1
|
Tseng HS, Lin CF, Yang HC, Chen CJ, Lin SC, Wu HM, Hu YS, Lin CJ, Chung WY, Shiau CY, Guo WY, Hung-Chi Pan D, Lee CC. Natural History and Histopathology of Expanding Cysts and Hematomas After Stereotactic Radiosurgery for Arteriovenous Malformations of the Brain: A Case Series. World Neurosurg 2024; 182:e854-e865. [PMID: 38104931 DOI: 10.1016/j.wneu.2023.12.063] [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: 08/07/2023] [Revised: 12/10/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND We reviewed the clinical course and histopathologic findings for cases involving the formation of expanding cysts and/or hematomas after gamma knife surgery (GKS) for arteriovenous malformations (AVMs). METHODS We report a single-center retrospective review of 18 patients who presented with cyst and/or hematoma expansion after GKS for AVMs between 1993 and 2023. Expanding cysts and hematomas were defined as well-demarcated cavities filled with fluid or well-marginated heterogenous hematomas presenting with expansion proximal to or in the location of the original AVM, respectively. Patient demographics, AVM characteristics, history of interventions and surgeries, and imaging and histopathologic features of expanding cysts and hematomas were collected for analysis. RESULTS Among 1072 AVM patients treated using GKS, 18 presented with expanding cysts or hematomas during a total follow-up period of 16,757 patient-years (0.11 case/100 persons/patient-year). The time to cyst or hematoma identification was 4-13 years after initial GKS, with a mean duration of 8.6 years. Among the patients examined, 7 (38.9%) presented mainly with hematoma, 10 (55.6%) presented mainly with cysts, and 1 presented with approximately equal components of both. Among the 18 patients, 13 (72.2%) underwent craniotomy to treat cyst or hematoma expansion. All the specimens had similar histopathologic characteristics, including organizing hematoma with fresh and old hemorrhage, fibrinoid necrosis of the vessels, gliosis of normal brain tissue, infiltration of hemosiderin-laden histiocytes, and extravascular protein leakage. CONCLUSIONS Our findings suggest that the formation of these 2 complications can be attributed to a common mechanism involving radiation-induced vascular damage in brain tissue adjacent to the AVM and subsequent chronic inflammation and capillary dilatation.
Collapse
Affiliation(s)
- Han-Song Tseng
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chun-Fu Lin
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung 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
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Shih-Chieh Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Pathology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yong-Sin Hu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - 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.
| |
Collapse
|
2
|
Demetz M, Mangesius J, Krigers A, Nevinny-Stickel M, Thomé C, Freyschlag CF, Kerschbaumer J. Tumor Location Impacts the Development of Radiation Necrosis in Benign Intracranial Tumors. Cancers (Basel) 2023; 15:4760. [PMID: 37835452 PMCID: PMC10571857 DOI: 10.3390/cancers15194760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/04/2023] [Accepted: 09/13/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Radiation necrosis (RN) is a possible late complication of stereotactic radiosurgery (SRS), but only a few risk factors are known. The aim of this study was to assess tumor location in correlation to the development of radiation necrosis for skull base (SB) and non-skull base tumors. METHODS All patients treated with radiosurgery for benign neoplasms (2004-2020) were retrospectively evaluated. The clinical, imaging and medication data were obtained and the largest axial tumor diameter was determined using MRI scans in T1-weighted imaging with gadolinium. The diagnosis of RN was established using imaging parameters. Patients with tumors located at the skull base were compared to patients with tumors in non-skull base locations. RESULTS 205 patients could be included. Overall, 157 tumors (76.6%) were located at the SB and compared to 48 (23.4%) non-SB tumors. Among SB tumors, the most common were vestibular schwannomas (125 cases) and meningiomas (21 cases). In total, 32 (15.6%) patients developed RN after a median of 10 (IqR 5-12) months. Moreover, 62 patients (30.2%) had already undergone at least one surgical resection. In multivariate Cox regression, SB tumors showed a significantly lower risk of radiation necrosis with a Hazard Ratio (HR) of 0.252, p < 0.001, independently of the applied radiation dose. Furthermore, higher radiation doses had a significant impact on the occurrence of RN (HR 1.372, p = 0.002). CONCLUSIONS The risk for the development of RN for SB tumors appears to be low but should not be underestimated. No difference was found between recurrent tumors and newly diagnosed tumors, which may support the value of radiosurgical treatment for patients with recurrent SB tumors.
Collapse
Affiliation(s)
- Matthias Demetz
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Julian Mangesius
- Department of Radiation Oncology, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Aleksandrs Krigers
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | | | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Christian F Freyschlag
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Johannes Kerschbaumer
- Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| |
Collapse
|
3
|
Ohadi MAD, Iranmehr A, Chavoshi M, Fatollahi MA, Aleyasin MS, Hadjipanayis CG. Stereotactic radiosurgery outcome for deep-seated cerebral arteriovenous malformations in the brainstem and thalamus/basal ganglia: systematic review and meta-analysis. Neurosurg Rev 2023; 46:148. [PMID: 37358733 DOI: 10.1007/s10143-023-02059-4] [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: 04/21/2023] [Revised: 06/03/2023] [Accepted: 06/19/2023] [Indexed: 06/27/2023]
Abstract
Deep-seated unruptured AVMs located in the thalamus, basal ganglia, or brainstem have a higher risk of hemorrhage compared to superficial AVMs and surgical resection is more challenging. Our systematic review and meta-analysis provide a comprehensive summary of the stereotactic radiosurgery (SRS) outcomes for deep-seated AVMs. This study follows the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement. We conducted a systematic search in December 2022 for all reports of deep-seated arteriovenous malformations treated with SRS. Thirty-four studies (2508 patients) were included. The mean obliteration rate in brainstem AVM was 67% (95% CI: 0.60-0.73), with significant inter-study heterogeneity (tau2 = 0.0113, I2 = 67%, chi2 = 55.33, df = 16, p-value < 0.01). The mean obliteration rate in basal ganglia/thalamus AVM was 65% (95% CI: 0.58-0.72) with significant inter-study heterogeneity (tau2 = 0.0150, I2 = 78%, chi2 = 81.79, df = 15, p-value < 0.01). The presence of deep draining veins (p-value: 0.02) and marginal radiation dose (p-value: 0.04) were positively correlated with obliteration rate in brainstem AVMs. The mean incidence of hemorrhage after treatment was 7% for the brainstem and 9% for basal ganglia/thalamus AVMs (95% CI: 0.05-0.09 and 95% CI: 0.05-0.12, respectively). The meta-regression analysis demonstrated a significant positive correlation (p-value < 0.001) between post-operative hemorrhagic events and several factors, including ruptured lesion, previous surgery, and Ponce C classification in basal ganglia/thalamus AVMs. The present study found that radiosurgery appears to be a safe and effective modality in treating brainstem, thalamus, and basal ganglia AVMs, as evidenced by satisfactory rates of lesion obliteration and post-surgical hemorrhage.
Collapse
Affiliation(s)
- Mohammad Amin Dabbagh Ohadi
- Departments of Pediatric Neurosurgery Children's Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Interdisciplinary Neuroscience Research Program, Tehran University of Medical Sciences, Tehran, Iran
| | - Arad Iranmehr
- Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
- Gammakinfe Radiosurgery Centre Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammadreza Chavoshi
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin Fatollahi
- Interdisciplinary Neuroscience Research Program, Tehran University of Medical Sciences, Tehran, Iran
| | - Mir Sajjad Aleyasin
- Interdisciplinary Neuroscience Research Program, Tehran University of Medical Sciences, Tehran, Iran
| | | |
Collapse
|
4
|
Shinya Y, Hasegawa H, Shin M, Kawashima M, Koizumi S, Katano A, Suzuki Y, Kashiwabara K, Saito N. Stereotactic Radiosurgery Provides Long-Term Safety for Patients With Arteriovenous Malformations in the Diencephalon and Brainstem: The Optimal Dose Selection and Long-Term Outcomes. Neurosurgery 2022; 91:485-495. [PMID: 35876672 DOI: 10.1227/neu.0000000000002064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Arteriovenous malformations (AVMs) of the diencephalon (DC) and brainstem (BS) are difficult to treat. Stereotactic radiosurgery (SRS) is a reasonable option; however, an optimal radiosurgical dose needs to be established to optimize long-term outcomes. OBJECTIVE To evaluate dose-dependent long-term outcomes of SRS for DC/BS-AVMs. METHODS We retrospectively analyzed the long-term outcomes of 118 patients who had SRS-treated DC/BS-AVMs. The outcomes included post-SRS hemorrhage, AVM obliteration, neurological outcomes, and disease-specific survival. According to margin doses, the patients were classified into low (<18 Gy), medium (18-20 Gy), and high (>20 Gy) dose groups. RESULTS SRS reduced the annual hemorrhage rate from 8.6% to 1.6% before obliteration and 0.0% after obliteration. The cumulative hemorrhage rate in the low dose group was likely to be higher than that in the other groups ( P = .113). The cumulative obliteration rates in the entire cohort were 74% and 83% at 5 and 10 years, respectively, and were significantly lower in the low dose group than in the other groups (vs medium dose: P = .027, vs high dose: P = .016). Multivariate analyses demonstrated that low dose SRS was significantly associated with worse obliteration rates (hazard ratio 0.18, 95% CI 0.04-0.79; P = .023). CONCLUSION SRS with a margin dose of 18 to 20 Gy for DC/BS-AVMs may be optimal, providing a higher obliteration rate and lower risk of post-SRS hemorrhage than lower dose SRS. Dose reduction to <18 Gy should only be optional when higher doses are intolerable.
Collapse
Affiliation(s)
- Yuki Shinya
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuichi Suzuki
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kosuke Kashiwabara
- Biostatistics Division, Central Coordinating Unit, Clinical Research Support Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| |
Collapse
|
5
|
Hu YS, Yang HC, Lin CJ, Lee CC, Guo WY, Luo CB, Liu KD, Chung WY, Wu HM. Imaging Markers Associated With Radiation-Induced Changes in Brain Arteriovenous Malformations After Radiosurgery. Neurosurgery 2022; 90:464-474. [PMID: 35080514 DOI: 10.1227/neu.0000000000001864] [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: 04/14/2021] [Accepted: 10/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Radiation-induced changes (RICs) in brain tissue, seen as increased perinidal T2-weighted hyperintensity on MRI, are commonly observed in patients with brain arteriovenous malformations (BAVMs) within 2 years after Gamma Knife (Elekta) radiosurgery (GKRS). OBJECTIVE To explore the imaging markers associated with RICs in patients with BAVMs. METHODS We retrospectively included 106 treatment-naïve patients with BAVMs who received GKRS alone between 2011 and 2018 and had ≥24 months of clinical and MRI follow-up. Pre-GKRS angiography and MRIs were analyzed for morphological characteristics and quantitative digital subtraction angiography parameters. RIC severity was categorized as mild (grade I), moderate (grade II), or severe (grade III). Firth logistic regression analysis was conducted to determine the associations between the parameters and RICs. RESULTS Among the 106 patients, 83 (78.3%) developed RICs, with 16 categorized as grade I, 62 as grade II, and 5 as grade III. RICs were symptomatic in 19 patients (17.9%). In multivariable models, BAVMs with a volume of >5 cm3 (odds ratio [OR]: 4.322, P = .024) and neoangiogenesis on angiography before treatment (OR: 3.846, P = .029), and thrombus within nidus or drainage vein on follow-up MRI (OR: 3.679, P = .001) were independently associated with grade II or III RICs. Symptomatic RICs were more likely to develop in basal ganglia or brainstem. CONCLUSION Large BAVMs and neoangiogenesis were associated with moderate to severe RICs in treatment-naïve patients with BAVMs. Our findings may assist with the complication risk assessment for these patients.
Collapse
Affiliation(s)
- Yong-Sin Hu
- Department of Radiology, Taoyuan Branch, Taipei Veterans General Hospital, Taoyuan, Taiwan
- Department of Radiology, Taipei Hospital, Ministry of Health and Welfare, New Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chao-Bao Luo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kang-Du Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| |
Collapse
|
6
|
Abstract
The treatment of arteriovenous malformations (AVMs) has evolved over the last 10 years. It is now possible to see that obliteration continues for up to 10 years and that the final obliteration rate may be between 85% and 90%. Improved imaging has made the treatment more efficient and has reduced the complications. It is possible to treat larger AVMs in a single session than was previously thought possible without increases in the complication rates. In addition, treatments of larger lesions can be staged. The use of 3D rotating angiography produces remarkable images which can be imported into GammaPlan. On the other hand efforts are ongoing to avoid the need for digital subtraction angiography, which would make the treatment a lot more comfortable.
Collapse
Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
| |
Collapse
|
7
|
Treatment of Radiation-Induced Brain Necrosis. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2021:4793517. [PMID: 34976300 PMCID: PMC8720020 DOI: 10.1155/2021/4793517] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/25/2021] [Accepted: 12/08/2021] [Indexed: 02/07/2023]
Abstract
Radiation-induced brain necrosis (RBN) is a serious complication of intracranial as well as skull base tumors after radiotherapy. In the past, due to the lack of effective treatment, radiation brain necrosis was considered to be progressive and irreversible. With better understanding in histopathology and neuroimaging, the occurrence and development of RBN have been gradually clarified, and new treatment methods are constantly emerging. In recent years, some scholars have tried to treat RBN with bevacizumab, nerve growth factor, and gangliosides and have achieved similar results. Some cases of brain necrosis can be repairable and reversible. We aimed to summarize the incidence, pathogenesis, and treatment of RBN.
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Cortese J, Delaitre M, Shotar E, Lenck S, Premat K, Hasboun D, Talbi A, Grand T, Boch AL, Mathon B, Valery CA, Drir M, Sourour NA, Clarençon F. Clinical Characteristics, Angioarchitecture and Management of Tectum Mesencephali Arteriovenous Malformations : A Retrospective Case Series. Clin Neuroradiol 2021; 32:445-454. [PMID: 34152431 DOI: 10.1007/s00062-021-01047-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Tectum mesencephali arteriovenous malformations (TM-AVMs) are rare lesions deeply located close to eloquent structures making them challenging to treat. We aimed to present clinical presentation, angiographic features and treatment strategies of TM-AVMs through a single center retrospective case series. METHODS A TM-AVMs is defined as a nidus located in the parenchyma or on the pia mater of the posterior midbrain. Records of consecutive patients admitted with TM-AVMs over a 21-year period were retrospectively analyzed. Vascular anatomy of the region is also reviewed. RESULTS In this study 13 patients (1.63% of the complete cohort; 10 males), mean age 48 years, were included. All patients presented with intracranial hemorrhage and two patients (15%) died after an early recurrent bleeding. Mean size of the TM-AVMs was 10.1 ± 5 mm. Multiple arterial feeders were noted in every cases. Of the patients 11 underwent an exclusion treatment, 8 via embolization (6 via arterial access and 2 via venous access) and 4 via stereotactic radiosurgery (SRS) (1 patient received both). Overall success treatment rate was 7/11 patients (64% overall; 63% in the embolization group, 25% in the SRS group). Two hemorrhagic events led to a worsened outcome, one during embolization and one several years after SRS. All other patients remained clinically stable or improved. CONCLUSION The TM-AVMs are rare but stereotypic lesions found in a hemorrhagic context. Multiple arterial feeders are always present. Endovascular treatment seems to be an effective technique with relatively low morbidity; SRS had a low success rate but was only use in a limited number of patients.
Collapse
Affiliation(s)
- Jonathan Cortese
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | | | - Eimad Shotar
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Stéphanie Lenck
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Kévin Premat
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France.,Sorbonne University, Paris, France
| | - Dominique Hasboun
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France.,Sorbonne University, Paris, France
| | - Atika Talbi
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Téodor Grand
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Anne-Laure Boch
- APHP. Department of Neurosurgery, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Bertrand Mathon
- Sorbonne University, Paris, France.,APHP. Department of Neurosurgery, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Charles-Ambroise Valery
- APHP. Department of Neurosurgery, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Mehdi Drir
- APHP. Department of Anesthesiology and Neuro-critical Care, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Nader-Antoine Sourour
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France
| | - Frédéric Clarençon
- APHP. Department of Neuroradiology, Pitié-Salpêtrière University Hospital, Sorbonne University, Paris, France. .,Sorbonne University, Paris, France. .,GRC BioFast, Sorbonne University, Paris, France.
| |
Collapse
|
10
|
Ai X, Xu J. The predictors of clinical outcomes in brainstem arteriovenous malformations after stereotactic radiosurgery. Medicine (Baltimore) 2021; 100:e26203. [PMID: 34087891 PMCID: PMC8183693 DOI: 10.1097/md.0000000000026203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 05/11/2021] [Indexed: 02/05/2023] Open
Abstract
The brainstem arteriovenous malformations (BS-AVMs) have a high morbidity and mortality and stereotactic radiosurgery (SRS) has been widely used to treat BS-AVMs. However, no consensus is reached in the explicit predictors of obliteration for BS-AVMs after SRS.To identify the predictors of clinical outcomes for BS-AVMs treated by SRS, we performed a retrospective observational study of BS-AVMs patients treated by SRS at our institution from 2006 to 2016. The primary outcomes were obliteration of nidus and favorable outcomes (AVM nidus obliteration with mRS score ≤2). For getting the outcomes more accurate, we also pooled the results of previous studies as well as our study by meta-analysis.A total of 26 patients diagnosed with BS-AVMs, with mean volume of 2.6 ml, were treated with SRS. Hemorrhage presentation accounted for 69% of these patients. Overall obliteration rate was 42% with mean follow-up of more than five years and two patients (8%) had a post-SRS hemorrhage. Favorable outcomes were observed in 8 patients (31%). Higher margin dose (>15Gy) was associated with higher obliteration (P = .042) and small volume of nidus was associated with favorable outcomes (P = .036). After pooling the results of 7 studies and present study, non-prior embolization (P = .049) and higher margin dose (P = .04) were associated with higher obliteration rate, in addition, the lower Virginia Radiosurgery AVM Scale (VRAS) was associated with favorable outcomes (P = .02) of BS-AVMs after SRS.In the BS-AVMs patients treated by SRS, higher margin dose (19-24Gy) and non-prior embolization were the independent predictors of higher obliteration rate. In addition, smaller volume of nidus and lower VRAS were the potential predictors of long-term favorable outcomes for these patients.
Collapse
Affiliation(s)
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
11
|
Kaya I, Çakır V, Cingoz ID, Atar M, Gurkan G, Sahin MC, Saygili SK, Yuceer N. Comparison of cerebral AVMs in patients undergoing surgical resection with and without prior endovascular embolization. Int J Neurosci 2021; 132:735-743. [PMID: 33866943 DOI: 10.1080/00207454.2021.1918689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM Brain arteriovenous malformations (AVMs) are congenital anomalies that present as intracranial hemorrhage or epilepsy. AVMs often remain clinically silent for extended periods. Although AVM treatment methods are controversial, three treatment strategies are usually combined or applied alone: surgical removal, embolization and stereotactic radiosurgery. We compared clinical and radiological outcomes in intracranial AVM patients treated via surgical resection with and without prior embolization. MATERIALS AND METHODS Patients who did (30 patients) and did not (30 patients) undergo endovascular embolization before surgical resection at the İzmir Katip Çelebi University Atatürk Training and Research Hospital Neurosurgery Clinic from 2011 to 2019 were included in this retrospective, cohort study. Symptoms at diagnosis, comorbidities and clinical (AVM and Spetzler-Martin grade) and morphological characteristics were assessed. RESULTS A mean one-year follow-up assessed outcomes using the modified Rankin score, and imaging studies assessed AVM obliteration post-procedure. Mean operation times for surgical resection with and without embolization were 166.50 ± 32.02 and 204.47 ± 26.66 min, respectively. Mean patient hospitalization periods for surgical resection with and without embolization were 8.43 ± 3.60 and 12.00 ± 5.51 days, respectively. CONCLUSION Among patients who underwent surgical resection, significant operation time and hospitalization time differences were observed in favor of patients who underwent embolization, indicating that preoperative embolization is a safe and beneficial method for treating ruptured and non-ruptured AVMs.
Collapse
Affiliation(s)
- Ismail Kaya
- Medical Faculty, Department of Neurosurgery, Usak University, Usak, Turkey
| | - Volkan Çakır
- Medical Faculty, Department of Interventional Radiology, Tınaztepe University, Izmir, Turkey
| | - Ilker Deniz Cingoz
- Medical Faculty, Department of Neurosurgery, Usak University, Usak, Turkey
| | - Murat Atar
- Department of Neurosurgery, Sultan 2.Abdulhamid Han Sample Training And Research Hospital, Istanbul, Turkey
| | - Gokhan Gurkan
- Medical Faculty, Department of Neurosurgery, Katip Çelebi University, Izmir, Turkey
| | - Meryem Cansu Sahin
- Training and Research Center, Kutahya Health Sciences University, Kutahya, Turkey
| | - Suna Karadeniz Saygili
- Medical Faculty, Department of Histology and Embryology, Kutahya Health Sciences University, Kutahya, Turkey
| | - Nurullah Yuceer
- Medical Faculty, Department of Neurosurgery, Katip Çelebi University, Izmir, Turkey
| |
Collapse
|
12
|
Stereotactic radiosurgery training patterns across neurosurgical programs: a multi-national survey. J Neurooncol 2021; 151:325-330. [PMID: 33394260 DOI: 10.1007/s11060-020-03670-x] [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: 10/26/2020] [Accepted: 11/30/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The field of neurosurgery has witnessed a dramatic increase in the use of stereotactic radiosurgery (SRS) as a modality to treat various cranial and spinal pathologies. However, studies have consistently demonstrated disparities in SRS training. Accordingly, the present study represents a cross-sectional analysis of current SRS training and practice patterns. METHODS An online survey was utilized to collect data from participants. Two-sided t-tests were used in order to compare frequency tables for statistically significant differences between groups. Qualitative analyses were performed by modified thematic analyses, employing open and axial coding. RESULTS A total of 67 participants completed the online survey (16.4% response rate). The majority of participants were neurosurgery attendings (58.2%), followed by neurosurgery residents (25.4%). The majority of participants reported that resident exposure to SRS was gained primarily through non-SRS focused rotations (52.2%). The survey found that exposure to tumor cases was most frequent, followed by functional, vascular, and spine indications. The majority of participants (49.3%) indicate that residents are not competent or exhibit a low level of competency in SRS at the completion of neurosurgical residency. Qualitative analyses demonstrated that respondents believe SRS is a critical modality in current cranial neurosurgical care and that increased training is needed. CONCLUSIONS This study provides a multi-national analysis of SRS residency training and practice patterns, and aims to stimulate improvement in SRS in training worldwide. Enhanced resident training in SRS must include wider exposure to vascular, neoplastic, functional and pediatric indications for SRS.
Collapse
|
13
|
Lehrer EJ, Prabhu AV, Sindhu KK, Lazarev S, Ruiz-Garcia H, Peterson JL, Beltran C, Furutani K, Schlesinger D, Sheehan JP, Trifiletti DM. Proton and Heavy Particle Intracranial Radiosurgery. Biomedicines 2021; 9:31. [PMID: 33401613 PMCID: PMC7823941 DOI: 10.3390/biomedicines9010031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/23/2020] [Accepted: 12/30/2020] [Indexed: 12/25/2022] Open
Abstract
Stereotactic radiosurgery (SRS) involves the delivery of a highly conformal ablative dose of radiation to both benign and malignant targets. This has traditionally been accomplished in a single fraction; however, fractionated approaches involving five or fewer treatments have been delivered for larger lesions, as well as lesions in close proximity to radiosensitive structures. The clinical utilization of SRS has overwhelmingly involved photon-based sources via dedicated radiosurgery platforms (e.g., Gamma Knife® and Cyberknife®) or specialized linear accelerators. While photon-based methods have been shown to be highly effective, advancements are sought for improved dose precision, treatment duration, and radiobiologic effect, among others, particularly in the setting of repeat irradiation. Particle-based techniques (e.g., protons and carbon ions) may improve many of these shortcomings. Specifically, the presence of a Bragg Peak with particle therapy at target depth allows for marked minimization of distal dose delivery, thus mitigating the risk of toxicity to organs at risk. Carbon ions also exhibit a higher linear energy transfer than photons and protons, allowing for greater relative biological effectiveness. While the data are limited, utilization of proton radiosurgery in the setting of brain metastases has been shown to demonstrate 1-year local control rates >90%, which are comparable to that of photon-based radiosurgery. Prospective studies are needed to further validate the safety and efficacy of this treatment modality. We aim to provide a comprehensive overview of clinical evidence in the use of particle therapy-based radiosurgery.
Collapse
Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (K.K.S.); (S.L.)
| | - Arpan V. Prabhu
- Department of Radiation Oncology, UAMS Winthrop P. Rockefeller Cancer Institute University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Kunal K. Sindhu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (K.K.S.); (S.L.)
| | - Stanislav Lazarev
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (K.K.S.); (S.L.)
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - Jennifer L. Peterson
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - Chris Beltran
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - Keith Furutani
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - David Schlesinger
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA 22903, USA; (D.S.); (J.P.S.)
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA 22903, USA; (D.S.); (J.P.S.)
| | - Daniel M. Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| |
Collapse
|
14
|
Graffeo CS, Sahgal A, De Salles A, Fariselli L, Levivier M, Ma L, Paddick I, Regis JM, Sheehan J, Suh J, Yomo S, Pollock BE. Stereotactic Radiosurgery for Spetzler-Martin Grade I and II Arteriovenous Malformations: International Society of Stereotactic Radiosurgery (ISRS) Practice Guideline. Neurosurgery 2020; 87:442-452. [PMID: 32065836 PMCID: PMC7426190 DOI: 10.1093/neuros/nyaa004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 11/30/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND No guidelines have been published regarding stereotactic radiosurgery (SRS) in the management of Spetzler-Martin grade I and II arteriovenous malformations (AVMs). OBJECTIVE To establish SRS practice guidelines for grade I-II AVMs on the basis of a systematic literature review. METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant search of Medline, Embase, and Scopus, 1986-2018, for publications reporting post-SRS outcomes in ≥10 grade I-II AVMs with a follow-up of ≥24 mo. Primary endpoints were obliteration and hemorrhage; secondary outcomes included Spetzler-Martin parameters, dosimetric variables, and “excellent” outcomes (defined as total obliteration without new post-SRS deficit). RESULTS Of 447 abstracts screened, 8 were included (n = 1, level 2 evidence; n = 7, level 4 evidence), representing 1102 AVMs, of which 836 (76%) were grade II. Obliteration was achieved in 884 (80%) at a median of 37 mo; 66 hemorrhages (6%) occurred during a median follow-up of 68 mo. Total obliteration without hemorrhage was achieved in 78%. Of 836 grade II AVMs, Spetzler-Martin parameters were reported in 680: 377 were eloquent brain and 178 had deep venous drainage, totaling 555/680 (82%) high-risk SRS-treated grade II AVMs. CONCLUSION The literature regarding SRS for grade I-II AVM is low quality, limiting interpretation. Cautiously, we observed that SRS appears to be a safe, effective treatment for grade I-II AVM and may be considered a front-line treatment, particularly for lesions in deep or eloquent locations. Preceding publications may be influenced by selection bias, with favorable AVMs undergoing resection, whereas those at increased risk of complications and nonobliteration are disproportionately referred for SRS.
Collapse
Affiliation(s)
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Antonio De Salles
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California
| | - Laura Fariselli
- Fondazione IRCCS Istituto Neurologico Carlo Besta Milano, Unità di Radioterapia, Milan, Italy
| | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Ian Paddick
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Jean Marie Regis
- Department of Functional Neurosurgery, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - John Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota.,Department Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
15
|
Ding K, Romiyo P, Ng E, Udawatta M, Dejam D, Phillips HW, Sun MZ, Yang I. A systematic analysis of stereotactic radiosurgery surveys for residents in neurosurgery training programs. J Neurol Sci 2020; 417:116867. [PMID: 32423574 DOI: 10.1016/j.jns.2020.116867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/26/2020] [Indexed: 10/24/2022]
Abstract
OBJECT The use of stereotactic radiosurgery (SRS) has increased. SRS training has not risen congruently. Neurosurgeons have conducted surveys and advocated implementation of widespread, standardized radiosurgery training. Here we analyze the SRS surveys conducted throughout the past decade. METHODS This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic literature review. A broad search of the literature was conducted in October 2018 through the PubMed, Scopus, Embase, and Web of Science databases. This study included surveys evaluating SRS training in neurosurgery and excluded those regarding other specialties. RESULTS An overview of surveys showed that neurosurgery residents possess gaps in SRS knowledge and procedural competency that have persisted through the past decade. There is an overwhelming sentiment that current radiosurgery training is not adequate to prepare residents for future practice. Our recommendation is for residency programs to integrate formal SRS training electives, with a movement towards creating more options for extended SRS fellowships post-residency. CONCLUSIONS We present data from SRS competency and current training surveys. Although resident SRS training still lags behind other subspecialties, we see indications for growth. To keep up with the role of SRS in neurosurgery, residencies need more formalized SRS rotations.
Collapse
Affiliation(s)
- Kevin Ding
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Prasanth Romiyo
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Edwin Ng
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Methma Udawatta
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Dillon Dejam
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - H Westley Phillips
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Matthew Z Sun
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Isaac Yang
- Departments of Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA; Office of the Patient Experience, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA; Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA; Head and Neck Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA; UCLA Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA; Department of Neurosurgery at Harbor-UCLA Medical Center, Torrance, CA, USA; Los Angeles Biomedical Research Institute (LA BioMed) at Harbor-UCLA Medical Center, Torrance, CA, USA.
| |
Collapse
|
16
|
Chen Y, Li R, Ma L, Meng X, Yan D, Wang H, Ye X, Jin H, Li Y, Gao D, Sun S, Liu A, Wang S, Chen X, Zhao Y. Long-term outcomes of brainstem arteriovenous malformations after different management modalities: a single-centre experience. Stroke Vasc Neurol 2020; 6:65-73. [PMID: 32928999 PMCID: PMC8005895 DOI: 10.1136/svn-2020-000407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 07/13/2020] [Accepted: 07/29/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The aims of this study are to clarify the long-term outcomes of brainstem arteriovenous malformations (AVMs) after different management modalities. METHODS The authors retrospectively reviewed 61 brainstem AVMs in their institution between 2011 and 2017. The rupture risk was represented by annualised haemorrhagic rate. Patients were divided into five groups: conservation, microsurgery, embolisation, stereotactic radiosurgery (SRS) and embolisation+SRS. Neurofunctional outcomes were evaluated by the modified Rankin Scale (mRS). Subgroup analysis was conducted between different management modalities to compare the long-term outcomes in rupture or unruptured cohorts. RESULTS All of 61 brainstem AVMs (12 unruptured and 49 ruptured) were followed up for an average of 4.5 years. The natural annualised rupture risk was 7.3%, and the natural annualised reruptured risk in the ruptured cohort was 8.9%. 13 cases were conservative managed and 48 cases underwent intervention (including 6 microsurgery, 12 embolisation, 21 SRS and 9 embolisation+SRS). In the selection of interventional indication, diffuse nidus were often suggested conservative management (p=0.004) and nidus involving the midbrain were more likely to be recommended for intervention (p=0.034). The risk of subsequent haemorrhage was significantly increased in partial occlusion compared with complete occlusion and conservative management (p<0.001, p=0.036, respectively). In the subgroup analysis, the follow-up mRS scores of different management modalities were similar whether in the rupture cohort (p=0.064) or the unruptured cohort (p=0.391), as well as the haemorrhage-free survival (p=0.145). In the adjusted Bonferroni correction analysis of the ruptured cohort, microsurgery and SRS could significantly improve the obliteration rate compared with conservation (p<0.001, p=0.001, respectively) and SRS may have positive effect on avoiding new-onset neurofunctional deficit compared with microsurgery and embolisation (p=0.003, p=0.003, respectively). CONCLUSIONS Intervention has similar neurofunctional outcomes as conservation in these brainstem AVM cohorts. If intervention is adopted, partial obliteration should be avoided because of the high subsequent rupture risk. TRIAL REGISTRATION NUMBER NCT04136860.
Collapse
Affiliation(s)
- Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Li Ma
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiangyu Meng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Debin Yan
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China
| | - Hao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China
| | - Xun Ye
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Dezhi Gao
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Beijing, China
| | - Shibin Sun
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Beijing, China
| | - Ali Liu
- Department of Gamma-Knife Center, Beijing Tiantan Hospital, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Beijing, China .,Department of Neurosurgery, Peking University International Hospital, Beijing, China
| |
Collapse
|
17
|
Dedeciusova M, Tuleasca C, Hajdu SD, Schiappacasse L, Patin D, Levivier M. Stereotactic Gamma Knife Radiosurgery for Extracranial Arteriovenous Malformations. Stereotact Funct Neurosurg 2020; 98:424-431. [PMID: 32906136 DOI: 10.1159/000509753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 06/11/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Head and neck extracranial arteriovenous malformations (AVMs) are rare pathological conditions which pose diagnostic and reconstruction challenges. Stereotactic radiosurgery (SRS) is nowadays an established treatment method for brain AVMs, with high obliteration and low complication rates. Here we describe the first report of head extracranial AVMs successfully treated by Gamma Knife (GK) as a retrospective historical cohort. METHODS Over a 9-year period, 2 cases of extracranial AVMs were treated by GK Perfexion (Elekta Instruments AB, Stockholm, Sweden) at a single institution. A stereotactic frame and multimodal imaging, including digital subtraction angiography (DSA), were used. The prescribed dose was 24 Gy at the 50% isodose line. RESULTS The first case was of a patient with pulsating tinnitus and left superficial parotido-condylian AVM. Embolization achieved partial obliteration. Tinnitus disappeared during the following 6 months after GK. The second case was a patient with repetitive gingival hemorrhages and right superior maxillary AVM, fed by the right internal maxillary and facial arteries. Embolization achieved partial obliteration with recurrence of symptoms. GK was further performed. DSA confirmed complete obliteration in both patients. CONCLUSIONS Single-fraction GK radiosurgery appears to be safe and effective for extracranial AVMs. We recommend prescribing doses that are comparable to the ones used for brain AVMs (i.e., 24 Gy). A stereotactic frame is an important tool to ensure higher accuracy in the context of these particular locations. However, in selected cases, a mask could be applied either for single fraction purposes (if in a non-mobile location) or for hypofractionation, in case of larger volumes. These findings should be validated in larger cohorts, inclusively in terms of dose prescription.
Collapse
Affiliation(s)
- Michaela Dedeciusova
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,First Faculty of Medicine, Charles University in Prague, Prague, Czechia.,Department of Neurosurgery and Neurooncology, Military University Hospital Prague, Prague, Czechia
| | - Constantin Tuleasca
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland, .,Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland, .,Signal Processing Laboratory (LTS 5), Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland, .,Faculté de Médecine, Sorbonne Université, Paris, France, .,Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Paris-Sud, Centre Hospitalier Universitaire Bicêtre, Service de Neurochirurgie, Paris, France,
| | - Steven David Hajdu
- Radiology Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Luis Schiappacasse
- Radiation Therapy Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - David Patin
- Institute of Radiation Physics, Lausanne, Switzerland
| | - Marc Levivier
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,First Faculty of Medicine, Charles University in Prague, Prague, Czechia
| |
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|
19
|
Pandelaki J, Prasetyono TOH, Sidipratomo P, Ramandika H. Torrential bleeding of arteriovenous malformation in hand post-ethanol sclerotherapy: A case report. Radiol Case Rep 2020; 15:1496-1501. [PMID: 32670448 PMCID: PMC7339009 DOI: 10.1016/j.radcr.2020.06.017] [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: 06/01/2020] [Revised: 06/05/2020] [Accepted: 06/05/2020] [Indexed: 11/24/2022] Open
Abstract
Embolization or sclerotherapy is considered as the first-line therapy for the management of arteriovenous malformations (AVM) and can be performed directly targeting the nidus. Ethanol is an effective embolic agent; however, some complications may arise. This paper illustrates a case of torrential bleeding following ethanol sclerotherapy in a patient with progressive hand arteriovenous malformations with a poor prognosis and was suggested to be amputated. Direct pressure, tourniquet appliance, and split-thickness skin graft procedure were performed to stop the bleeding successfully. No recurrence of bleeding was reported; and complete alleviation of pain was achieved.
Collapse
Affiliation(s)
- Jacub Pandelaki
- Division of Interventional Radiology, Department of Radiology, Cipto Mangunkusumo Hospital/ Faculty of Medicine Universitas Indonesia
| | | | - Prijo Sidipratomo
- Division of Interventional Radiology, Department of Radiology, Cipto Mangunkusumo Hospital/ Faculty of Medicine Universitas Indonesia
| | - Heltara Ramandika
- Division of Interventional Radiology, Department of Radiology, Cipto Mangunkusumo Hospital/ Faculty of Medicine Universitas Indonesia
| |
Collapse
|
20
|
Lehrer EJ, Snyder MH, Desai BD, Li CE, Narayan A, Trifiletti DM, Schlesinger D, Sheehan JP. Clinical and radiographic adverse events after Gamma Knife radiosurgery for brainstem lesions: A dosimetric analysis. Radiother Oncol 2020; 147:200-209. [PMID: 32413528 DOI: 10.1016/j.radonc.2020.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/30/2020] [Accepted: 05/08/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To analyze the association between dosvolume relationships and adverse events in brainstem lesions treated with Gamma Knife radiosurgery (GKRS). METHODS Treatment plans were generated on BrainLab Elements and GammaPlan software. Dosimetric data were analyzed as continuous variables for patients who received GKRS to brain metastases or arteriovenous malformations (AVM) within or abutting the brainstem. Adverse events were classified as clinical and/or radiographic. Logistic and cox regression were used to assess the relationship between dosimetric variables and adverse events. RESULTS Sixty-one patients who underwent single fraction GKRS for brain metastases or AVM were retrospectively analyzed. Median age was 62 years (range: 12-92 years) and the median prescription dose was 18 Gy (range: 13-25 Gy). Median follow-up was 6months. Clinical and radiographic complications were seen in ten (16.4%) and 17 (27.9%) patients, respectively. On logistic regression, increasing D05% was found to be associated with an increased probability of developing a clinical complication post-GKRS (OR: 1.18; 95% CI: 1.01-1.39; p = 0.04). Furthermore, mean brainstem dose (HR: 1.43; 95% CI: 1.05-1.94; p < 0.02), D05% (HR: 1.09; 95% CI: 1.01-1.18; p = 0.03), and D95% (HR: 2.37; 95% CI: 0.99-5.67; p = 0.05) were associated with an increased hazard of experiencing post-GKRS complications over time. CONCLUSIONS Increasing D05% to the brainstem is associated with an increased risk of developing clinical complications. Clinicians may consider this parameter in addition to fractionated stereotactic radiation therapy when well-established dose constraints are not met in this patient population. Additional data are needed to further validate these findings.
Collapse
Affiliation(s)
- Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - M Harrison Snyder
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Bhargav D Desai
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Chelsea E Li
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Aditya Narayan
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | | | - David Schlesinger
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, USA
| |
Collapse
|
21
|
Unnithan AKA. Overview of the current concepts in the management of arteriovenous malformations of the brain. Postgrad Med J 2020; 96:212-220. [DOI: 10.1136/postgradmedj-2019-137202] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/12/2019] [Accepted: 01/11/2020] [Indexed: 12/12/2022]
Abstract
BackgroundThere is a lack of consensus in the management of arteriovenous malformations (AVMs) of the brain since ARUBA (A Randomised trial of Unruptured Brain Arteriovenous malformations) trial showed that medical management is superior to interventional therapy in patients with unruptured brain AVMs. The treatment of brain AVM is associated with significant morbidity.Objectives and methodsA review was done to determine the behaviour of brain AVMs and analyse the risks and benefits of the available treatment options. A search was done in the literature for studies on brain AVMs. Descriptive analysis was also done.ResultsThe angiogenic factors such as vascular endothelial growth factor and inflammatory cytokines are involved in the growth of AVMs. Proteinases such as matrix metalloproteinase-9 contribute to the weakening and rupture of the nidus. The risk factors for haemorrhage are prior haemorrhage, deep and infratentorial AVM location, exclusive deep venous drainage and associated aneurysms. The advancements in operating microscope and surgical techniques have facilitated microsurgery. Stereotactic radiosurgery causes progressive vessel obliteration over 2–3 years. Endovascular embolisation can be done prior to microsurgery or radiosurgery and for palliation.ConclusionsSpetzler-Martin grades I and II have low surgical risks. The AVMs located in the cerebellum, subarachnoid cisterns and pial surfaces of the brainstem can be treated surgically. Radiosurgery is preferable for deep-seated AVMs. A combination of microsurgery, embolisation and radiosurgery is recommended for deep-seated and Spetzler-Martin grade III AVMs. Observation is recommended for grades IV and V.
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Kondziolka D. Current and novel practice of stereotactic radiosurgery. J Neurosurg 2019; 130:1789-1798. [PMID: 31153140 DOI: 10.3171/2019.2.jns181712] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 02/05/2019] [Indexed: 11/06/2022]
Abstract
Stereotactic radiosurgery emerged as a neurosurgical discipline in order to utilize energy for the manipulation of brain or nerve tissue, with the goal of minimal access and safe and effective care of a spectrum of neurosurgical disorders. Perhaps no other branch of neurosurgery has been so disruptive across the entire discipline of brain tumor care, treatment of vascular disorders, and management of functional problems. Radiosurgery is mainstream, supported by thousands of peer-reviewed outcomes reports. This article reviews current practice with a focus on challenges, emerging trends, and areas of investigation.
Collapse
|
24
|
Cohen-Inbar O, Sviri GE. Adaptive Hybrid Surgery: Paradigm Shift for Patient-centered Neurosurgery. Rambam Maimonides Med J 2018; 9:RMMJ.10346. [PMID: 30089092 PMCID: PMC6115482 DOI: 10.5041/rmmj.10346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The surgical management of cerebral and skull base lesions has evolved greatly in the last few decades. Still, a complete resection of lesions abutting critical neurovascular structures carries significant morbidity. Stereotactic radiosurgery (SRS) has emerged as an increasingly accepted treatment option. Minimally invasive, SRS results in excellent tumor control and low complication rates in patients with moderate-size tumors. The management of large cerebral and skull base tumors remains a formidable challenge. In such large tumors, radical surgical extirpation offers a significantly higher risk of neurological deficit, and SRS alone cannot be used because of the elevated incidence of radiation-induced complications known to be associated with large-volume tumors. With increasing treatment volumes, SRS-associated tumor control rates decrease and complication rates increase. Planned subtotal resection (STR) with adjuvant SRS (adaptive hybrid surgery [AHS]) has gained increasing interest in recent years as a multimodal approach. In AHS, a planned STR (aimed at decreasing surgical morbidity) followed by SRS to a preplanned residual tumor aids in harnessing advantages offered by both approaches. Although intuitive and reasonable, this paradigm shift from maximal resection at all cost has not been adopted widely. Combining open microsurgery with SRS requires a good understanding of both surgical and SRS modalities and their respective safety-efficacy features. We present a review and discussion on AHS as a modern, multidisciplinary treatment approach. Available data and views are discussed for vestibular schwannoma (VS) as a sample tumor. Other indications for AHS are mentioned in brief.
Collapse
Affiliation(s)
- Or Cohen-Inbar
- Department of Neurological Surgery, Rambam Maimonides Health Care Campus, Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- Department of Neurological Surgery and Gamma-Knife Center, University of Virginia Health Care Campus, Charlottesville, VA, USA
- To whom correspondence should be addressed. E-mail:
| | - Gil E Sviri
- Department of Neurological Surgery, Rambam Maimonides Health Care Campus, Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| |
Collapse
|
25
|
Kano H, Flickinger JC, Nakamura A, Jacobs RC, Tonetti DA, Lehocky C, Park KJ, Yang HC, Niranjan A, Lunsford LD. How to improve obliteration rates during volume-staged stereotactic radiosurgery for large arteriovenous malformations. J Neurosurg 2018; 130:1809-1816. [PMID: 30028266 DOI: 10.3171/2018.2.jns172964] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 02/22/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The management of large-volume arteriovenous malformations (AVMs) with stereotactic radiosurgery (SRS) remains challenging. The authors retrospectively tested the hypothesis that AVM obliteration rates can be improved by increasing the percentage volume of an AVM that receives a minimal threshold dose of radiation. METHODS In 1992, the authors prospectively began to stage anatomical components in order to deliver higher single doses to AVMs > 15 cm3 in volume. Since that time 60 patients with large AVMs have undergone volume-staged SRS (VS-SRS). The median interval between the first stage and the second stage was 4.5 months (2.8-13.8 months). The median target volume was 11.6 cm3 (range 4.3-26 cm3) in the first-stage SRS and 10.6 cm3 (range 2.8-33.7 cm3) in the second-stage SRS. The median margin dose was 16 Gy (range 13-18 Gy) for both SRS stages. RESULTS AVM obliteration after the initial two staged volumetric SRS treatments was confirmed by MRI alone in 4 patients and by angiography in 11 patients at a median follow-up of 82 months (range 0.4-206 months) after VS-SRS. The post-VS-SRS obliteration rates on angiography were 4% at 3 years, 13% at 4 years, 23% at 5 years, and 27% at 10 years. In multivariate analysis, only ≥ 20-Gy volume coverage was significantly associated with higher total obliteration rates confirmed by angiography. When the margin dose is ≥ 17 Gy and the 20-Gy SRS volume included ≥ 63% of the total target volume, the angiographically confirmed obliteration rates increased to 61% at 5 years and 70% at 10 years. CONCLUSIONS The outcomes of prospective VS-SRS for large AVMs can be improved by prescribing an AVM margin dose of ≥ 17 Gy and adding additional isocenters so that ≥ 63% of the internal AVM dose receives more than 20 Gy.
Collapse
Affiliation(s)
- Hideyuki Kano
- Departments of1Neurological Surgery and
- the3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John C Flickinger
- 2Radiation Oncology, and
- the3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Aya Nakamura
- the3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rachel C Jacobs
- the3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Craig Lehocky
- the3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kyung-Jae Park
- 4Department of Neurosurgery, College of Medicine, Korea University, Seoul, South Korea; and
| | - Huai-Che Yang
- 5Department of Neurosurgery, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Ajay Niranjan
- Departments of1Neurological Surgery and
- the3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- Departments of1Neurological Surgery and
- the3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
26
|
Samuel N, Philteos J, Alotaibi NM, Ahuja C, Mansouri A, Kulkarni AV. Canadian Neurosurgery Educators' Views on Stereotactic Radiosurgery in Residency Training. World Neurosurg 2018; 112:e208-e215. [PMID: 29331746 DOI: 10.1016/j.wneu.2018.01.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 01/02/2018] [Accepted: 01/04/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Despite the increasing prominence of stereotactic radiosurgery (SRS) in treating intracranial and spinal pathologies, there is currently a dearth of exposure to this modality in the neurosurgical residency. To address this gap, the aim of this study is to assess neurosurgery educators' views regarding the current state of SRS exposure, and to identify potential approaches to improve residency education in this domain. METHODS Qualitative thematic analysis and constructivist grounded theory methodology were employed. Semistructured telephone-based interviews were conducted with current or past residency program directors, as well as current departmental chairs across neurosurgical departments in Canada. Interviews were transcribed and subjected to thematic analysis using open and axial coding. RESULTS Of the 34 eligible participants, the overall response rate was 41.1% (14/34), with a 35.3% participation rate (12/34). Participants represented 9 of the 12 Canadian institutions surveyed. The majority of participants were current program directors (n = 8), followed by past program directors (n = 2), and departmental chairs (n = 2). Most respondents 75% (9/12) view an increasing role for SRS in neurosurgery. Unanimously, respondents endorse greater exposure to SRS during residency through formal residency rotations and engagement in interdisciplinary tumor boards to facilitate involvement in clinical decision-making. CONCLUSIONS This is the first study to systematically collate neurosurgery educators' views on SRS in residency in Canada and demonstrates recognition of the discordance between SRS in practice and residency training. Neurosurgery educators broadly endorse increased exposure to this modality. Future work is needed to delineate the requirements necessary to achieve adequate competency in SRS.
Collapse
Affiliation(s)
- Nardin Samuel
- MD/PhD Program, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Justine Philteos
- Undergraduate Medical Program, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Naif M Alotaibi
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Ahuja
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Division of Neurology and Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Abhaya V Kulkarni
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|