 02/21/2024] [Indexed: 03/06/2024] Open
Abstract
Background Brain Arteriovenous Malformations (AVMs) located in proximity to eloquent brain regions are associated with poor surgical outcomes, which may be due to higher rates of postoperative neurological deterioration. Current treatment protocols include stereotactic radiosurgery, transarterial embolization, and surgical resection under general anesthesia. Awake Craniotomy (AC) allows intraoperative mapping of eloquent areas to improve post-operative neurologic outcomes. Objectives We reviewed the current literature reporting surgical outcomes and assessed the feasibility of AC for AVM resection. Methods The PRISMA guidelines were utilized as a template for the review. Three databases including PubMed, Scopus, and Cochrane Library were searched using a predefined search strategy. After removing duplicates and screening, full texts were analyzed. Outcomes including the extent of resection, intra-operative and post-operative complications, and long-term neurologic outcomes were assessed. Results 12 studies were included with a total of 122 AVM cases. Spetzler-Martin grading was used for the classification of the AVMs. The asleep-awake-asleep protocol was most commonly used for AC. Complete resection was achieved in all cases except 5. Intraoperative complications included seizures (n = 2) and bleeding (n = 4). Short-term post-operative complications included hemorrhage (n = 3), neurologic dysfunctions including paresis (n = 3), hemiplegia (n = 10), dysphasia/aphasia (n = 6), cranial nerve dysfunction (n = 3), and pulmonary embolism (n = 1). Almost all neurological deficits after surgery gradually improved on subsequent follow-ups. Conclusion AVMs may shift the anatomical location of eloquent brain areas which may be mapped during AC. All studies recommended AC for the resection of AVMs in close proximity to eloquent areas as mapping during AC identifies the eloquent cortex thus promoting careful tissue handling which may preserve neurologic function and/or predict the postoperative functional status of the patients We, therefore, conclude that AC is a viable modality for AVMs resection near eloquent language and motor areas.
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Affiliation(s)
- Rabeet Tariq
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | | | - Ahmer Nasir Baig
- Department of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Saad Akhtar Khan
- Department of Neurosurgery, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Areeba Tariq
- Department of Neurosurgery, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Saqib Kamran Bakhshi
- Department of Neurosurgery, Liaquat National Hospital and Medical College, Karachi, Pakistan
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2
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Huang PW, Peng SJ, Pan DHC, Yang HC, Tsai JT, Shiau CY, Su IC, Chen CJ, Wu HM, Lin CJ, Chung WY, Guo WY, Lo WL, Lai SW, Lee CC. Vascular compactness of unruptured brain arteriovenous malformation predicts risk of hemorrhage after stereotactic radiosurgery. Sci Rep 2024; 14:4011. [PMID: 38369533 PMCID: PMC10874940 DOI: 10.1038/s41598-024-54369-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/12/2024] [Indexed: 02/20/2024] Open
Abstract
The aim of the study was to investigate whether morphology (i.e. compact/diffuse) of brain arteriovenous malformations (bAVMs) correlates with the incidence of hemorrhagic events in patients receiving Stereotactic Radiosurgery (SRS) for unruptured bAVMs. This retrospective study included 262 adult patients with unruptured bAVMs who underwent upfront SRS. Hemorrhagic events were defined as evidence of blood on CT or MRI. The morphology of bAVMs was evaluated using automated segmentation which calculated the proportion of vessel, brain tissue, and cerebrospinal fluid in bAVMs on T2-weighted MRI. Compactness index, defined as the ratio of vessel to brain tissue, categorized bAVMs into compact and diffuse types based on the optimal cutoff. Cox proportional hazard model was used to identify the independent factors for post-SRS hemorrhage. The median clinical follow-ups was 62.1 months. Post-SRS hemorrhage occurred in 13 (5.0%) patients and one of them had two bleeds, resulting in an annual bleeding rate of 0.8%. Multivariable analysis revealed bAVM morphology (compact versus diffuse), bAVM volume, and prescribed margin dose were significant predictors. The post-SRS hemorrhage rate increased with larger bAVM volume only among the diffuse nidi (1.7 versus 14.9 versus 30.6 hemorrhage per 1000 person-years in bAVM volume < 20 cm3 versus 20-40 cm3 versus > 40 cm3; p = 0.022). The significantly higher post-SRS hemorrhage rate of Spetzler-Martin grade IV-V compared with grade I-III bAVMs (20.0 versus 3.3 hemorrhages per 1000 person-years; p = 0.001) mainly originated from the diffuse bAVMs rather than the compact subgroup (30.9 versus 4.8 hemorrhages per 1000 person-years; p = 0.035). Compact and smaller bAVMs, with higher prescribed margin dose harbor lower risks of post-SRS hemorrhage. The post-SRS hemorrhage rate exceeded 2.2% annually within the diffuse and large (> 40 cm3) bAVMs and the diffuse Spetzler-Martin IV-V bAVMs. These findings may help guide patient selection of SRS for the unruptured bAVMs.
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Affiliation(s)
- Po-Wei Huang
- Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Syu-Jyun Peng
- Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jo-Ting Tsai
- Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - I-Chang Su
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Texas Health Science Center, Houston, TX, USA
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Lun Lo
- Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan
| | - Shao-Wen Lai
- Product and Engineering, Zippin, San Carlos, CA, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Dayawansa S, Schlesinger D, Mantziaris G, Dumot C, Donahue JH, Sheehan JP. Incorporation of Brain Connectomics for Stereotactic Radiosurgery Treatment Planning. Oper Neurosurg (Hagerstown) 2023; 25:e211-e215. [PMID: 37543746 DOI: 10.1227/ons.0000000000000818] [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: 04/20/2023] [Accepted: 05/08/2023] [Indexed: 08/07/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Neurosurgeons have integrated neuroanatomy-based tractography to avoid critical structures during dose planning. However, they have yet to integrate more comprehensive connectome networks for radiosurgical planning. CLINICAL PRESENTATION A young man presented with a Spetzler-Martin Grade 3 right temporal arteriovenous malformation. DISCUSSION As proof of concept, we incorporated connectomic networks including default mode network, optic radiation and central executive network into the Gamma Knife radiosurgical treatment planning workflow. Connectome networks were created from T1 anatomic and diffusion-weighted images magnetic resonance images using Quicktome software. The resulting networks were voxel-encoded in the magnetic resonance images, imported into GammaPlan, and segmented by image thresholding. The GammaPlan Lightning optimizer was used to create radiosurgical plans with a dose of 20 Gy to the 50% isodose line delivered to the arteriovenous malformation nidus both with and without treating these networks as risk structures. When taking into account the connectome networks, a maximum dose restriction of 14 Gy was placed on each network during lightning dose planning. With default mode network, optic radiation, and central executive network as risk structures, the maximum dose and V 12Gy were reduced by 23.4% and 88.3%, 20% and 34.3%, and 29.8% and 63.2%, respectively. CONCLUSION We were able to incorporate connectomes into radiosurgical dose planning approaches. This allowed for dose reductions to the networks while still achieving delivery of a therapeutic dose to the target volume.
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Affiliation(s)
- Sam Dayawansa
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - David Schlesinger
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Chloe Dumot
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Joseph H Donahue
- Department of Radiology, University of Virginia, Charlottesville, Virginia, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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Vinchon M, Toubol A, Karnoub MA, Aboukais R, Leclerc X, Reyns N. Unruptured cerebral arteriovenous malformation in children: Outcome in treated and untreated patients. Neurochirurgie 2023; 69:101440. [PMID: 37060846 DOI: 10.1016/j.neuchi.2023.101440] [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: 12/07/2022] [Revised: 01/17/2023] [Accepted: 03/21/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND The management of unruptured cerebral arteriovenous malformation (URCAVM) is highly controversial; however, data regarding URCAVM in children are scarce. MATERIAL AND METHODS We retrospectively reviewed consecutive children followed for URCAVM in our department between 2001 and 2021. RESULTS Out of 36 patients, 12 were initially managed by observation, and 24 underwent first-line treatment: 8 by microsurgery, 10 by radiosurgery, 2 by embolization, and 4 by combined treatment. Mean follow-up of the whole group was 63months. Complete cure of the malformation was obtained in 14 patients (58%) in the treatment group: 8/8 in the microsurgery group, 5/10 in the radiosurgery group, 1/4 in the combined treatment group, and none in the embolization group. Two of the initially non-treated patients presented cerebral hemorrhage, with significant neurological consequences. In the treatment group, 5 patients presented new neurological deficits, only 1 of which, however, was functionally significant. Headache improved in 11 cases, mostly in the treatment group. Overall, 6 patients in the treatment group became asymptomatic, versus none in the observation group. CONCLUSIONS The treatment of URCAVM is a reasonable option in many pediatric cases, considering the cumulative risk of cerebral hemorrhage during the child's lifetime, as well as the symptoms specific to URCAVM. Microsurgery, when feasible, offers the best functional results and control of the AVM; however, the risk-benefit ratio should be weighed on a case-by-case basis. More studies will be needed to inform treatment decisions in pediatric URCAVM.
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Affiliation(s)
| | - Amelie Toubol
- Neurosurgery Clinic, Lille University Hospital, Lille, France
| | | | - Rabih Aboukais
- Neurosurgery Clinic, Lille University Hospital, Lille, France
| | - Xavier Leclerc
- Interventional Neuroradiology, Lille University Hospital, Lille, France
| | - Nicolas Reyns
- Neurosurgery Clinic, Lille University Hospital, Lille, France
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Bustuchina Vlaicu M. New approaches for brain arteriovenous malformations-related epilepsy. Rev Neurol (Paris) 2023; 179:188-200. [PMID: 36180290 DOI: 10.1016/j.neurol.2022.05.011] [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: 09/23/2021] [Revised: 02/21/2022] [Accepted: 05/25/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The purpose of this review is to present the current literature and to highlight the most recent findings in brain arteriovenous malformations (bAVM)-related epilepsy research. METHODS We searched Medline, PubMed, Biblioinserm, Cochrane Central to study the latest research reports about the different factors that could be responsible for the genesis of bAVM-related epilepsy. We analyzed if epileptogenesis has any characteristics traits and its relation with the vascular malformation. The results of different treatments on epilepsy were considered. Typical errors that may lead towards incorrect or worse management of the seizures for these patients were also examined. RESULTS The development of bAVM results from multifactorial etiologies and bAVM-related epileptogenesis is likely specific for this pathology. Different types of evidence demonstrate a bidirectional relationship between bAVM and epilepsy. Currently, there is not enough published data to determine what may be the right management for these patients. CONCLUSIONS A better understanding of epileptogenesis in conjunction with knowledge of the complex alterations of structures and functions following bAVM-related seizures is necessary. Identification of biomarkers that can identify subgroups most likely to benefit from a specific intervention are needed to help guide clinical management. A new concept for the treatment of epilepsy related to an unruptured bAVM that cannot be treated invasively is proposed as well as new therapeutic perspectives. The next necessary step will be to propose additional algorithms to improve the development of future trials.
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Affiliation(s)
- M Bustuchina Vlaicu
- Pitié-Salpêtrière Hospital, Department of Neurosurgery, Paris, France; Inserm U0955, Translational Neuro-Psychiatry team, Créteil, France.
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Ung TH, Belanger K, Hashmi A, Sekar V, Meola A, Chang SD. Microenvironment changes in arteriovenous malformations after stereotactic radiation. Front Hum Neurosci 2022; 16:982190. [PMID: 36590065 PMCID: PMC9797682 DOI: 10.3389/fnhum.2022.982190] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/23/2022] [Indexed: 12/23/2022] Open
Abstract
Cerebral arteriovenous malformations are dysplastic vascular tangles with aberrant vascular dynamics and can result significant morbidity and mortality. A myriad of challenges are encountered when treating these lesions and are largely based on nidal size, location, and prior hemorrhage. Currently, stereotactic radiosurgery is an accepted form of treatment for small to medium sized lesions and is especially useful in the treatment of lesions in non-surgically assessable eloquent areas of the brain. Despite overall high rates of nidal obliteration, there is relatively limited understand on the mechanisms that drive the inflammatory and obliterative pathways observed after treatment with stereotactic radiosurgery. This review provides an overview of arteriovenous malformations with respect to stereotactic radiosurgery and the current understanding of the mechanisms that lead to nidal obliteration.
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Affiliation(s)
- Timothy H. Ung
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States,Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States,*Correspondence: Timothy H. Ung
| | - Katherine Belanger
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Ayesha Hashmi
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States
| | - Vashisht Sekar
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States
| | - Antonio Meola
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States
| | - Steven D. Chang
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States
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Dumot C, Picart T, Eker O, Guyotat J, Berhouma M, Pelissou-Guyotat I. Outcomes of Unruptured Low-Grade Brain Arteriovenous Malformations Using TOBAS (Treatment of Brain Arteriovenous Malformations Study) Criteria. World Neurosurg 2022; 167:e1050-e1061. [PMID: 36089272 DOI: 10.1016/j.wneu.2022.08.152] [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: 07/16/2022] [Revised: 08/28/2022] [Accepted: 08/30/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Treatment of an unruptured brain arteriovenous malformation (bAVM) is a matter of debate, especially for low-grade bAVM (Spetzler-Martin grade I and II). The aim is to compare the outcomes of patients with low-grade unruptured bAVM after interventional or medical management in a pragmatic manner. METHODS Adults with unruptured low-grade bAVM diagnosed between 2006 and 2016 were included. The primary end points were death from all causes and disabling stroke that resulted in a modified Rankin Scale (mRS) score >2 at last follow-up. RESULTS Eighty-four patients presented with an unruptured Spetzler-Martin low-grade bAVM. Among these patients, 55 (65.5%) were treated and 29 (34.5%) were untreated, with no differences regarding clinical and radiologic characteristics. The modality of treatment was embolization in 25.5%, radiosurgery (alone, 30.9%; with embolization, 18.2%), and surgery (alone, 5.5%; with embolization, 20%). The rupture rate was 6.7% person-year in the untreated group; 12.7% (n = 7) of treated and 16.7% (n = 5) of untreated patients achieved the primary evaluation criteria (P = 0.744). Using a Kaplan-Meier curve, the probability of reaching this criterion at 5 years was not different between groups (P = 0.07). Complications resulting in an mRS score >2 at last follow-up occurred in 9.1%, in 80% of cases after embolization. CONCLUSIONS This study shows no differences between treated and untreated low-grade bAVM. Embolization seems to carry a high risk of complication and should be used with caution. The small number of cases must encourage cautious interpretations especially because of the spontaneous high-rupture rate. One major interest is to investigate center habits in pathology when treatment standards are limited.
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Affiliation(s)
- Chloe Dumot
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Lyon, France; Claude Bernard University, Lyon, Lyon, France; CarMeN laboratory, InsermU1060, INRAU1397, INSA Lyon, Université Claude Bernard, Lyon, Lyon, France.
| | - Thiebaud Picart
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Lyon, France; Claude Bernard University, Lyon, Lyon, France; Department of Cancer Cell Plasticity-INSERMU1052, Cancer Research Center of Lyon, Lyon, France
| | - Omer Eker
- Claude Bernard University, Lyon, Lyon, France; CarMeN laboratory, InsermU1060, INRAU1397, INSA Lyon, Université Claude Bernard, Lyon, Lyon, France; Department of Neurointerventional Radiology, Pierre Wertheimer Neurological and Neurosurgical Hospital, Lyon, France
| | - Jacques Guyotat
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Lyon, France
| | - Moncef Berhouma
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Lyon, France; Claude Bernard University, Lyon, Lyon, France; CREATIS Laboratory, InsermU1206, UMR 5220, Claude Bernard University of Lyon, Villeurbanne, France
| | - Isabelle Pelissou-Guyotat
- Department of Neurosurgical Oncology and Vascular Neurosurgery, Pierre Wertheimer Neurological and Neurosurgical Hospital, Lyon, France
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Gao D, Meng X, Jin H, Liu A, Sun S. Assessment of gamma knife radiosurgery for unruptured cerebral arterioveneus malformations based on multi-parameter radiomics of MRI. Magn Reson Imaging 2022; 92:251-259. [PMID: 35870722 DOI: 10.1016/j.mri.2022.07.008] [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: 03/25/2022] [Revised: 06/13/2022] [Accepted: 07/11/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The treatment of Gamma knife radiosurgery (GKS) for unruptured Arteriovenous Malformations (AVM) remains controversial. A safe, effective and non-invasive method to predict outcome seems attractive for GKS. The purpose of this study was to develop and validate a MRI based multi-parameter radiomics model predicting the outcome of GKS for unruptured AVM. METHODS Eighty-eight unruptured AVM patients who initial underwent GKS between January 2011 and December 2016 in our hospital were included in this retrospective study. Patients were divided into two groups named as favourable and unfavourable outcome, according to the clinical outcome. Favourable outcome was defined as obliteration without post-SRS hemorrhage or permanent radiation-induced changes (RIC). Multivariate logistic regression analysis was used to select appropriate clinical features and construct a clinical predicting model. In terms of radiomic model, manually segmentation and radiomics extracted were performed on each AVM lesions. Finally, 1684 radiomics features were extracted and Recursive Feature Elimination (RFE) method combined with Random forest classifier were used for feature selection and model construction. The performance of the radiomics model was evaluated by the area under the curve (AUC), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). In addition, the favourable group was further divided into early and late respond subgroup according to the time of obliteration evaluated by 2 years. The selected features were further compared according the respond time. RESULTS The median duration of neuroimaging follow-up was 65 months, 56 patients showed favourable outcome and 17 patients were observed obliteration within 2 years. The radiomics model constructed by 12 selected features achieved significant higher AUC of 0.88 (95% confidence interval 0.87-0.90) than traditional scoring system for predicting AVM outcome. Two selected radiomics features named "Dependence Variance" and "firstorder-Skewness" were found significant difference between the patients with early or late-respond. CONCLUSIONS The results suggest that the radiomics features could be successfully used for the pretreatment prediction of outcome for GKS in unruptured AVMs, which is helpful for decision-making process on unruptured AVM patients.
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Affiliation(s)
- Dezhi Gao
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Gamma-Knife Center, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiangyu Meng
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hengwei Jin
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ali Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Gamma-Knife Center, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shibin Sun
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Gamma-Knife Center, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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9
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Ilyas A, Chen CJ, Abecassis IJ, Al-Saiegh F, Ironside N, Jabbour PM, Tjoumakaris S, Gooch MR, Lee CC, Sheehan JP, Ding D. Stereotactic Radiosurgery for A Randomized Trial of Unruptured Brain Arteriovenous Malformations-Eligible Patients: A Meta-Analysis. Neurosurgery 2022; 91:684-692. [PMID: 36001787 DOI: 10.1227/neu.0000000000002115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 06/12/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The outcomes of A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) were controversial, and they suggested that intervention is inferior to medical management for unruptured brain arteriovenous malformations (AVMs). However, several studies have shown that stereotactic radiosurgery (SRS) is an acceptable therapy for unruptured AVMs. OBJECTIVE To test the hypothesis that ARUBA intervention arm's SRS results are meaningfully inferior to those from similar populations reported by other studies. METHODS We performed a literature review to identify SRS studies of patients who met the eligibility criteria for ARUBA. Patient, AVM, treatment, and outcome data were extracted for statistical analysis. Regression analyses were pooled to identify factors associated with post-SRS obliteration and hemorrhage. RESULTS The study cohort included 8 studies comprising 1620 ARUBA-eligible patients who underwent SRS. At the time of AVM diagnosis, 36% of patients were asymptomatic. The mean follow-up duration was 80 months. Rates of radiologic, symptomatic, and permanent radiation-induced changes were 45%, 11%, and 2%, respectively. The obliteration rate was 68% at last follow-up. The post-SRS hemorrhage and mortality rates were 8%, and 2%, respectively. Lower Spetzler-Martin grade (odds ratios [OR] = 0.84 [0.74-0.95], P = .005), lower radiosurgery-based AVM score (OR = 0.75 [0.64-0.95], P = .011), lower Virginia Radiosurgery AVM Scale (OR = 0.86 [0.78-0.95], P = .003), and higher margin dose (OR = 1.13 [1.02-1.25], P = .025) were associated with obliteration. CONCLUSION SRS carries a favorable risk to benefit profile for appropriately selected ARUBA-eligible patients, particularly those with smaller volume AVMs. Our findings suggest that the results of ARUBA do not reflect the real-world safety and efficacy of SRS for unruptured AVMs.
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Affiliation(s)
- Adeel Ilyas
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Isaac Josh Abecassis
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Fadi Al-Saiegh
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Natasha Ironside
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Pascal M Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Dale Ding
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
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10
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Hak JF, Borius PY, Spatola G, Chopinet S, Testud B, Girard N, Brunel H, Regis J. Upfront and Repeated Gamma-Knife Radiosurgery for Small (≤5 mL) Unruptured Brain Arteriovenous Malformation: A Cohort of 249 Consecutive Patients. World Neurosurg 2021; 158:e889-e895. [PMID: 34844005 DOI: 10.1016/j.wneu.2021.11.091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE According to A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA), conservative treatment seems to be superior to any intervention for unruptured brain arteriovenous malformations (AVMs). This study aims to evaluate safety and efficacy of upfront and repeated Gamma-Knife Radiosurgery (GKRS) in patients harboring small AVMs fulfilling the inclusion criteria of ARUBA. METHODS A retrospective study was conducted to evaluate outcomes of unruptured naive brain AVM with a volume ⩽ 5 mL eligible to ARUBA treated by GKRS with at least 3 years of follow-up. RESULTS From 1992 to 2014, 249 patients fulfilled the inclusion criteria of this study. The median age was 36 years (range: 18-78 years). The median treated volume of the nidus was 1.3 mL (range: 0.4-5 mL) and 63% of the AVM were in eloquent areas. Radiosurgery-based AVM score was 1-1.8 (76%), the Spetzler-Martin grade was II-III (73%), and the Virginia Radiosurgery AVM scale was ≤1 point (75%). The overall AVM obliteration rate was 77.1% after up to 3 GKRS sessions. The median dose at the margin was 24 Gy (15-25 Gy) and the median follow-up was 45 months (range: 36-205 months). Eight patients (3.2%) experienced hemorrhage after GKRS, corresponding to a post-GKRS hemorrhage annual rate of 1.03%. Permanent symptomatic radio-induced changes rate was 2% (4 increased seizures, 1 neurologic deficit). CONCLUSIONS The very low toxicity rate and the high occlusion rate suggest in favor of upfront and repeated GKRS for unruptured small AVMs (⩽5 mL).
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Affiliation(s)
- Jean-François Hak
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Timone APHM, Marseille, France
| | - Pierre-Yves Borius
- Department of Neurosurgery and GammaKnife Unit, Pitié Salpêtrière Sorbonne University Hospital, Paris, France.
| | - Giorgio Spatola
- Department of Functional Neurosurgery, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Sophie Chopinet
- Department of Digestive Surgery, University Hospital Timone APHM, Marseille, France
| | - Benoit Testud
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Timone APHM, Marseille, France
| | - Nadine Girard
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Timone APHM, Marseille, France
| | - Hervé Brunel
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Timone APHM, Marseille, France
| | - Jean Regis
- Department of Functional Neurosurgery, Timone University Hospital, Aix-Marseille University, Marseille, France
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11
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Li W, Wang Y, Lu L, Zhang Y. The factors associated with obliteration following stereotactic radiosurgery in patients with brain arteriovenous malformations: a meta-analysis. ANZ J Surg 2021; 92:970-979. [PMID: 34676665 DOI: 10.1111/ans.17299] [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: 08/01/2021] [Revised: 09/26/2021] [Accepted: 10/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Various factors have been reported to affect the obliteration of brain arteriovenous malformations (AVM) following stereotactic radiosurgery (SRS). This meta-analysis was conducted to identify the factors potentially associated with AVM obliteration after SRS. METHODS We comprehensively searched databases and included studies that evaluated predictors of AVM obliteration after SRS using Cox proportional hazard regression analysis. Hazard ratios (HRs) with 95% confidence intervals (CIs) were utilized as effect estimates. RESULTS Twelve studies, involving 4415 AVM cases, were included. According to combined estimates on univariate (UV) and multivariate (MV) analysis, age, gender and prior haemorrhage did not affect the closure probability. The following factors showed a significant and independent association with increased AVM obliteration: smaller AVMs maximal diameter (MV, HR: 1.32), smaller AVM volume (MV, HR: 1.05), AVM volume <10-15 cc (MV, HR: 1.55), higher margin dose (MV, HR: 1.05), margin dose ≥17-18 Gy (MV, HR: 3.71) and early treatment period (MV, HR: 1.78). Previous embolization and deep-seated AVM were independently negative predictors of obliteration whereas deep venous drainage was a positive predictor. Prior surgery, compactness of nidus, lower grading scores and higher SRS maximum dose were associated factors subject to confounding factors. CONCLUSION Multiple factors associated with obliteration should be taken into consideration for selection of candidates with AVMs for SRS. AVM volume and radiation dose are the most prominent factor in assessing obliteration after SRS. Age, gender and prior haemorrhage may not affect the consideration of SRS treatment. Cautious use of SRS is needed for previously embolized AVM patients.
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Affiliation(s)
- Weiyan Li
- Department of General Surgery, Tianjin Fifth Central Hospital, Tianjin, 300450, China
| | - Yuqiang Wang
- Department of General Surgery, Tianjin Fifth Central Hospital, Tianjin, 300450, China
| | - Lantao Lu
- Department of General Surgery, Tianjin Fifth Central Hospital, Tianjin, 300450, China
| | - Yi Zhang
- Department of General Surgery, Tianjin Fifth Central Hospital, Tianjin, 300450, China
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12
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Liu R, Zhan Y, Piao J, Yang Z, Wei Y, Liu P, Chen X, Jiang Y. Treatments of unruptured brain arteriovenous malformations: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e26352. [PMID: 34160402 PMCID: PMC8238300 DOI: 10.1097/md.0000000000026352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/10/2021] [Accepted: 05/28/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The best therapeutic option for unruptured brain arteriovenous malformations (bAVMs) patients is disputed. OBJECTIVE To assess the occurrence of obliteration and complications of patients with unruptured bAVMs after various treatments. METHODS A systematic literature search was performed in PubMed, EMBASE, Web of Science, and so on to identify studies fulfilling predefined inclusion criteria. Baseline, treatment, and outcomes data were extracted for statistical analysis. RESULTS We identified 28 eligible studies totaling 5852 patients. The obliteration rates were 98% in microsurgery group (95% confidence interval (CI): 96%-99%, I2 = 74.5%), 97% in surgery group (95%CI: 95%-99%, I2 = 18.3%), 87% in endovascular treatment group (95%CI: 80%-93%, I2 = 0.0%), and 68% in radiosurgery group (95%CI: 66%-69%, I2 = 92.0%). The stroke or death rates were 1% in microsurgery group (95%CI: 0%-2%, I2 = 0.0%), 0% in surgery group (95%CI: 0%-1%, I2 = 0.0%), 4% in endovascular treatment group (95%CI: 0%-8%, I2 = 85.8%), and 3% in radiosurgery group (95%CI: 3%-4%, I2 = 82.9%). In addition, the proportions of hemorrhage were 2% in microsurgery group (95%CI: 1%-4%, I2 = 0.0%), 23% in endovascular treatment group (95%CI: 7%-39%), and 12% in radiosurgery group (95%CI: 12%-13%, I2 = 99.2%). As to neurological deficit, the occurrence was 9% in microsurgery group (95%CI: 6%-11%, I2 = 94.1%), 20% in surgery group (95%CI: 13%-27%, I2 = 0.0%), 14% in endovascular treatment group (95%CI: 10%-18%, I2 = 64.0%), and 8% in radiosurgery group (95%CI: 7%-9%, I2 = 66.6%). CONCLUSIONS We found that microsurgery might provide lasting clinical benefits in some unruptured bAVMs patients for its high obliteration rates and low hemorrhage. These findings are helpful to provide a reference basis for neurosurgeons to choose the treatment of patients with unruptured bAVMs.
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Affiliation(s)
- Renjie Liu
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Yongle Zhan
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jianmin Piao
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Zhongxi Yang
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Yun Wei
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Pengcheng Liu
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Xuan Chen
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Yu Jiang
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Nesvick CL, Graffeo CS, Brown PD, Link MJ, Stafford SL, Foote RL, Laack NN, Pollock BE. The Role of Biological Effective Dose in Predicting Obliteration After Stereotactic Radiosurgery of Cerebral Arteriovenous Malformations. Mayo Clin Proc 2021; 96:1157-1164. [PMID: 33958052 DOI: 10.1016/j.mayocp.2020.09.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 09/14/2020] [Accepted: 09/23/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether biological effective dose (BED) was predictive of obliteration after stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations (AVMs). PATIENTS AND METHODS We studied patients undergoing single-session AVM SRS between January 1, 1990, and December 31, 2014, with at least 2 years of imaging follow-up. Excluded were patients with syndromic AVM, previous SRS or embolization, and patients treated with volume-staged SRS. Biological effective dose was calculated using a mono-exponential model described by Jones and Hopewell. The primary outcome was likelihood of total obliteration defined by digital subtraction angiography or magnetic resonance imaging (MRI). Variables were analyzed as continuous and dichotomous variables based on the maximum value of (sensitivity-[1-specificity]). RESULTS This study included 352 patients (360 AVM, median follow-up, 5.9 years). The median margin dose prescribed was 18.75 Gy (interquartile range [IQR]: 18 to 20 Gy). Two hundred fifty-nine patients (71.9%) had obliteration shown by angiography (n=176) or MRI (n=83) at a median of 36 months after SRS (IQR: 26 to 44 months). Higher BED was associated with increased likelihood of obliteration in univariate Cox regression analyses, when treated as either a dichotomous (≥133 Gy; hazard ratio [HR],1.52; 95% confidence interval [CI], 1.19 to 1.95; P<.001) or continuous variable (HR, 1.00, 95% CI, 1.0002 to 1.005; P=.04). In multivariable analyses including dichotomized BED and location, BED remained associated with obliteration (P=.001). CONCLUSION Biological effective dose ≥133 Gy was predictive of AVM obliteration after single-session SRS within the prescribed margin dose range 15 to 25 Gy. Further study is warranted to determine whether BED optimization should be considered as well as treatment dose for AVM SRS planning.
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Affiliation(s)
- Cody L Nesvick
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| | | | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Michael J Link
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| | | | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN; Department of Radiation Oncology, Mayo Clinic, Rochester, MN.
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14
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Kim BS, Yeon JY, Shin HS, Kim JS, Hong SC, Shin HJ, Hwang YS, Lee JI. Gamma Knife Radiosurgery for Incidental, Symptomatic Unruptured, and Ruptured Brain Arteriovenous Malformations. Cerebrovasc Dis 2021; 50:222-230. [PMID: 33652439 DOI: 10.1159/000513280] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/13/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND This study was performed to investigate clinical characteristics and outcome after gamma knife radiosurgery (GKS) in patients with incidental, symptomatic unruptured, or ruptured arteriovenous malformations (AVMs). METHODS A total of 491 patients with brain AVMs treated with GKS from June 2002 to September 2017 were retrospectively reviewed. All patients were classified into the incidental (n = 105), symptomatic unruptured (n = 216), or ruptured AVM (n = 170) groups. RESULTS The mean age at diagnosis of incidental, symptomatic unruptured, and ruptured AVMs was 40.3, 36.7, and 27.6 years, respectively. The mean nidus volume was 3.9, 5.7, and 2.4 cm3, respectively. Deep venous drainage was identified in 34, 54, and 76% patients, respectively. There were no significant differences in obliteration rates after GKS between the 3 groups (64.8, 61.1, and 65.9%, respectively) after a mean follow-up period of 60.5 months; however, patients with incidental AVM had a significantly lower post-GKS hemorrhage rate than patients with symptomatic unruptured or ruptured AVMs (annual hemorrhage rate of 1.07, 2.87, and 2.69%; p = 0.028 and p = 0.049, respectively). CONCLUSIONS There is a significant difference in clinical and anatomical characteristics between incidental, symptomatic unruptured, and ruptured AVMs. The obliteration rate after GKS is not significantly different between the 3 groups. Meanwhile, an older age at diagnosis and lower hemorrhage rate after GKS in incidental AVMs suggest that they have a more indolent natural course with a lower life-long risk of hemorrhage.
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Affiliation(s)
- Byung Sup Kim
- Department of Neurosurgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyung Shik Shin
- Department of Neurosurgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Jong-Soo Kim
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Chyul Hong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyung Jin Shin
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yong Soon Hwang
- Department of Neurosurgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea,
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15
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Zhu S, Brodin NP, Garg MK, LaSala PA, Tomé WA. Systematic Review and Meta-Analysis of the Dose-Response and Risk Factors for Obliteration of Arteriovenous Malformations Following Radiosurgery: An Update Based on the Last 20 Years of Published Clinical Evidence. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okab004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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16
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Alkhabiry A, Almutairi OT, Elarjani T, Bafaquh M, Alassaf H, Alturki AY. Bibliometric analysis of the top-100 most cited articles on the radiosurgical management of cerebral arteriovenous malformation. Surg Neurol Int 2021; 11:477. [PMID: 33500815 PMCID: PMC7827432 DOI: 10.25259/sni_760_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/09/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Radiosurgery is an effective, alternative treatment modality in managing patients with cerebral arteriovenous malformations (AVMs). The present study aims to highlight the scholarly impact of the top-100 most cited articles on the radiosurgical management of AVMs. Methods: A title-specific search using the keyword “arteriovenous malformation” was conducted in the Scopus database. The outcome of the search was rearranged based on the citations count. Articles were categorized into four entities; clinical, gamma knife radiosurgery, linear accelerator (LINAC) radiosurgery, and proton beam radiosurgery. The exclusion criteria were applied to spinal or non-intracranial AVM, conference papers, non-English articles predominantly discussing the endovascular or microsurgical management. Results: The top-100 articles on the radiosurgical management of AVM were published between 1972 and 2016. Approximately one-third of the publications were produced between 1995 and 2000. The average citations per year for all papers were seven. The most-studied entity was pertinent to the clinical application of gamma knife radiosurgery in AVM (68%). The United States was the most active country in studying the radiosurgical application in AVM. The Journal of Neurosurgery published approximately one-third of the most-cited articles in the list. The top-3 most contributing authors, publishing 80% of articles in the list, were Lunsford et al. Conclusion: The radiosurgical management of AVMs evolved significantly throughout the years. Identifications of the publication trends facilitate the acquisition of evidence-based articles for authors investigating various radiosurgical techniques in the treatment of AVMs.
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Affiliation(s)
- Ali Alkhabiry
- Department of Neurosurgery, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Othman T Almutairi
- Department of Adult Neurosurgery, National National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Turki Elarjani
- Department of Neurosurgery, University of Miami, Miami, Florida, United States
| | - Mohammed Bafaquh
- Department of Adult Neurosurgery, National National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Hossam Alassaf
- Department of Radiation Oncology, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman Y Alturki
- Department of Adult Neurosurgery, National National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
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17
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Kelly R, Conte A, Nair MN, Voyadzis JM, Anaizi A, Collins S, Kalhorn C, Stemer A, Mai J, Armonda R, Lischalk J, Berkowitz F, Nayar V, McGrail K, Collins BT. Arteriovenous Malformations Treated With Frameless Robotic Radiosurgery Using Non-Invasive Angiography: Long-Term Outcomes of a Single Center Pilot Study. Front Oncol 2020; 10:570782. [PMID: 33330045 PMCID: PMC7734323 DOI: 10.3389/fonc.2020.570782] [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: 06/09/2020] [Accepted: 09/22/2020] [Indexed: 12/31/2022] Open
Abstract
Objective CT-guided, frameless robotic radiosurgery is a novel radiotherapy technique for the treatment of intracranial arteriovenous malformations (AVMs) that serves as an alternative to traditional catheter-angiography targeted, frame-based methods. Methods Patients diagnosed with AVMs who completed single fraction frameless robotic radiosurgery at Medstar Georgetown University Hospital between July 20, 2006 – March 11, 2013 were included in the present study. All patients received pre-treatment planning with CT angiogram (CTA) and MRI, and were treated using the CyberKnife radiosurgery platform. Patients were followed for at least four years or until radiographic obliteration of the AVM was observed. Results Twenty patients were included in the present study. The majority of patients were diagnosed with Spetzler Martin Grade II (35%) or III (35%) AVMs. The AVM median nidus diameter and nidal volume was 1.8 cm and 4.38 cc, respectively. Median stereotactic radiosurgery dose was 1,800 cGy. After a median follow-up of 42 months, the majority of patients (81.3%) had complete obliteration of their AVM. All patients who were treated to a total dose of 1800 cGy demonstrated complete obliteration. One patient treated at a dose of 2,200 cGy developed temporary treatment-related toxicity, and one patient developed post-treatment hemorrhage. Conclusions Frameless robotic radiosurgery with non-invasive CTA and MRI radiography appears to be a safe and effective radiation modality and serves as a novel alternative to traditional invasive catheter-angiography, frame-based methods for the treatment of intracranial AVMs. Adequate obliteration can be achieved utilizing 1,800 cGy in a single fraction, and minimizes treatment-related side effects.
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Affiliation(s)
- Ryan Kelly
- Georgetown University School of Medicine, Washington, DC, United States
| | - Anthony Conte
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - M Nathan Nair
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Amjad Anaizi
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Sean Collins
- Department of Radiation Medicine, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Christopher Kalhorn
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Andrew Stemer
- Department of Neurology, Medstar Georgetown University Hospital, Washington, DC, United States.,Department of Radiology, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Jeffery Mai
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, United States
| | - Rocco Armonda
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, United States
| | - Jonathan Lischalk
- Department of Radiation Medicine, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Frank Berkowitz
- Department of Radiology, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Vikram Nayar
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Kevin McGrail
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Brian Timothy Collins
- Department of Radiation Medicine, Medstar Georgetown University Hospital, Washington, DC, United States
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18
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Radiosurgery for unruptured brain arteriovenous malformations in the pre-ARUBA era: long-term obliteration rate, risk of hemorrhage and functional outcomes. Sci Rep 2020; 10:21427. [PMID: 33293642 PMCID: PMC7723058 DOI: 10.1038/s41598-020-78547-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 11/11/2020] [Indexed: 11/18/2022] Open
Abstract
The management of non-hemorrhagic arteriovenous malformations (AVMs) remains a subject of debate, even more since the ARUBA trial. Here, we report the obliteration rate, the risk of hemorrhage and the functional outcomes after Gamma Knife radiosurgery (GKRS) as first-line treatment for non-hemorrhagic AVMs treated before the ARUBA publication, in a reference university center with multimodal AVM treatments available. We retrospectively analyzed data from a continuous series of 172 patients harboring unruptured AVMs treated by GKRS as first-line treatment in our Lille University Hospital, France, between April 2004 and December 2013. The primary outcome was obliteration rate. Secondary outcomes were the hemorrhage rate, the modified Rankin Scale (mRS), morbidity and epilepsy control at last follow-up. The minimal follow-up period was of 3 years. Median age at presentation was 40 years (IQR 28; 51). Median follow-up was 8.8 years (IQR 6.8; 11.3). Median target volume was 1.9 cm3 (IQR 0.8–3.3 cm3), median Spetzler-Martin grade: 2 (IQR 1–2), median Pollock-Flickinger score: 1.07 (IQR 0.82–2.94), median Virginia score: 1 (IQR 1–2). Median treatment dose was 24 Gy at 50% isodose line. Twenty-three patients underwent a second GKRS after a median time of 58 months after first GKRS. The overall obliteration rate was of 76%, based primarily on cerebral angiography and/or rarely only upon MRI. Hemorrhage during the post-treatment follow-up was reported in 18 (10%) patients (annual risk of 1.1%). Transient post-GKRS morbidity was reported in 14 cases (8%) and persistent neurological deficit in 8 (4.6%) of patients. At last follow-up, 86% of patients had a mRS ≤ 1. Concerning patients with pretherapeutic epilepsy, 84.6% of them were seizure-free at last follow-up. GKRS as first-line therapeutic option for unruptured cerebral AVMs achieves high obliteration rates (76%) while maintaining a high-level patient’s autonomy. All hemorrhagic events occurred during the first 4 years after the initial GKRS. In cases with epilepsy, there was 84.6% seizure free at last follow-up. Permanent morbidity was reported in only 4.6%.
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19
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Chye CL, Wang KW, Chen HJ, Yeh SA, Tang JT, Liang CL. Haemorrhage rates of ruptured and unruptured brain arteriovenous malformation after radiosurgery: a nationwide population-based cohort study. BMJ Open 2020; 10:e036606. [PMID: 33051231 PMCID: PMC7554462 DOI: 10.1136/bmjopen-2019-036606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES The present nationwide population-based cohort study aims to assess the effectiveness of gamma knife radiosurgery (GKS) on ruptured and unruptured brain arteriovenous malformations (AVMs) by evaluating the haemorrhage rates. DESIGN A nationwide, retrospective cohort study. SETTING Taiwan National Health Insurance Research Database (NHIRD). PARTICIPANTS An observational study of 1515 patients who were diagnosed with brain AVMs between 1997 and 2013 from the Taiwan NHIRD. PRIMARY OUTCOME AND SECONDARY OUTCOME MEASURES We performed a survival analysis using the Kaplan-Meier method. Multivariate Cox proportional hazards regression models were used to explore the relationship between treatment modalities (GKS vs non-GKS) and haemorrhage, adjusted for age and sex. RESULTS The GKS and non-GKS groups included 317 and 1198 patients, respectively. Patients in the GKS group (mean±SD, 33.08±15.48 years of age) tended to be younger than those in the non-GKS group (37.40±17.62) (p<0.001). The 15-year follow-up revealed that the rate of bleeding risk was lower in the GKS group than in the non-GKRS group (adjusted HR (aHR) 0.61; 95% CI 0.40 to 0.92). The bleeding risk of ruptured AVMs was significantly lower in GKS group than in the non-GKS group (aHR 0.34; 95% CI 0.19 to 0.62). On the other hand, the bleeding risk of unruptured AVMs was higher in the GKS group than in the non-GKS group (aHR 1.95; 95% CI 1.04 to 3.65). In the unruptured AVM group, the incidence of bleeding was significantly higher among patients in the GKS group that were of >40 years of age (aHR 3.21; 95% CI 1.12 to 9.14). CONCLUSIONS GKS is safe and it reduces the risk of haemorrhage in patients with ruptured AVMs. The administration of GKS to patients with unruptured AVMs who are above the age of 40 years old male might increase the risk of haemorrhage.
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Affiliation(s)
- Cien-Leong Chye
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Kuo-Wei Wang
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Han-Jung Chen
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Shyh-An Yeh
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Radiation Oncology, E-Da Hospital, Kaohsiung, Taiwan
| | - James Taoqian Tang
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Community Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Cheng-Loong Liang
- I-Shou University, School of Medicine, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
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20
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Chen Y, Meng X, Ma L, Zhao Y, Gu Y, Jin H, Gao D, Li Y, Sun S, Liu A, Zhao Y, Chen X, Wang S. Contemporary management of brain arteriovenous malformations in mainland China: a web-based nationwide questionnaire survey. Chin Neurosurg J 2020; 6:26. [PMID: 32922955 PMCID: PMC7461270 DOI: 10.1186/s41016-020-00206-0] [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: 03/23/2020] [Accepted: 07/03/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In the benefit of the large population and rapid economic growth, the interventional techniques and equipment for brain arteriovenous malformations (bAVMs) in mainland China have been rapidly improved. Chinese neurosurgical cerebrovascular physicians have accumulated rich experience and made pioneering explorations. This study aims to summarize the experience and treatment progress of bAVMs in mainland China. METHODS We performed a web-based nationwide questionnaire survey among 67 tertiary neurosurgical institutions that had acknowledged treating bAVMs in the primary survey. Our questionnaire included clinical characteristics, radiological findings, intervention indications/contraindications, intervention timing, and intraoperative management of different treatment modalities. RESULTS A total of 63 participants from 49 (73.1%) tertiary neurosurgical institutions responded to our questionnaire. Forty-two (66.7%) were neurosurgeons, 13 (20.6%) were neurointerventionists, and 8 (12.7%) were radiosurgeons. Approximately 3500 to 4000 cases of bAVMs were treated annually in these 49 departments. All participants agreed that the conclusions of ARUBA are debatable. Flow-related aneurysms, deep venous drainage, and arteriovenous fistula were considered as common hemorrhagic risk factors. Unruptured SM IV-V bAVMs, giant bAVMs, pediatric bAVMs, elderly bAVMs, and eloquent bAVMs were not absolute contraindications to intervention. Maximum lesion occlusion and minimal functional impairment were the principles of intervention management. Most of the neurosurgeons and neurointerventionists recommended early intervention (< 30 days) for ruptured bAVMs, and the radiosurgeons suggested intervention in the chronic phase or recovery phase (P < 0.01) and preferably 3 months after bleeding. Multi-modality strategies were thought effective for complex bAVMs, and more exploration of individualized intraoperative management was necessary. CONCLUSIONS Intervention was acceptable for specific selected unruptured bAVMs in mainland China, especially in patients with hemorrhagic risk factors. The application of multidisciplinary cerebrovascular team and multicenter large-sample international registry study might be the next work for Chinese neurosurgical cerebrovascular physicians.
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Affiliation(s)
- Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Xiangyu Meng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China
| | - Ye Gu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dezhi Gao
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shibin Sun
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ali Liu
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070 China
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Jacob J, Reyns N, Valéry CA, Feuvret L, Simon JM, Mazeron JJ, Jenny C, Cuttat M, Maingon P, Pasquier D. Radiotherapy of non-tumoral refractory neurological pathologies. Cancer Radiother 2020; 24:523-533. [PMID: 32859467 DOI: 10.1016/j.canrad.2020.06.012] [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: 05/15/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 10/23/2022]
Abstract
Intracranial radiotherapy has been improved, primarily because of the development of stereotactic approaches. While intracranial stereotactic body radiotherapy is mainly indicated for treatment of benign or malignant tumors, this procedure is also effective in the management of other neurological pathologies; it is delivered using GammaKnife® and linear accelerators. Thus, brain arteriovenous malformations in patients who are likely to experience permanent neurological sequelae can be managed by single session intracranial stereotactic body radiotherapy, or radiosurgery, in specific situations, with an advantageous benefit/risk ratio. Radiosurgery can be recommended for patients with disabling symptoms, which are poorly controlled by medication, such as trigeminal neuralgia, and tremors, whether they are essential or secondary to Parkinson's disease. This literature review aims at defining the place of intracranial stereotactic body radiotherapy in the management of patients suffering from non-tumoral refractory neurological pathologies. It is clear that the multidisciplinary collaboration of experienced teams from Neurosurgery, Neurology, Neuroradiology, Radiation Oncology and Medical Physics is needed for the procedures using high precision radiotherapy techniques, which deliver high doses to locations near functional brain areas.
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Affiliation(s)
- J Jacob
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Radiation Oncology, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - N Reyns
- Centre Hospitalier Régional Universitaire de Lille, Department of Neurosurgery and Neuro-Oncology, Neurosurgery service, 2, avenue Oscar-Lambret, 59000 Lille, France; Lille University, Inserm, U1189-ONCO-THAI-Image Assisted Laser Therapy for Oncology, 1, avenue Oscar-Lambret, 59000 Lille, France
| | - C-A Valéry
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Neurosurgery, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - L Feuvret
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Radiation Oncology, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - J-M Simon
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Radiation Oncology, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - J-J Mazeron
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Radiation Oncology, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - C Jenny
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Medical Physics, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - M Cuttat
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Medical Physics, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - P Maingon
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière-Charles-Foix, Department of Radiation Oncology, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - D Pasquier
- Centre Oscar-Lambret, Academic Department of Radiation Oncology, 3, rue Frédéric-Combemale, 59000 Lille, France; Lille University, Centre de Recherche en Informatique, Signal et Automatique de Lille, CRIStAL UMR 9189, Scientific Campus, bâtiment Esprit, avenue Henri-Poincaré, 59655 Villeneuve-d'Ascq, France
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22
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Daou BJ, Palmateer G, Thompson BG, Maher CO, Hayman JA, Lam KL, Wahl DR, Kim M, Pandey AS. Stereotactic Radiosurgery for Brain Arteriovenous Malformations: Evaluation of Obliteration and Review of Associated Predictors. J Stroke Cerebrovasc Dis 2020; 29:104863. [PMID: 32689634 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104863] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/11/2020] [Accepted: 04/02/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND High arteriovenous malformation (AVM) obliteration rates have been reported with stereotactic radiosurgery (SRS), and multiple factors have been found to be associated with AVM obliteration. These predictors have been inconsistent throughout studies. We aimed to analyze our experience with linear accelerator (LINAC)-based SRS for brain AVMs, evaluate outcomes, assess factors associated with AVM obliteration and review the various reported predictors of AVM obliteration. METHODS Electronic medical records were retrospectively reviewed to identify consecutive patients with brain AVMs treated with SRS over a 27-year period with at least 2 years of follow-up. Logistic regression analysis was performed to identify factors associated with AVM obliteration. RESULTS One hundred twenty-eight patients with 142 brain AVMs treated with SRS were included. Mean age was 34.4 years. Fifty-two percent of AVMs were associated with a hemorrhage before SRS, and 14.8% were previously embolized. Mean clinical and angiographic follow-up times were 67.8 months and 58.6 months, respectively. The median Spetzler-Martin grade was 3. Mean maximal AVM diameter was 2.8 cm and mean AVM target volume was 7.4 cm3 with a median radiation dose of 16 Gy. Complete AVM obliteration was achieved in 80.3%. Radiation-related signs and symptoms were encountered in 32.4%, only 4.9% of which consisted of a permanent deficit. Post-SRS AVM-related hemorrhage occurred in 6.3% of cases. In multivariate analysis, factors associated with AVM obliteration included younger patient age (P = .019), male gender (P = .008), smaller AVM diameter (P = .04), smaller AVM target volume (P = .009), smaller isodose surface volume (P = .005), a higher delivered radiation dose (P = .013), and having only one major draining vein (P = .04). CONCLUSIONS AVM obliteration with LINAC-based radiosurgery was safe and effective and achieved complete AVM obliteration in about 80% of cases. The most prominent predictors of AVM success included AVM size, AVM volume, radiation dose, number of draining veins and patient age.
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Affiliation(s)
- Badih J Daou
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - Gregory Palmateer
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - B Gregory Thompson
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - Cormac O Maher
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - James A Hayman
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Kwok L Lam
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Daniel R Wahl
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Michelle Kim
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Aditya S Pandey
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
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23
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Chen CJ, Ding D, Wang TR, Buell TJ, Ilyas A, Ironside N, Lee CC, Kalani MY, Park MS, Liu KC, Sheehan JP. Microsurgery Versus Stereotactic Radiosurgery for Brain Arteriovenous Malformations: A Matched Cohort Study. Neurosurgery 2020; 84:696-708. [PMID: 29762746 DOI: 10.1093/neuros/nyy174] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 04/05/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Microsurgery (MS) and stereotactic radiosurgery (SRS) remain the preferred interventions for the curative treatment of brain arteriovenous malformations (AVM), but their relative efficacy remains incompletely defined. OBJECTIVE To compare the outcomes of MS to SRS for AVMs through a retrospective, matched cohort study. METHODS We evaluated institutional databases of AVM patients who underwent MS and SRS. MS-treated patients were matched, in a 1:1 ratio based on patient and AVM characteristics, to SRS-treated patients. Statistical analyses were performed to compare outcomes data between the 2 cohorts. The primary outcome was defined as AVM obliteration without a new permanent neurological deficit. RESULTS The matched MS and SRS cohorts were each comprised of 59 patients. Both radiological (85 vs 11 mo; P < .001) and clinical (92 vs 12 mo; P < .001) follow-up were significantly longer for the SRS cohort. The primary outcome was achieved in 69% of each cohort. The MS cohort had a significantly higher obliteration rate (98% vs 72%; P = .001), but also had a significantly higher rate of new permanent deficit (31% vs 10%; P = .011). The posttreatment hemorrhage rate was significantly higher for the SRS cohort (10% for SRS vs 0% for MS; P = .027). In subgroup analyses of ruptured and unruptured AVMs, no significant differences between the primary outcomes were observed. CONCLUSION For patients with comparable AVMs, MS and SRS afford similar rates of deficit-free obliteration. Nidal obliteration is more frequently achieved with MS, but this intervention also incurs a greater risk of new permanent neurological deficit.
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Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Tony R Wang
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Natasha Ironside
- Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - M Yashar Kalani
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Min S Park
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kenneth C Liu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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24
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Chen CJ, Kearns KN, Ding D, Kano H, Mathieu D, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Grills IS, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for arteriovenous malformations of the basal ganglia and thalamus: an international multicenter study. J Neurosurg 2020; 132:122-131. [PMID: 30641831 DOI: 10.3171/2018.8.jns182106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 08/31/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Arteriovenous malformations (AVMs) of the basal ganglia (BG) and thalamus are associated with elevated risks of both hemorrhage if left untreated and neurological morbidity after resection. Therefore, stereotactic radiosurgery (SRS) has become a mainstay in the management of these lesions, although its safety and efficacy remain incompletely understood. The aim of this retrospective multicenter cohort study was to evaluate the outcomes of SRS for BG and thalamic AVMs and determine predictors of successful endpoints and adverse radiation effects. METHODS The authors retrospectively reviewed data on patients with BG or thalamic AVMs who had undergone SRS at eight institutions participating in the International Gamma Knife Research Foundation (IGKRF) from 1987 to 2014. Favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RICs). Multivariable models were developed to identify independent predictors of outcome. RESULTS The study cohort comprised 363 patients with BG or thalamic AVMs. The mean AVM volume and SRS margin dose were 3.8 cm3 and 20.7 Gy, respectively. The mean follow-up duration was 86.5 months. Favorable outcome was achieved in 58.5% of patients, including obliteration in 64.8%, with rates of post-SRS hemorrhage and permanent RIC in 11.3% and 5.6% of patients, respectively. Independent predictors of favorable outcome were no prior AVM embolization (p = 0.011), a higher margin dose (p = 0.008), and fewer isocenters (p = 0.044). CONCLUSIONS SRS is the preferred intervention for the majority of BG and thalamic AVMs. Patients with morphologically compact AVMs that have not been previously embolized are more likely to have a favorable outcome, which may be related to the use of a higher margin dose.
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Affiliation(s)
- Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kathryn N Kearns
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- 2Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Hideyuki Kano
- 3Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - David Mathieu
- 4Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Quebec, Canada
| | - Douglas Kondziolka
- 5Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Caleb Feliciano
- 6Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Inga S Grills
- 7Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan; and
| | - Gene H Barnett
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - L Dade Lunsford
- 3Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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25
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Hu YS, Lee CC, Wu HM, Yang HC, Lin TM, Luo CB, Guo WY, Chung WY, Lin CJ. Stagnant Venous Outflow Predicts Brain Arteriovenous Malformation Obliteration After Gamma Knife Radiosurgery Without Prior Intervention. Neurosurgery 2019; 87:338-347. [DOI: 10.1093/neuros/nyz507] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 09/10/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Gamma Knife radiosurgery (GKRS) obliterates 65% to 82% of brain arteriovenous malformations (BAVMs).
OBJECTIVE
To explore the impact of hemodynamics on GKRS outcomes.
METHODS
We retrospectively (2011-2017) included 98 patients with BAVMs who had received GKRS alone. Two evaluators, blinded to the outcomes, analyzed the pre-GKRS angiography and magnetic resonance images to obtain the morphological characteristics and quantitative digital subtraction angiography (QDSA) parameters. The venous stasis index was defined as the inflow gradient divided by the absolute value of the outflow gradient. Patients’ follow-up magnetic resonance or digital subtraction angiography images were evaluated for the presence of complete obliteration (CO). Cox regression and Kaplan–Meier analyses were conducted to determine the correlations between the parameters and outcomes.
RESULTS
Among the 98 patients, 63 (63.4%) achieved CO after GKRS at a median latency period of 31 mo. In multivariable analyses with adjustments for age and sex, increased BAVM volume (hazard ratio (HR) 0.949, P = .022) was an independent characteristic predictor, and venous stenosis (HR 2.595, P = .009), venous rerouting (HR 0.375, P = .022), and larger stasis index (HR 1.227, P = .025) were independent angiographic predictors of CO. BAVMs with a stasis index of >1.71 had a higher 36-mo probability of CO than those with a stasis index of ≤1.71 (61.1% vs 26.7%, P < .001).
CONCLUSION
BAVMs with a larger stasis index, indicating more stagnant venous outflow, may predict obliteration after GKRS. QDSA analysis may help in predicting BAVM treatment outcomes and making therapeutic decisions.
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Affiliation(s)
- Yong-Sin Hu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Brain Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Te-Ming Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Muir M, Patel R, Gadgil N, Pan I, Lam S. Postoperative 30-day outcomes after craniotomy for supratentorial AVM resection in children. J Clin Neurosci 2019; 70:108-112. [DOI: 10.1016/j.jocn.2019.08.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/06/2019] [Indexed: 11/28/2022]
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Kato Y, Dong VH, Chaddad F, Takizawa K, Izumo T, Fukuda H, Hara T, Kikuta K, Nakai Y, Endo T, Kurita H, Xu B, Beneš V, Christian R, Pavesi G, Hodaie M, Sharma RK, Agarwal H, Mohan K, Liew BS. Expert Consensus on the Management of Brain Arteriovenous Malformations. Asian J Neurosurg 2019; 14:1074-1081. [PMID: 31903343 PMCID: PMC6896626 DOI: 10.4103/ajns.ajns_234_19] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Brain arteriovenous malformations (bAVMs) are complex, heterogeneous, and uncommon intracranial lesions. They can be treated by one or a combination of the following treatment modalities, namely embolization, radiosurgery, or microsurgical resection. In Spetzler-Martin Grade 4 and 5 arteriovenous malformations (AVMs), conservative management may be the best option. A group of experts in the management of AVMs of different disciplines gathered in January 2019 in Hanoi to compile the “Expert Consensus on the Management of Brain Arteriovenous Malformations”.
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Affiliation(s)
- Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Van He Dong
- Department of Neurosurgery, VietDuc University Hospital, Hoan Kiem, Hanoi, Vietnam
| | - Feres Chaddad
- Department of Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Katsumi Takizawa
- Department of Neurosurgery, Japanese Red Cross Asahikawa Hospital, Asahikawa, Japan
| | - Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto, Nagasaki, Japan
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kochi University Hospital, Nankoku, Kochi, Japan
| | - Takayuki Hara
- Department of Neurosurgery, Toranomon Hospital, MinatoKu, Tokyo, Japan
| | | | - Yasunobu Nakai
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Toshiki Endo
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryo Aoba, Sendai, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Bin Xu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Vladimír Beneš
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University, Military University Hospital, Prague, Czech Republic
| | - Raftopoulos Christian
- Department of Neurosurgery, Cliniques Universitaires SaintLuc Bruxelles, Brussels, Belgium
| | - Giacomo Pavesi
- Department of Neurosurgery, Sant'Agostino Estense Hospital, Modena, Italy
| | - Mojgan Hodaie
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rajan Kumar Sharma
- Department of Neurosurgery, Bir Hospital, National Academy of Medical Sciences, Kathmandu, Nepal
| | | | - Krishna Mohan
- Department of Neurosurgery, SVIMS, Tirupathi, Andhra Pradesh, India
| | - Boon Seng Liew
- Department of Neurosurgery, Hospital Sungai Buloh, Selangor, Malaysia
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Tzikoulis V, Gkantaifi A, Alongi F, Tsoukalas N, Saraireh HH, Charalampakis N, Tzikoulis G, Andreou E, Tsapakidis K, Kardamakis D, Tsanadis K, Kyrgias G, Tolia M. Benign Intracranial Lesions - Radiotherapy: An Overview of Treatment Options, Indications and Therapeutic Results. Rev Recent Clin Trials 2019; 15:93-121. [PMID: 31713498 DOI: 10.2174/1574887114666191111100635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 10/14/2019] [Accepted: 10/26/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Radiation Therapy (RT) is an established treatment option for benign intracranial lesions. The aim of this study is to display an update on the role of RT concerning the most frequent benign brain lesions and tumors. METHODS Published articles about RT and meningiomas, Vestibular Schwannomas (VSs), Pituitary Adenomas (PAs), Arteriovenous Malformations (AVMs) and craniopharyngiomas were reviewed and extracted data were used. RESULTS In meningiomas RT is applied as an adjuvant therapy, in case of patientrefusing surgery or in unresectable tumors. The available techniques are External Beam RT (EBRT) and stereotactic ones such as Stereotactic Radiosurgery (SRS), Fractionated Stereotactic RT (FSRT), Intensity Modulated RT (IMRT) and proton-beam therapy. The same indications are considered in PAs, in which SRS and FSRT achieve excellent tumor control rate (92-100%), acceptable hormone remission rates (>50%) and decreased Adverse Radiation Effects (AREs). Upon tumor growth or neurological deterioration, RT emerges as alone or adjuvant treatment against VSs, with SRS, FSRT, EBRT or protonbeam therapy presenting excellent tumor control growth (>90%), facial nerve (84-100%), trigeminal nerve (74-99%) and hearing (>50%) preservation. SRS poses an effective treatment modality of certain AVMs, demonstrating a 3-year obliteration rate of 80%. Lastly, a combination of microsurgery and RT presents equal local control and 5-year survival rate (>90%) but improved toxicity profile compared to total resection in case of craniopharyngiomas. CONCLUSION RT comprises an effective treatment modality of benign brain and intracranial lesions. By minimizing its AREs with optimal use, RT projects as a potent tool against such diseases.
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Affiliation(s)
- Vasileios Tzikoulis
- School of Health Sciences, Faculty of Medicine, Biopolis, University of Thessaly, Larisa, 41500, Greece
| | - Areti Gkantaifi
- Radiotherapy Department, Interbalkan Medical Center, Thessaloniki, Greece
| | - Filippo Alongi
- Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Nikolaos Tsoukalas
- Oncology Department, Veterans Hospital (NIMTS), 10-12 Monis Petraki Str., 115 21, Athens, Greece
| | - Haytham Hamed Saraireh
- Radiation Oncology Department, Jordanian Royal Medical Services, King Hussein Medical Center, King Abdullah II St 230, Amman, Jordan
| | | | - Georgios Tzikoulis
- Department of Biochemistry and Biotechnology, University of Thessaly, Biopolis, 41500, Larisa, Greece
| | - Emmanouil Andreou
- School of Health Sciences, Faculty of Medicine, Biopolis, University of Thessaly, Larisa, 41500, Greece
| | - Konstantinos Tsapakidis
- Department of Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larisa, Greece
| | - Dimitrios Kardamakis
- Department of Radiation Oncology, Medical School, University of Patras, 265 04, Patra, Greece
| | - Konstantinos Tsanadis
- Department of Radiotherapy/Radiation Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larisa, Biopolis, 41500 Larisa, Greece
| | - George Kyrgias
- Department of Radiotherapy/Radiation Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larisa, Biopolis, 41500 Larisa, Greece
| | - Maria Tolia
- Department of Radiotherapy/Radiation Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larisa, Biopolis, 41500 Larisa, Greece
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Hirschmann D, Goebl P, Witte FH, Gatterbauer B, Wang WT, Dodier P, Bavinzski G, Ertl A, Marik W, Mallouhi A, Roetzer T, Dorfer C, Eisner W, Gruber A, Kitz K, Frischer JM. Evaluation of the radiosurgical treatment of cerebral arteriovenous malformations: a retrospective single-center analysis of three decades. J Neurointerv Surg 2019; 12:401-406. [PMID: 31558656 DOI: 10.1136/neurintsurg-2019-015332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Gamma Knife radiosurgery (GKRS) in the treatment of arteriovenous malformations (AVMs) is still controversially discussed. OBJECTIVE To present long-term follow-up data on patients after Gamma Knife radiosurgery for cerebral AVMs. METHODS Overall, 516 patients received radiosurgery for cerebral AVMs between 1992 and 2018 at our department, of whom 265 received radiosurgery alone and 207 were treated with a combined endovascular-radiosurgical approach. Moreover, 45 patients were treated with a volume-staged approach. Two eras were analyzed, the pre-modern era between 1992 and 2002 and the modern era thereafter. RESULTS In GKRS-only treated patients, median time to nidus occlusion was 3.8 years. Spetzler-Ponce (SP) class was a significant predictor for time to obliteration in the whole sample. Median time to obliteration for the combined treatment group was 6.5 years. Patients in the pre-modern era had a significantly higher obliteration rate than those treated in the modern era. Overall, the calculated yearly hemorrhage risk in the observation period after first GKRS was 1.3%. Permanent post-radiosurgical complications occurred in 4.9% of cases but did not differ between the treatment groups or treatment eras. The obliteration rate was significantly lower and the hemorrhage rate was higher in volume-staged treated patients than in conventionally treated patients. CONCLUSION GKRS is an effective treatment option for SP class A and B cerebral AVMs. After combined endovascular-radiosurgical treatment, the outcome of selected SP class C AVMs aligns with that of SP class B lesions. Both the combined therapy and radiosurgery alone constitute sound methods for treatment of cerebral AVMs.
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Affiliation(s)
- Dorian Hirschmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Goebl
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Frederic H Witte
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | | | - Wei-Te Wang
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Adolf Ertl
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Marik
- Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Ammar Mallouhi
- Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Thomas Roetzer
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Christian Dorfer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Eisner
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Johannes Kepler Universitat Linz, Linz, Austria
| | - Klaus Kitz
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Josa M Frischer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
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30
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Ding D, Chen CJ, Starke RM, Kano H, Lee JY, Mathieu D, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Kondziolka D, Barnett GH, Lunsford LD, Sheehan JP. Risk of Brain Arteriovenous Malformation Hemorrhage Before and After Stereotactic Radiosurgery. Stroke 2019; 50:1384-1391. [DOI: 10.1161/strokeaha.118.024230] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dale Ding
- From the Department of Neurosurgery, University of Louisville, KY (D.D.)
| | - Ching-Jen Chen
- From the Department of Neurosurgery, University of Louisville, KY (D.D.)
| | - Robert M. Starke
- Department of Neurological Surgery, University of Miami, FL (R.M.S.)
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.)
| | - John Y.K. Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia (J.Y.K.L.)
| | - David Mathieu
- Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, QC, Canada (D.M.)
| | - Caleb Feliciano
- Section of Neurological Surgery, University of Puerto Rico, San Juan (C.F., R.R.-M., L.A.)
| | | | - Luis Almodovar
- Section of Neurological Surgery, University of Puerto Rico, San Juan (C.F., R.R.-M., L.A.)
| | | | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center (D.K.)
| | - Gene H. Barnett
- Department of Neurosurgery, Cleveland Clinic Foundation, OH (G.H.B.)
| | - L. Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.)
| | - Jason P. Sheehan
- From the Department of Neurosurgery, University of Louisville, KY (D.D.)
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31
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Hasegawa T, Kato T, Naito T, Tanei T, Torii J, Ishii K, Tsukamoto E, Hatanaka KC, Sugiyama T. Long-Term Outcomes for Pediatric Patients with Brain Arteriovenous Malformations Treated with Gamma Knife Radiosurgery, Part 2: The Incidence of Cyst Formation, Encapsulated Hematoma, and Radiation-Induced Tumor. World Neurosurg 2019; 126:e1526-e1536. [PMID: 30922905 DOI: 10.1016/j.wneu.2019.03.177] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Long-term data about the incidence of late adverse radiation effects (AREs) in pediatric brain arteriovenous malformations (AVMs) treated with Gamma Knife radiosurgery (GKRS) are lacking. This study addresses the incidence of late AREs, including cyst formation (CF), chronic encapsulated hematoma (CEH), and radiation-induced tumor, in pediatric patients with AVM treated with GKRS. METHODS This is a single-institutional study involving pediatric patients with AVM who underwent GKRS between 1991 and 2014. Among 201 pediatric patients with AVM (age ≤15 years), 189 who had at least 12 months of follow-up were assessed in this study. The median treatment volume was 2.2 cm3, and the median marginal dose was 20 Gy. RESULTS The mean follow-up period was 136 months. During the follow-up period, symptomatic radiation-induced perilesional edema was found in 5 patients (3%), CFs in 7 patients (4%), CEHs in 7 patients (4%), and radiation-induced tumors in 2 patients (1%). The cumulative incidences of late AREs including CF, CEH, and radiation-induced tumor were 1.2% at 5 years, 5.2% at 8 years, 6.1% at 10 years, 7.2% at 15 years, and 17.0% at 20 years. In the multivariate analysis, treatment volume alone was a significant factor for late AREs (P < 0.001; hazard ratio, 1.111). CONCLUSIONS GKRS is a reasonable treatment option for pediatric AVMs to prevent future intracranial hemorrhages, particularly in the eloquent regions. However, considerable attention should be paid to late AREs such as CFs, CEHs, and radiation-induced tumors because of longer life expectancy in pediatric patients.
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Affiliation(s)
- Toshinori Hasegawa
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan.
| | - Takenori Kato
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Takehiro Naito
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Takafumi Tanei
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Jun Torii
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Kazuki Ishii
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Eisuke Tsukamoto
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Kanako C Hatanaka
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Japan
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Hospital, Sapporo, Japan
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32
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Winkler EA, Lu AY, Raygor KP, Linzey JR, Jonzzon S, Lien BV, Rutledge WC, Abla AA. Defective vascular signaling & prospective therapeutic targets in brain arteriovenous malformations. Neurochem Int 2019; 126:126-138. [PMID: 30858016 DOI: 10.1016/j.neuint.2019.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/01/2019] [Accepted: 03/04/2019] [Indexed: 02/08/2023]
Abstract
The neurovascular unit is composed of endothelial cells, vascular smooth muscle cells, pericytes, astrocytes and neurons. Through tightly regulated multi-directional cell signaling, the neurovascular unit is responsible for the numerous functionalities of the cerebrovasculature - including the regulation of molecular and cellular transport across the blood-brain barrier, angiogenesis, blood flow responses to brain activation and neuroinflammation. Historically, the study of the brain vasculature focused on endothelial cells; however, recent work has demonstrated that pericytes and vascular smooth muscle cells - collectively known as mural cells - play critical roles in many of these functions. Given this emerging data, a more complete mechanistic understanding of the cellular basis of brain vascular malformations is needed. In this review, we examine the integrated functions and signaling within the neurovascular unit necessary for normal cerebrovascular structure and function. We then describe the role of aberrant cell signaling within the neurovascular unit in brain arteriovenous malformations and identify how these pathways may be targeted therapeutically to eradicate or stabilize these lesions.
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Affiliation(s)
- Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA.
| | - Alex Y Lu
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Kunal P Raygor
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Joseph R Linzey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Soren Jonzzon
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Brian V Lien
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Adib A Abla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
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33
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Ding D, Ilyas A, Sheehan JP. Contemporary Management of High-Grade Brain Arteriovenous Malformations. Neurosurgery 2018; 65:24-33. [DOI: 10.1093/neuros/nyy107] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/03/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Dale Ding
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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34
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Chen CJ, Norat P, Ding D, Mendes GAC, Tvrdik P, Park MS, Kalani MY. Transvenous embolization of brain arteriovenous malformations: a review of techniques, indications, and outcomes. Neurosurg Focus 2018; 45:E13. [DOI: 10.3171/2018.3.focus18113] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endovascular embolization of brain arteriovenous malformations (AVMs) is conventionally performed from a transarterial approach. Transarterial AVM embolization can be a standalone treatment or, more commonly, used as a neoadjuvant therapy prior to microsurgery or stereotactic radiosurgery. In contrast to the transarterial approach, curative embolization of AVMs may be more readily achieved from a transvenous approach. Transvenous embolization is considered a salvage therapy in contemporary AVM management. Proposed indications for this approach include a small (diameter < 3 cm) and compact AVM nidus, deep AVM location, hemorrhagic presentation, single draining vein, lack of an accessible arterial pedicle, exclusive arterial supply by perforators, and en passage feeding arteries. Available studies of transvenous AVM embolization in the literature have reported high complete obliteration rates, with reasonably low complication rates. However, evaluating the efficacy and safety of this approach is challenging due to the limited number of published cases. In this review the authors describe the technical considerations, indications, and outcomes of transvenous AVM embolization.
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Affiliation(s)
- Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Pedro Norat
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- 2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - George A. C. Mendes
- 3Department of Interventional Neuroradiology, Hôpital Dupuytren, Centre Regional Hospitalier Universitaire de Limoges, France
| | - Petr Tvrdik
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Min S. Park
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - M. Yashar Kalani
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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35
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Ye Z, Ai X, You C. Letter to the Editor. Volume-staged vs dose-staged SRS for large brain AVMs. J Neurosurg 2018; 129:262-265. [PMID: 29726773 DOI: 10.3171/2017.11.jns172921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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36
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Ye Z, Ai X, You C. Letter to the Editor. Cyst formation after stereotactic radiosurgery for brain AVMs. J Neurosurg 2018; 129:259-262. [PMID: 29676692 DOI: 10.3171/2017.11.jns172776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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37
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Ding D, Buell TJ, Raper DM, Chen CJ, Mastorakos P, Liu KC, Vollmer DG. Sylvian Arteriovenous Malformation Resection and Associated Middle Cerebral Artery Aneurysm Clipping: Technical Nuances of Concurrent Surgical Treatment. Cureus 2018; 10:e2166. [PMID: 29805922 PMCID: PMC5963952 DOI: 10.7759/cureus.2166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Approximately 10-30% of brain arteriovenous malformations (AVM) have associated arterial aneurysms (AAA), and the management of these lesions can be challenging. In this video technical note, we demonstrate the microsurgical treatment of an unruptured, Spetzler-Martin grade I AVM in the distal Sylvian fissure with two AAAs arising proximally from the inferior M2 trunk immediately distal to the middle cerebral artery (MCA) bifurcation. First, we resected the superficially located AVM to normalize the blood flow through the Sylvian vein. Next, we performed a Sylvian fissure dissection to access and clip the two MCA AAAs. We also discuss the technical nuances of tandem surgical intervention for AVMs with AAAs as it pertains to this case, particularly with respect to the order of lesion treatment, Sylvian fissure dissection, nidal resection, and aneurysm clipping.
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Affiliation(s)
- Dale Ding
- Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia
| | - Daniel M Raper
- Department of Neurological Sugery, University of Virginia, Charlottesville, United States
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia
| | | | - Kenneth C Liu
- Department of Neurological Surgery, University of Virginia, Charlottesville, United States
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