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Noda R, Akabane A, Kawashima M, Segawa M, Tsunoda S, Wada H, Watanabe M, Yamada H, Inoue T. Evaluation of micro-remnant niduses of arteriovenous malformations post-gamma knife radiosurgery by 3D-rotational angiography. Acta Neurochir (Wien) 2024; 166:359. [PMID: 39227482 DOI: 10.1007/s00701-024-06246-0] [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: 02/13/2024] [Accepted: 08/19/2024] [Indexed: 09/05/2024]
Abstract
PURPOSE Recent innovations in radiological imaging have enabled the detection of micro-remnant niduses of arteriovenous malformations (AVMs) after gamma knife radiosurgery (GKS), which have not been previously perceptible. Herein, we focus on the difficulty of evaluating micro-remnant AVMs after GKS that are hardly perceptible on conventional examinations and propose integrating follow-up three-dimensional rotational angiography (3D-RA) in the previous gamma plan as a solution. METHODS We retrospectively searched NTT Medical Center Tokyo hospital database for patients with AVMs who underwent both two-dimensional digital subtraction angiography (2D-DSA) and 3D-RA as follow-up for GKS from February 2021 to January 2024. Patients with suspected nidus occlusion on the latest non-contrast-enhanced magnetic resonance angiography (NC-MRA) were included, and contrast-enhanced magnetic resonance angiography (CE-MRA), 2D-DSA, and 3D-RA were evaluated. RESULTS Twelve patients with 13 AVM sites were defined as having complete nidus occlusion on upfront NC-MRA. On 2D-DSA, seven AVM sites showed the presence of slight remaining AVMs based on the detection of remnant drainage veins, however the nidus was not detected in three cases. Nevertheless, 3D-RA detected micro-remnant niduses in all seven AVM sites, and four patients underwent re-GKS. Nine patients with ten AVM sites also underwent CE-MRA, and six AVM sites were diagnosed with radiation-induced parenchymal injury. CONCLUSION Importing the 3D-RA image into the treatment planning has the potential to be more helpful than NC-MRA or CE-MRA to detect micro-remnant AVMs and evaluate the true remnant volume, and may contribute to a more detailed treatment planning, thereby improving the results of GKS retreatment.
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Affiliation(s)
- Ryuichi Noda
- Gamma Knife Center, NTT Medical Center Tokyo, Shinagawa-Ku, Tokyo, Japan.
- Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa-Ku, Tokyo, Japan.
| | - Atsuya Akabane
- Gamma Knife Center, NTT Medical Center Tokyo, Shinagawa-Ku, Tokyo, Japan
| | - Mariko Kawashima
- Gamma Knife Center, NTT Medical Center Tokyo, Shinagawa-Ku, Tokyo, Japan
| | - Masafumi Segawa
- Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa-Ku, Tokyo, Japan
| | - Sho Tsunoda
- Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa-Ku, Tokyo, Japan
| | - Hiroyuki Wada
- Department of Radiology, NTT Medical Center Tokyo, Shinagawa-Ku, Tokyo, Japan
| | - Makoto Watanabe
- Department of Radiology, NTT Medical Center Tokyo, Shinagawa-Ku, Tokyo, Japan
| | - Haruyasu Yamada
- Department of Radiology, NTT Medical Center Tokyo, Shinagawa-Ku, Tokyo, Japan
| | - Tomohiro Inoue
- Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa-Ku, Tokyo, Japan
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Shinya Y, Hasegawa H, Kawashima M, Koizumi S, Katano A, Umekawa M, Saito N. Prognosis of Rotational Angiography-Based Stereotactic Radiosurgery for Dural Arteriovenous Fistulas: A Retrospective Analysis. Neurosurgery 2023; 92:167-178. [PMID: 36255184 DOI: 10.1227/neu.0000000000002168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/26/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Cerebral dural arteriovenous fistulas (DAVFs) are intracranial vascular malformations with fine, abnormal vascular architecture. High-resolution vascular imaging is vital for their visualization. Currently, rotational angiography (RA) provides the finest 3-dimensional visualization of the arteriovenous shunt with high spatial resolution; however, the efficacies of the integration of RA have never been studied in stereotactic radiosurgery (SRS) for DAVFs until now. Since 2015, our institution has integrated RA into SRS (RA-SRS) to provide more conformal planning, thereby decreasing overtreatment and undertreatment. OBJECTIVE To analyze the outcomes of RA-SRS for DAVFs. METHODS We retrospectively analyzed the outcomes of 51 patients with DAVFs and compared those of 20 DAVFs treated with RA-SRS with those of 31 DAVFs treated with conventional SRS (c-SRS). RESULTS The time to obliteration was shorter in the RA-SRS group (median, 15 months vs 26 months [cumulative rate, 77% vs 33% at 2 years, 77% vs 64% at 4 years]; P = .015). Multivariate Cox proportional hazards analysis demonstrated that RA-SRS (hazard ratio 2.39, 95% CI 1.13-5.05; P = .022) and the absence of cortical venous reflux (hazard ratio 2.12, 95% CI 1.06-4.25; P = .034) were significantly associated with obliteration. The cumulative 5-year post-SRS stroke-free survival rates were 95% and 97% in the RA-SRS and c-SRS groups, respectively ( P = .615). Neurological improvement tended to occur earlier in the RA-SRS group than in the c-SRS group (median time to improvement, 5 months vs 20 months, log-rank test; P = .077). CONCLUSION RA-based SRS may facilitate earlier fistula obliteration and may contribute to early neurological improvement.
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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
| | - 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
| | - Motoyuki Umekawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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Al Saiegh F, Liu H, El Naamani K, Mouchtouris N, Chen CJ, Khanna O, Abbas R, Velagapudi L, Baldassari MP, Reyes M, Schmidt RF, Tjoumakaris S, Gooch MR, Rosenwasser RH, Shi W, Jabbour P. Frameless Angiography-Based Gamma Knife Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations: A Proof-of-Concept Study. World Neurosurg 2022; 164:e808-e813. [PMID: 35580781 DOI: 10.1016/j.wneu.2022.05.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Traditional Gamma Knife radiosurgery (GKRS) of brain arteriovenous malformations (AVMs) using digital subtraction angiography (DSA) requires head immobilization using a stereotactic frame. OBJECTIVE We describe our protocol of frameless GKRS using DSA while maintaining high spatial resolution for precision. METHODS This study is a retrospective review of patients with unruptured AVMs who underwent frameless GKRS. Magnetic resonance imaging and 3-dimensional DSA were obtained without a stereotactic frame for all patients. The imaging studies were merged for contouring of the AVM nidus. During GKRS treatment, patients were immobilized using an individually molded thermoplastic mask. RESULTS Thirty-one patients were included in the analysis. The median age is 45.0 years (interquartile range [IQR]: 28.0-55.0). The median nidus size is 3.0 cm (IQR: 2.0-3.4). One patient had a Spetzler-Martin grade I, 11 had a grade II, 11 had a grade III, 6 had a grade IV, and 2 had a grade V AVM. Eleven patients underwent preradiosurgical embolization, 3 patients had previous microsurgical resection and/or embolization, and 1 patient had prior radiosurgery. The median administered dose was 20 Gy (IQR: 18.0-21.0). All patients completed their treatment with the planned radiation dose without complications. CONCLUSION This is the first study that integrates DSA in the treatment planning of brain AVMs using GKRS without utilizing a stereotactic head frame. Frameless GKRS provides numerous advantages over frame-based techniques including improved patient experience and the capability of fractionation and thus expanding the eligibility of more AVMs for radiosurgery, while maintaining high spatial resolution of the AVM using angiography data.
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Affiliation(s)
- Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Haisong Liu
- Director of Radiosurgery Physics, Jefferson Hospital for Neuroscience, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lohit Velagapudi
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael P Baldassari
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Maikerly Reyes
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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4
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Burke RM, Chen CJ, Ding D, Buell TJ, Sokolowski J, Sheehan KA, Lee CC, Sheehan DE, Kano H, Kearns KN, Tzeng SW, Yang HC, Huang PP, Kondziolka D, Ironside N, Mathieu D, Iorio-Morin C, Grills IS, Feliciano C, Barnett G, Starke RM, Lunsford LD, Sheehan JP. Effect of Prior Embolization on Outcomes After Stereotactic Radiosurgery for Pediatric Brain Arteriovenous Malformations: An International Multicenter Study. Neurosurgery 2021; 89:672-679. [PMID: 34333653 DOI: 10.1093/neuros/nyab245] [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: 09/10/2020] [Accepted: 05/08/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pediatric brain arteriovenous malformations (AVMs) are a significant cause of morbidity but the role of multimodal therapy in the treatment of these lesions is not well understood. OBJECTIVE To compare the outcomes of stereotactic radiosurgery (SRS) with and without prior embolization for pediatric AVMs. METHODS We retrospectively evaluated the International Radiosurgery Research Foundation pediatric AVM database. AVMs were categorized, based on use of pre-embolization (E + SRS) or lack thereof (SRS-only). Outcomes were compared in unadjusted and inverse probability weight (IPW)-adjusted models. Favorable outcome was defined as obliteration without post-SRS hemorrhage or permanent radiation-induced changes (RIC). RESULTS The E + SRS and SRS-only cohorts comprised 91 and 448 patients, respectively. In unadjusted models, the SRS-only cohort had higher rates of obliteration (68.5% vs 43.3%, < .001) and favorable outcome (61.2% vs 36.3%, P < .001) but a lower rate of symptomatic RIC (9.0% vs 16.7%, P = .031). The IPW-adjusted rates of every outcome were similar between the 2 cohorts. However, cumulative obliteration rates at 3, 5, 8, and 10 yr remained higher in the absence of prior embolization (46.3%, 64.6%, 72.6%, and 77.4% for SRS-only vs 24.4%, 37.2%, 44.1%, and 48.7% for E + SRS cohorts, respectively; SHR = 0.449 [0.238-0.846], P = .013). CONCLUSION Embolization appears to decrease cumulative obliteration rates after SRS for pediatric AVMs without affecting the risk of post-treatment hemorrhage or adverse radiation effects arguing against the routine use of pre-SRS embolization. While endovascular therapy can be considered for occlusion of high-risk angioarchitectural features prior to SRS, future studies are necessary to clarify its role.
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Affiliation(s)
- Rebecca M Burke
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jennifer Sokolowski
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Kimball A Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Darrah E Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kathryn N Kearns
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Shih-Wei Tzeng
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Paul P Huang
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - David Mathieu
- Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Christian Iorio-Morin
- Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan, USA
| | - Caleb Feliciano
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | - Gene Barnett
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami, Florida, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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5
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Shinya Y, Hasegawa H, Shin M, Kawashima M, Sugiyama T, Ishikawa O, Koizumi S, Suzuki Y, Nakatomi H, Saito N. Rotational Angiography-Based Gamma Knife Radiosurgery for Brain Arteriovenous Malformations: Preliminary Therapeutic Outcomes of the Novel Method. Neurosurgery 2021; 89:60-69. [PMID: 33770182 DOI: 10.1093/neuros/nyab066] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 01/04/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND High-definition vascular imaging is desirable for treatment planning in Gamma Knife radiosurgery (GKRS; Elekta AB) for brain arteriovenous malformations (BAVMs). Currently, rotational angiography (RA) provides the clearest 3-dimensional visualization of niduses with high spatial resolution; however, its efficacy for GKRS has not been clarified. At our institution, RA has been integrated into GKRS (RA-GKRS) for better treatment planning and outcomes since 2015. OBJECTIVE To evaluate RA-GKRS outcomes of BAVMs and compare them with conventional GKRS (c-GKRS) outcomes. METHODS We retrospectively analyzed the radiosurgical outcomes of 50 BAVMs treated with RA-GKRS compared with the 306 BAVMs treated with c-GKRS. Considering possible differences in the baseline characteristics, we also created propensity score-matched cohorts and compared the radiosurgical outcomes between them to ensure comparability. RESULTS The obliteration time was shorter in the RA-GKRS group (cumulative rate, 88% vs 65% at 4 yr [P = .001]). Multivariate Cox proportional hazards analysis demonstrated that the RA-GKRS group (hazard ratio 2.38, 95% CI 1.58-3.60; P = .001) had a better obliteration rate. The cumulative 4-yr post-GKRS hemorrhage rates were 4.0% and 2.6% in the RA-GKRS and c-GKRS groups, respectively (P = .558). There was a trend toward early post-GKRS signal change in the RA-GKRS group compared with the c-GKRS group (cumulative rate, 38% vs 29% at 2 yr; P = .118). Those results were also confirmed in the matched cohort analyses. CONCLUSION The integration of RA into GKRS is promising and may provide earlier nidus obliteration.
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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.,Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Osamu Ishikawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuichi Suzuki
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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Anderson JL, Khattab MH, Sherry AD, Luo G, Chitale RV, Froehler MT, Fusco MR, Cmelak AJ, Attia A. Improved Cerebral Arteriovenous Malformation Obliteration With 3-Dimensional Rotational Digital Subtraction Angiography for Radiosurgical Planning: A Retrospective Cohort Study. Neurosurgery 2020; 88:122-130. [PMID: 32717053 DOI: 10.1093/neuros/nyaa321] [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: 09/24/2019] [Accepted: 05/24/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations (AVMs) is well-established. Radiographic advantages exist for 3-dimensional rotational digital subtraction angiography (3DRA) over 2-dimensional digital subtraction angiography (2D DSA) in delineating AVM nidus structure for SRS treatment planning. However, currently there is limited to no data directly comparing 2D DSA versus 3DRA in terms of patient outcomes. OBJECTIVE To investigate whether the use of 3DRA over 2D DSA in radiosurgical treatment planning for AVMs associates with improved clinical outcomes. METHODS All AVM patients treated with SRS at our institution between the years 2000 and 2018 were identified. Primary outcomes were obliteration rates and time to obliteration (TTO); secondary outcomes included rates of post-SRS hemorrhage, salvage therapy, and symptomatic radionecrosis. A minimum of 12 mo of follow-up imaging/angiogram post-SRS was required, or alternatively evidence of obliteration on angiogram prior to 12 mo post-SRS. Single predictor and multivariable Cox regression and logistic regression models were constructed to test for association between radiographic, clinical, and treatment factors with outcomes. RESULTS A total of 75 patients were included. Total 17 patients received 3DRA and 58 patients received 2D DSA, with a median follow-up of 3.29 yr. The 3DRA is significantly associated with improved TTO on single predictor (HR 2.87, 1.29-6.12; P = .0109) and multivariable analysis (HR 2.448, 1.076-5.750; P = .0330) and increased odds of achieving obliteration by 3 yr post-SRS on single predictor analysis (OR 6.044, 1.405-26.009; P = .0157). CONCLUSION The 3DRA over 2D DSA in SRS treatment planning for AVMs may result in improved TTO and 3-yr obliteration rates. Further investigation and prospective study are warranted.
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Affiliation(s)
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rohan V Chitale
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael T Froehler
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew R Fusco
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Hasegawa H, Yamamoto M, Shin M, Barfod BE. Gamma Knife Radiosurgery For Brain Vascular Malformations: Current Evidence And Future Tasks. Ther Clin Risk Manag 2019; 15:1351-1367. [PMID: 31819462 PMCID: PMC6874113 DOI: 10.2147/tcrm.s200813] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/22/2019] [Indexed: 12/25/2022] Open
Abstract
Gamma Knife radiosurgery (GKRS) has long been used for treating brain vascular malformations, including arteriovenous malformations (AVMs), dural arteriovenous fistulas (DAVFs), and cavernous malformations (CMs). Herein, current evidence and controversies regarding the role of stereotactic radiosurgery for vascular malformations are described. 1) It has already been established that GKRS achieves 70–85% obliteration rates after a 3–5-year latency period for small to medium-sized AVMs. However, late radiation-induced adverse events (RAEs) including cyst formation, encapsulated hematoma, and tumorigenesis have recently been recognized, and the associated risks, clinical courses, and outcomes are under investigation. SRS-based therapeutic strategies for relatively large AVMs, including staged GKRS and a combination of GKRS and embolization, continue to be developed, though their advantages and disadvantages warrant further investigation. The role of GKRS in managing unruptured AVMs remains controversial since a prospective trial showed no benefit of treatment, necessitating further consideration of this issue. 2) Regarding DAVFs, GKRS achieves 41–90% obliteration rates at the second post-GKRS year with a hemorrhage rate below 5%. Debate continues as to whether GKRS might serve as a first-line solo therapeutic modality given its latency period. Although the post-GKRS outcomes are thought to differ among lesion locations, further outcome analyses regarding DAVF locations are required. 3) GKRS is generally accepted as an alternative for small or medium-sized CMs in which surgery is considered to be too risky. The reported hemorrhage rates ranged from 0.5–5% after GKRS. Higher dose treatments (>15 Gy) were performed during the learning curve, while, with the current standard treatment, a dose range of 12–15 Gy is generally selected, and has resulted in acceptable complication rates (< 5%). Nevertheless, further elucidation of long-term outcomes is essential.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Bierta E Barfod
- Katsuta Hospital Mito Gamma House, Hitachinaka, Ibaraki, Japan
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8
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Wang T, Lei Y, Tian S, Jiang X, Zhou J, Liu T, Dresser S, Curran WJ, Shu HK, Yang X. Learning-based automatic segmentation of arteriovenous malformations on contrast CT images in brain stereotactic radiosurgery. Med Phys 2019; 46:3133-3141. [PMID: 31050804 DOI: 10.1002/mp.13560] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 04/23/2019] [Accepted: 04/23/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Stereotactic radiosurgery (SRS) is widely used to obliterate arteriovenous malformations (AVMs). Its performance relies on the accuracy of delineating the target AVM. Manual segmentation during a framed SRS procedure is time consuming and subject to inter- and intraobserver variation. To address these drawbacks, we proposed a deep learning-based method to automatically segment AVMs on CT simulation image sets. METHODS We developed a deep learning-based method using a deeply supervised three-dimensional (3D) V-Net with a compound loss function. A 3D supervision mechanism was integrated into a residual network, V-Net, to deal with the optimization difficulties when training deep networks with limited training data. The proposed compound loss function including logistic and Dice losses encouraged similarity and penalized discrepancy simultaneously between prediction and training dataset; this was utilized to supervise the 3D V-Net at different stages. To evaluate the accuracy of segmentation, we retrospectively investigated 80 AVM patients who had CT simulation and digital subtraction angiography (DSA) acquired prior to treatment. The AVM target volume was segmented by our proposed method. They were compared with clinical contours approved by physicians with regard to Dice overlapping, difference in volume and centroid, and dose coverage changes on original plan. RESULTS Contours created by the proposed method demonstrated very good visual agreement to the ground truth contours. The mean Dice similarity coefficient (DSC), sensitivity and specificity of the contours delineated by our method were >0.85 among all patients. The mean centroid distance between our results and ground truth was 0.675 ± 0.401 mm, and was not significantly different in any of the three orthogonal directions. The correlation coefficient between ground truth and AVM volume resulting from the proposed method was 0.992 with statistical significance. The mean volume difference among all patients was 0.076 ± 0.728 cc; there was no statistically significant difference. The average differences in dose metrics were all less than 0.2 Gy, with standard deviation less than 1 Gy. No statistically significant differences were observed in any of the dose metrics. CONCLUSION We developed a novel, deeply supervised, deep learning-based approach to automatically segment the AVM volume on CT images. We demonstrated its clinical feasibility by validating the shape and positional accuracy, and dose coverage of the automatic volume. These results demonstrate the potential of a learning-based segmentation method for delineating AVMs in the clinical setting.
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Affiliation(s)
- Tonghe Wang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA
| | - Yang Lei
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA
| | - Sibo Tian
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA
| | - Xiaojun Jiang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA
| | - Tian Liu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA
| | - Sean Dresser
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA
| | - Walter J Curran
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA
| | - Hui-Kuo Shu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, 30322, USA
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Hasegawa H, Hanakita S, Shin M, Kawashima M, Kin T, Takahashi W, Suzuki Y, Shinya Y, Ono H, Shojima M, Nakatomi H, Saito N. Integration of rotational angiography enables better dose planning in Gamma Knife radiosurgery for brain arteriovenous malformations. J Neurosurg 2018; 129:17-25. [DOI: 10.3171/2018.7.gks181565] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/16/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVEIn Gamma Knife radiosurgery (GKS) for arteriovenous malformations (AVMs), CT angiography (CTA), MRI, and digital subtraction angiography (DSA) are generally used to define the nidus. Although the AVM angioarchitecture can be visualized with superior resolution using rotational angiography (RA), the efficacy of integrating RA into the GKS treatment planning process has not been elucidated.METHODSUsing data collected from 25 consecutive patients with AVMs who were treated with GKS at the authors’ institution, two neurosurgeons independently created treatment plans for each patient before and after RA integration. For all patients, MR angiography, contrasted T1 imaging, CTA, DSA, and RA were performed before treatment. The prescription isodose volume before (PIVB) and after (PIVA) RA integration was measured. For reference purposes, a reference target volume (RTV) for each nidus was determined by two other physicians independent of the planning surgeons, and the RTV covered by the PIV (RTVPIV) was established. The undertreated volume ratio (UVR), overtreated volume ratio (OVR), and Paddick’s conformal index (CI), which were calculated as RTVPIV/RTV, RTVPIV/PIV, and (RTVPIV)2/(RTV × PIV), respectively, were measured by each neurosurgeon before and after RA integration, and the surgeons’ values at each point were averaged. Wilcoxon signed-rank tests were used to compare the values obtained before and after RA integration. The percentage change from before to after RA integration was calculated for the average UVR (%ΔUVRave), OVR (%ΔOVRave), and CI (%ΔCIave) in each patient, as ([value after RA integration]/[value before RA integration] − 1) × 100. The relationships between prior histories and these percentage change values were examined using Wilcoxon signed-rank tests.RESULTSThe average values obtained by the two surgeons for the median UVR, OVR, and CI were 0.854, 0.445, and 0.367 before RA integration and 0.882, 0.478, and 0.463 after RA integration, respectively. All variables significantly improved after compared with before RA integration (UVR, p = 0.009; OVR, p < 0.001; CI, p < 0.001). Prior hemorrhage was significantly associated with larger %ΔOVRave (median 20.8% vs 7.2%; p = 0.023) and %ΔCIave (median 33.9% vs 13.8%; p = 0.014), but not %ΔUVRave (median 4.7% vs 4.0%; p = 0.449).CONCLUSIONSIntegrating RA into GKS treatment planning may permit better dose planning owing to clearer visualization of the nidus and, as such, may reduce undertreatment and waste irradiation. Further studies examining whether the observed RA-related improvement in dose planning also improves the radiosurgical outcome are needed.
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Affiliation(s)
| | | | | | | | | | | | - Yuichi Suzuki
- 2Radiology, University of Tokyo Hospital, Tokyo, Japan
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10
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Conti A, Pontoriero A, Iatì G, Marino D, La Torre D, Vinci S, Germanò A, Pergolizzi S, Tomasello F. 3D-Printing of Arteriovenous Malformations for Radiosurgical Treatment: Pushing Anatomy Understanding to Real Boundaries. Cureus 2016; 8:e594. [PMID: 27335707 PMCID: PMC4914061 DOI: 10.7759/cureus.594] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Radiosurgery of arteriovenous malformations (AVMs) is a challenging procedure. Accuracy of target volume contouring is one major issue to achieve AVM obliteration while avoiding disastrous complications due to suboptimal treatment. We describe a technique to improve the understanding of the complex AVM angioarchitecture by 3D prototyping of individual lesions. Arteriovenous malformations of ten patients were prototyped by 3D printing using 3D rotational angiography (3DRA) as a template. A target volume was obtained using the 3DRA; a second volume was obtained, without awareness of the first volume, using 3DRA and the 3D-printed model. The two volumes were superimposed and the conjoint and disjoint volumes were measured. We also calculated the time needed to perform contouring and assessed the confidence of the surgeons in the definition of the target volumes using a six-point scale. The time required for the contouring of the target lesion was shorter when the surgeons used the 3D-printed model of the AVM (p=0.001). The average volume contoured without the 3D model was 5.6 ± 3 mL whereas it was 5.2 ± 2.9 mL with the 3D-printed model (p=0.003). The 3D prototypes proved to be spatially reliable. Surgeons were absolutely confident or very confident in all cases that the volume contoured using the 3D-printed model was plausible and corresponded to the real boundaries of the lesion. The total cost for each case was 50 euros whereas the cost of the 3D printer was 1600 euros. 3D prototyping of AVMs is a simple, affordable, and spatially reliable procedure that can be beneficial for radiosurgery treatment planning. According to our preliminary data, individual prototyping of the brain circulation provides an intuitive comprehension of the 3D anatomy of the lesion that can be rapidly and reliably translated into the target volume.
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Affiliation(s)
- Alfredo Conti
- Department of Neurological Surgery, University of Messina
| | | | | | - Daniele Marino
- Department of Neurological Surgery, University of Messina
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11
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Microsurgical Resection for Persistent Arteriovenous Malformations Following Gamma Knife Radiosurgery: A Case-Control Study. World Neurosurg 2016; 88:277-288. [DOI: 10.1016/j.wneu.2016.01.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 01/04/2016] [Accepted: 01/04/2016] [Indexed: 11/21/2022]
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Awad AJ, Walcott BP, Stapleton CJ, Ding D, Leed CC, Loeffler JS. Repeat radiosurgery for cerebral arteriovenous malformations. J Clin Neurosci 2015; 22:945-950. [PMID: 25913746 DOI: 10.1016/j.jocn.2015.01.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 12/30/2014] [Accepted: 01/01/2015] [Indexed: 10/23/2022]
Abstract
We perform a systematic review of repeat radiosurgery for cerebral arteriovenous malformations (AVM) with an emphasis on lesion obliteration rates and complications. Radiosurgery is an accepted treatment modality for AVM located in eloquent cortex or deep brain structures. For residual or persistent lesions, repeat radiosurgery can be considered if sufficient time has passed to allow for a full appreciation of treatment effects, usually at least 3years. A systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. References for this review were identified by searches of MEDLINE, Web of Science and Google Scholar databases. A total of 14 studies comprising 733 patients met the review criteria and were included. For series that reported target dose at both first and repeat treatments, the weighted means were 19.42Gy and 19.06Gy, respectively. The mean and median obliteration rate for the repeat radiosurgery treatments were 61% (95% confidence interval 51.9-71.7%) and 61.5%, respectively. The median follow up following radiosurgery ranged from 19.5 to 80months. Time to complete obliteration after the repeat treatment ranged from 21 to 40.8months. The most common complications of repeat radiosurgery for AVM included hemorrhage (7.6%) and radiation-induced changes (7.4%). Repeat radiosurgery can be used to treat incompletely obliterated AVM with an obliteration rate of 61%. Complications are related to treatment effect latency (hemorrhage risk) as well as radiation-induced changes. Repeat radiosurgery can be performed at 3 years following the initial treatment, allowing for full realization of effects from the initial treatment prior to commencing therapy.
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Affiliation(s)
- Ahmed J Awad
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Brian P Walcott
- Department of Neurological Surgery, Massachusetts General Hospital, White Building Room 502, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher J Stapleton
- Department of Neurological Surgery, Massachusetts General Hospital, White Building Room 502, 55 Fruit Street, Boston, MA 02114, USA
| | - Dale Ding
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Cheng-Chia Leed
- Department of Neurological Surgery, Massachusetts General Hospital, White Building Room 502, 55 Fruit Street, Boston, MA 02114, USA
| | - Jay S Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Safain MG, Rahal JP, Raval A, Rivard MJ, Mignano JE, Wu JK, Malek AM. Use of cone-beam computed tomography angiography in planning for gamma knife radiosurgery for arteriovenous malformations: a case series and early report. Neurosurgery 2015; 74:682-95; discussion 695-6. [PMID: 24584136 DOI: 10.1227/neu.0000000000000331] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The effectiveness of Gamma Knife radiosurgery (GKR) for cerebral arteriovenous malformations (AVMs) is predicated on inclusion of the entire nidus while excluding normal tissue. As such, GKR may be limited by the resolution and accuracy of the imaging modality used in targeting. OBJECTIVE We present the first case series to demonstrate the feasibility of using ultrahigh-resolution C-arm cone-beam computed tomography angiography (CBCT-A) in AVM targeting. METHODS From June 2009 to June 2013, CBCT-A was used for targeting of all patients with AVMs treated with GKR at our institution. Patients underwent Leksell stereotactic head frame placement followed by catheter-based biplane 2-dimensional digital subtraction angiography, 3-dimensional rotational angiography, as well as CBCT-A. The CBCT-A dataset was used for stereotactic planning for GKR. Patients were followed at 1, 3, 6, and 12 months and then annually thereafter. RESULTS CBCT-A-based targeting was used in 22 consecutive patients. CBCT-A provided detailed spatial resolution and sensitivity of nidal angioarchitecture enabling treatment. The average radiation dose to the margin of the AVM nidus corresponding to the 50% isodose line was 15.6 Gy. No patient had treatment-associated hemorrhage. At early follow-up (mean, 16 months), 84% of patients had a decreasing or obliterated AVM nidus. CONCLUSION CBCT-A-guided radiosurgery is feasible and useful because it provides sufficient detailed resolution and sensitivity for imaging brain AVMs.
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Affiliation(s)
- Mina G Safain
- *Cerebrovascular and Endovascular Division, Department of Neurosurgery, ‡Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts; §Boston Gamma Knife Center, Boston, Massachusetts
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Mirza-Aghazadeh J, Andrade-Souza YM, Zadeh G, Scora D, Tsao MN, Schwartz ML. Radiosurgical Retreatment for Brain Arteriovenous Malformation. Can J Neurol Sci 2014; 33:189-94. [PMID: 16736728 DOI: 10.1017/s0317167100004959] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACT:Objective:To analyze our experience with a second radiosurgical treatment for brain arteriovenous malformations (BAVMs) after an unsuccessful first radiosurgical treatment.Methods:Between 1993 and 2000, 242 patients were treated by the Toronto Sunnybrook Regional Cancer Center using a LINAC system. Fifteen of these patients required a second radiosurgical intervention due to the failure of the first procedure. Data was collected on baseline patient characteristics, BAVM features, radiosurgery treatment plan and outcomes. Brain arteriovenous malformation obliteration was determined by follow-up MRI and angiography and the obliteration prediction index (OPI) calculated according to a previously established formula.Results:The median interval between the first and second treatment was 46 months (range 39-109). The median follow-up after the second procedure was 39 months (range 26 to 72). The mean BAVM volume before the first treatment was 8.9cm3 (range 0.3-21) and before the second treatment was 3.6cm3 (range 0.2-11.6). The mean marginal dose during the first treatment was 18Gy (range 12-25) and during the second treatment was 16Gy (range 12-20). After the second treatment, nine patients had obliteration of their BAVM confirmed by angiography and one patient had obliteration confirmed by MRI, resulting in an obliteration rate of 66.6%, which is very comparable to that predicted by the OPI (65%). After the second treatment two patients had a radiation-induced complication (13.3%).Conclusion:Retreatment of BAVM using a second radiosurgery procedure is a safe and effective option that offers the same rate of success as the initial radiosurgery and an acceptable risk of radiation-induced complication.
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Affiliation(s)
- Javad Mirza-Aghazadeh
- Division of Neurosurgery, Sunnybrook and Women's College Health Science Centre, Department of Radiation Oncology, Toronto-Sunnybrook Regional Cancer Centre, University of Toronto, Ontario, Canada
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15
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Kang J, Huang J, Gailloud P, Rigamonti D, Lim M, Bernard V, Ehtiati T, Ford EC. Planning evaluation of C-arm cone beam CT angiography for target delineation in stereotactic radiation surgery of brain arteriovenous malformations. Int J Radiat Oncol Biol Phys 2014; 90:430-7. [PMID: 25015197 DOI: 10.1016/j.ijrobp.2014.05.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 04/18/2014] [Accepted: 05/07/2014] [Indexed: 12/26/2022]
Abstract
PURPOSE Stereotactic radiation surgery (SRS) is one of the therapeutic modalities currently available to treat cerebral arteriovenous malformations (AVM). Conventionally, magnetic resonance imaging (MRI) and MR angiography (MRA) and digital subtraction angiography (DSA) are used in combination to identify the target volume for SRS treatment. The purpose of this study was to evaluate the use of C-arm cone beam computed tomography (CBCT) in the treatment planning of SRS for cerebral AVMs. METHODS AND MATERIALS Sixteen consecutive patients treated for brain AVMs at our institution were included in this retrospective study. Prior to treatment, all patients underwent MRA, DSA, and C-arm CBCT. All images were coregistered using the GammaPlan planning system. AVM regions were delineated independently by 2 physicians using either C-arm CBCT or MRA, resulting in 2 volumes: a CBCT volume (VCBCT) and an MRA volume (VMRA). SRS plans were generated based on the delineated regions. RESULTS The average volume of treatment targets delineated using C-arm CBCT and MRA were similar, 6.40 cm(3) and 6.98 cm(3), respectively (P=.82). However, significant regions of nonoverlap existed. On average, the overlap of the MRA with the C-arm CBCT was only 52.8% of the total volume. In most cases, radiation plans based on VMRA did not provide adequate dose to the region identified on C-arm CBCT; the mean minimum dose to VCBCT was 29.5%, whereas the intended goal was 45% (P<.001). The mean volume of normal brain receiving 12 Gy or more in C-arm CBCT-based plans was not greater than in the MRA-based plans. CONCLUSIONS Use of C-arm CBCT images significantly alters the delineated regions of AVMs for SRS planning, compared to that of MRA/MRI images. CT-based planning can be accomplished without increasing the dose to normal brain and may represent a more accurate definition of the nidus, increasing the chances for successful obliteration.
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Affiliation(s)
- Jun Kang
- Radiation Oncology Department, Abington Memorial Hospital, Philadelphia, Pennsylvania; Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniele Rigamonti
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vincent Bernard
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Eric C Ford
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland; Radiation Oncology, University of Washington, Seattle, Washington.
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Luo CB, Guo WY, Chang FC, Wu HM, Teng MMH, Lin CJ, Pan DHC, Chung WY, Chang CY. Fistula component of cerebral arteriovenous malformations: morphologic change after stereotactic radiosurgery and outcome of embolisation. Acta Neurochir (Wien) 2014; 156:85-92; discussion 92. [PMID: 24287681 DOI: 10.1007/s00701-013-1939-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Accepted: 11/01/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND The angioarchitecture of arteriovenous fistulas (AVFs) of cerebral arteriovenous malformation (CAVM) after stereotactic radiosurgery (SRS) remain unclear. The purpose of this study is to report the angiographic change of AVF components of CAVMs after SRS and outcomes of endovascular embolisation. METHODS From 2002 to 2012, a total of 523 CAVMs had been treated primarily by SRS with more than 3-year latency. Among these databases, there were 19 patients with 21 AVFs undergoing embolization after SRS. We retrospectively analyzed the angioarchitecture of the CAVM to identify AVFs, morphologic change and outcomes of AVFs after SRS and embolisation. RESULTS Eight AVFs were in the periphery of CAVMs, the other 13 were in a central location. Eighteen of 21 AVFs remained constant in morphology after SRS, while three feeders of AVFs were associated with radiation arteritis. The causes of failure to identify AVFs before SRS were overlooked (n = 7) or there was superimposition with feeders, nidus and/or venous drains of CAVMs (n = 14). Total fistula occlusion was achieved in all 21 AVFs; residual CAVMs was totally obliterated by embolisation and/or additional SRS in 12 patients. One patient had a small procedure-related intracerebral hemorrhage. Mean follow-up period was 26 months. CONCLUSIONS Early detection of AVF components of CAVMs prior to SRS may be difficult, particularly those in a central location. However, most AVFs became evident and showed consistency in angiographic morphology after obliteration of the majority nidus parts of CAVMs. Endovascular embolisation is effective in managing these AVF components.
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Affiliation(s)
- Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan, Republic of China,
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Abstract
Stereotactic radiosurgery for intracranial arteriovenous malformations (AVMs) has been performed since the 1970s. When an AVM is treated with radiosurgery, radiation injury to the vascular endothelium induces the proliferation of smooth muscle cells and the elaboration of extracellular collagen, which leads to progressive stenosis and obliteration of the AVM nidus. Obliteration after AVM radiosurgery ranges from 60% to 80%, and relates to the size of the AVM and the prescribed radiation dose. The major drawback of radiosurgical AVM treatment is the risk of bleeding during the latent period (typically 2 years) between treatment and AVM thrombosis.
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Affiliation(s)
- William A Friedman
- Department of Neurological Surgery, University of Florida, PO Box 100265, MBI, Gainesville, FL 32610, USA.
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18
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Taeshineetanakul P, Krings T, Geibprasert S, Menezes R, Agid R, Terbrugge KG, Schwartz ML. Angioarchitecture determines obliteration rate after radiosurgery in brain arteriovenous malformations. Neurosurgery 2013; 71:1071-8; discussion 1079. [PMID: 22922676 DOI: 10.1227/neu.0b013e31826f79ec] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Radiosurgery as a potential treatment modality for brain arteriovenous malformations (AVM) has 60% to 90% obliteration rates. OBJECTIVE To test whether AVM angioarchitecture determines obliteration rate after radiosurgery. METHODS This study was a retrospective analysis of 139 patients with AVM who underwent radiosurgery. Multiple angioarchitectural characteristics were reviewed on conventional angiogram on the day of radiosurgery: enlargement of feeding arteries, flow-related or intranidal aneurysms, perinidal angiogenesis, arteriovenous transit time, nidus type, venous ectasia, focal pouches, venous rerouting, and presence of a pseudophlebitic pattern. The radiation plan was reviewed for nidus volume and eloquence of AVM location. A chart review was performed to determine clinical presentation and previous treatment. Outcome was dichotomized into complete/incomplete obliteration, and various statistics were performed, examining whether outcome status was associated with the investigated factors. RESULTS Marginal dose ranged from 15 to 25 Gy (mean, 18.8 Gy), with lower doses prescribed in eloquent locations. Sizes of AVMs ranged from 0.08 to 21 cm (mean, 3.78 ± 4.19 cm). Complete AVM obliteration was achieved in 92 patients (66%) and was related to these independent factors: noneloquent location (odds ratio [OR], 3.20), size (OR, 0.88), low flow (OR, 3.47), no or mild arterial enlargement (OR, 3.32), and absence of perinidal angiogenesis (OR, 2.61). Concerning the 3 last angioarchitectural characteristics, if no or only a single factor was present in an individual patient (n = 92 patients), obliteration was observed in 74 (80%); if 2 or 3 factors were present (n = 47), obliteration was observed in 18 patients (38%; OR, 6.62). CONCLUSION Angioarchitectural factors that indicate high flow are associated with a lower rate of AVM obliteration after radiosurgery.
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Veeravagu A, Hansasuta A, Jiang B, Karim AS, Gibbs IC, Chang SD. Volumetric analysis of intracranial arteriovenous malformations contoured for CyberKnife radiosurgery with 3-dimensional rotational angiography vs computed tomography/magnetic resonance imaging. Neurosurgery 2013; 73:262-70. [PMID: 23615081 DOI: 10.1227/01.neu.0000430285.00928.30] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Accurate target delineation has significant impact on brain arteriovenous malformation (AVM) obliteration, treatment success, and potential complications of stereotactic radiosurgery. OBJECTIVE We compare the nidal contouring of AVMs using fused images of contrasted computed tomography (CT) and magnetic resonance imaging (MRI) with matched images of 3-dimensional (3-D) cerebral angiography for CyberKnife radiosurgery (CKRS) treatment planning. METHODS Between May 2009 and April 2012, 3-D cerebral angiography was integrated into CKRS target planning for 30 consecutive patients. The AVM nidal target volumes were delineated using fused CT and MRI scans vs fused CT, MRI, and 3-D cerebral angiography for each patient. RESULTS The mean volume of the AVM nidus contoured with the addition of 3-D cerebral angiography to the CT/MRI fusion (9.09 cm(3), 95% confidence interval: 5.39 cm(3)-12.8 cm(3)) was statistically smaller than the mean volume contoured with CT/MRI fused scans alone (14.1 cm(3), 95% confidence interval: 9.16 cm(3)-19.1 cm(3)), with a mean volume difference of δ = 5.01 cm(3) (P = .001). Diffuse AVM nidus was associated with larger mean volume differences compared with a compact nidus (δ = 6.51 vs 2.11 cm(3), P = .02). The mean volume difference was not statistically associated with the patient's sex (male δ = 5.61, female δ = 5.06, P = .84), previous hemorrhage status (yes δ = 5.69, no δ = 5.23, P = .86), or previous embolization status (yes δ = 6.80, no δ = 5.95, P = .11). CONCLUSION For brain AVMs treated with CKRS, the addition of 3-D cerebral angiography to CT/MRI fusions for diagnostic accuracy results in a statistically significant reduction in contoured nidal volume compared with standard CT/MRI fusion-based contouring.
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Affiliation(s)
- Anand Veeravagu
- †Departments of Neurological Surgery, Stanford University School of Medicine, Stanford, California; ‡Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; §Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Abstract
Stereotactic radiosurgery is the term coined by Lars Leksell to describe the application of a single, high dose of radiation to a stereotactically defined target volume. In the 1970s, reports began to appear documenting the successful obliteration of arteriovenous malformations (AVMs) with radiosurgery. When an AVM is treated with radiosurgery, a pathologic process appears to be induced that is similar to the response-to-injury model of atherosclerosis. Radiation injury to the vascular endothelium is believed to induce the proliferation of smooth-muscle cells and the elaboration of extracellular collagen, which leads to progressive stenosis and obliteration of the AVM nidus thereby eliminating the risk of hemorrhage. The advantages of radiosurgery - compared to microsurgical and endovascular treatments - are that it is noninvasive, has minimal risk of acute complications, and is performed as an outpatient procedure requiring no recovery time for the patient. The primary disadvantage of radiosurgery is that cure is not immediate. While thrombosis of the lesion is achieved in the majority of cases, it commonly does not occur until two or three years after treatment. During the interval between radiosurgical treatment and AVM thrombosis, the risk of hemorrhage remains. Another potential disadvantage of radiosurgery is possible long term adverse effects of radiation. Finally, radiosurgery has been shown to be less effective for lesions over 10 cc in volume. For these reasons, selection of the optimal treatment for an AVM is a complex decision requiring the input of experts in endovascular, open surgical, and radiosurgical treatment. In the pages below, we will review the world's literature on radiosurgery for AVMs. Topics reviewed will include the following: radiosurgical technique, radiosurgery results (gamma knife radiosurgery, particle beam radiosurgery, linear accelerator radiosurgery), hemorrhage after radiosurgery, radiation induced complications, repeat radiosurgery, and radiosurgery for other types of vascular malformation.
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Affiliation(s)
- William A Friedman
- Department of Neurological Surgery, University of Florida, Gainesville, FL 32610, USA.
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Flores GL, Sallabanda K, dos Santos MA, Gutiérrez J, Salcedo JCBP, Beltrán C, Fernández CP, Atienza MG, Samblás J. Linac stereotactic radiosurgery for the treatment of small arteriovenous malformations: lower doses can be equally effective. Stereotact Funct Neurosurg 2011; 89:338-45. [PMID: 22005899 DOI: 10.1159/000330837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 07/12/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the efficacy and toxicity of treating small arteriovenous malformations (AVMs) (≤3 cm in diameter) with a median marginal applied dose of 14 Gy. METHODS Two hundred and thirteen patients diagnosed with AVMs were treated between January 1991 and December 2005. Seventy-three percent of the patients had hemorrhaged prior to treatment, 13% had had previous surgery and 19.2% had had previous embolization. The median follow-up duration was 48.1 months. RESULTS The Kaplan-Meier analysis estimated that the 36-month obliteration rate was 65.5% for patients undergoing their first stereotactic radiosurgery (SRS) and 68.3% for those undergoing repeated SRS. The Kaplan-Meier analysis estimated the 60-month AVMs obliteration rate for the entire cohort to be 82.4%. The median time to AVM obliteration was 40 ± 2.8 months. We found a statistically significant relationship between the time of obliteration and the following factors: site of the AVMs (sites other than brainstem), a higher prescribed dose and a positive history of previous hemorrhage. Thirteen patients (7.6%) experienced toxicities. CONCLUSIONS SRS was an effective and safe treatment for AVMs ≤3 cm in diameter, with acceptable toxicity.
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Affiliation(s)
- G L Flores
- Radiotherapy Department, Instituto Madrileño de Oncologia/Grupo IMO, Madrid, Spain
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Yashar P, Amar AP, Giannotta SL, Yu C, Pagnini PG, Liu CY, Apuzzo MLJ. Cerebral arteriovenous malformations: issues of the interplay between stereotactic radiosurgery and endovascular surgical therapy. World Neurosurg 2011; 75:638-47. [PMID: 21704930 DOI: 10.1016/j.wneu.2011.01.042] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 01/25/2011] [Accepted: 01/28/2011] [Indexed: 11/25/2022]
Abstract
Intracranial arteriovenous malformations (AVMs) are congenital lesions frequently diagnosed as a result of hemorrhage or other neurological symptoms. Prevention of such devastating neurological injury has promoted a variety of treatment strategies. The rich history of multimodal therapy in the treatment of AVMs includes microsurgery, endovascular embolization, and stereotactic radiosurgery (SRS). This article reviews the biology and natural history of AVMs, as well as their treatment with both SRS and endovascular neurosurgery. It considers various paradigms and goals of endovascular treatment, along with relevant issues such as the features of an AVM to be targeted. Issues of the interplay between SRS and endovascular neurosurgery include the compartments of an embolized AVM to contain within the radiosurgery plan, the radioprotective and radiosensitizing effects of the embolic agent, the durability of embolization, and the sequencing of embolization with respect to the radiosurgical treatment. Published literature on these topics is sparse, and the flimsiness of the data offers limited guidance.
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Affiliation(s)
- Parham Yashar
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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Stahl JM, Chi YY, Friedman WA. Repeat Radiosurgery for Intracranial Arteriovenous Malformations. Neurosurgery 2011; 70:150-4; discussion 154. [PMID: 21743357 DOI: 10.1227/neu.0b013e31822c5740] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Despite a high success rate in the stereotactic radiosurgical treatment of intracranial arteriovenous malformations (AVMs) that cannot be safely resected with microsurgery, some patients must be managed after treatment failure.
OBJECTIVE
To provide an update on the use of repeat linear accelerator radiosurgery as a treatment for failed AVM radiosurgery at the University of Florida.
METHODS
We reviewed 103 patients who underwent repeat radiosurgical treatment for residual AVM at the University of Florida between December 1991 and December 2007. Each of these patients had at least 2 radiosurgical treatments for the same AVM. Patient information, including AVM nidus volume, prescription dose, age, and sex, was collected at the time of initial treatment and again at the time of retreatment. Patients were followed up after treatment with magnetic resonance, computed tomography, and angiographic imaging at standard intervals to determine the status of their AVM. The median follow-up after retreatment was 31 months.
RESULTS
Between the first and second treatments, the median AVM nidus volume was decreased by 69% (from a median volume of 12.7 to 4.0 cm3), allowing the median prescribed dose to be increased from 1500 cGy on initial treatment to 1750 cGy on retreatment. The final obliteration rate on retreatment was 65.3%. After salvage retreatment, 5 patients (4.9%) experienced radiation-induced complications, and 6 patients (5.8%) experienced posttreatment hemorrhage.
CONCLUSION
Repeat radiosurgery is a safe and effective salvage treatment for AVMs.
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Affiliation(s)
- John M. Stahl
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Yueh-Yun Chi
- Department of Epidemiology and Health Policy Research, University of Florida, Gainesville, Florida
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Conti A, Pontoriero A, Faragò G, Midili F, Siragusa C, Granata F, Pitrone A, De Renzis C, Longo M, Tomasello F. Integration of three-dimensional rotational angiography in radiosurgical treatment planning of cerebral arteriovenous malformations. Int J Radiat Oncol Biol Phys 2011; 81:e29-37. [PMID: 21345616 DOI: 10.1016/j.ijrobp.2010.12.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Revised: 11/05/2010] [Accepted: 12/20/2010] [Indexed: 11/18/2022]
Abstract
PURPOSE Accuracy in delineating the target volume is a major issue for successful stereotactic radiosurgery for arteriovenous malformations. The aim of the present study was to describe a method to integrate three-dimensional (3D) rotational angiography (3DRA) into CyberKnife treatment planning and to investigate its potential advantages compared with computed tomography angiography (CTA) and magnetic resonance angiography. METHODS AND MATERIALS A total of 20 patients with a diagnosis of cerebral arteriovenous malformation were included in the present study. All patients underwent multislice computed tomography and 3D-volumetric CTA, 3DRA, and 3D magnetic resonance angiography. The contouring of the target and critical volumes was done separately using CTA and thereafter directly using 3DRA. The composite, conjoint, and disjoint volumes were measured. RESULTS The use of CTA or 3DRA resulted in significant differences in the target and critical volumes. The target volume averaged 3.49 ± 3.01 mL measured using CTA and 3.26 ± 2.93 mL measured using 3DRA, for a difference of 8% (p < .05). The conjoint and disjoint volume analysis showed an 88% volume overlap. The qualitative evaluation showed that the excess volume obtained using CTA was mostly tissue surrounding the nidus and venous structures. The mean contoured venous volume was 0.67 mL measured using CTA and 0.88 mL (range, 0.1-2.7) measured using 3DRA (p < .05). CONCLUSIONS 3DRA is a volumetric angiographic study that can be integrated into computer-based treatment planning. Although whether 3DRA provides superior accuracy has not yet been proved, its high spatial resolution is attractive and offers a superior 3D view. This allows a better 3D understanding of the target volume and distribution of the radiation doses within the volume. Additional technical efforts to improve the temporal resolution and the development of software tools aimed at improving the performance of 3D contouring are warranted.
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Affiliation(s)
- Alfredo Conti
- Department of Neurosurgery, University of Messina, Messina, Italy.
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Friedman WA, Bova FJ. Radiosurgery for Arteriovenous Malformations. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10073-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Response of Arteriovenous Malformations to Gamma Knife Therapy Evaluated With Pulsed Arterial Spin-Labeling MRI Perfusion. AJR Am J Roentgenol 2011; 196:15-22. [DOI: 10.2214/ajr.10.5290] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Yen CP, Jain S, Haq IU, Jagannathan J, Schlesinger D, Sheehan J, Steiner L. Repeat Gamma Knife Surgery for Incompletely Obliterated Cerebral Arteriovenous Malformations. Neurosurgery 2010; 67:55-64; discussion 64. [DOI: 10.1227/01.neu.0000370204.68711.ac] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
The causes of failure after an initial Gamma procedure were studied, along with imaging and clinical outcomes, in a series of 140 patients with cerebral arteriovenous malformations (AVMs) treated with repeat Gamma Knife surgery (GKS).
METHODS
Causes of initial treatment failure included inaccurate nidus definition in 14 patients, failure to fill part of the nidus as a result of hemodynamic factors in 16, recanalization of embolized AVM compartments in 6, and suboptimal dose (< 20 Gy) in 23. Nineteen patients had repeat GKS for subtotal obliteration of AVMs. In 62 patients, the AVM failed to obliterate despite correct target definition and adequate dose. At the time of retreatment, the nidus volume ranged from 0.1 to 6.9 cm3 (mean, 1.4 cm3), and the mean prescription dose was 20.3 Gy.
RESULTS
Repeat GKS yielded a total angiographic obliteration in 77 patients (55%) and subtotal obliteration in 9 (6.4%). In 38 patients (27.1%), the AVMs remained patent, and in 16 patients (11.4%), no flow voids were observed on magnetic resonance imaging. Clinically, 126 patients improved or remained stable, and 14 experienced deterioration (8 resulting from a rebleed, 2 caused by persistent arteriovenous shunting, and 4 related to radiation-induced changes).
CONCLUSION
By using repeat GKS, we achieved a 55% angiographic cure rate. Although radiation-induced changes as visualized on magnetic resonance imaging occurred in 48 patients (39%), only 4 patients (3.6%) developed permanent neurological deficits. These findings may be useful in deciding the management of AVMs in whom total obliteration after initial GKS was not achieved.
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Affiliation(s)
- Chun-Po Yen
- Lars Leksell Center for Gamma Surgery, Department of Neurological Surgery, University of Virginia Health Sciences System, Charlottesville, Virginia
| | - Surbhi Jain
- Lars Leksell Center for Gamma Surgery, Department of Neurological Surgery, University of Virginia Health Sciences System, Charlottesville, Virginia
| | - Iftikhar-ul Haq
- Lars Leksell Center for Gamma Surgery, Department of Neurological Surgery, University of Virginia Health Sciences System, Charlottesville, Virginia
| | - Jay Jagannathan
- Lars Leksell Center for Gamma Surgery, Department of Neurological Surgery, University of Virginia Health Sciences System, Charlottesville, Virginia
| | - David Schlesinger
- Lars Leksell Center for Gamma Surgery, Department of Neurological Surgery, University of Virginia Health Sciences System, Charlottesville, Virginia
| | - Jason Sheehan
- Lars Leksell Center for Gamma Surgery, Department of Neurological Surgery, University of Virginia Health Sciences System, Charlottesville, Virginia
| | - Ladislau Steiner
- Lars Leksell Center for Gamma Surgery, Department of Neurological Surgery, University of Virginia Health Sciences System, Charlottesville, Virginia
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Clinical outcome after repeated radiosurgery for brain arteriovenous malformations. Radiother Oncol 2010; 95:250-6. [PMID: 20362350 DOI: 10.1016/j.radonc.2010.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Revised: 02/28/2010] [Accepted: 03/07/2010] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We assessed the clinical and radiological outcome after repeated radiosurgery for brain arteriovenous malformations (bAVMs) after failure of initial radiosurgery. MATERIALS AND METHODS Fifteen patients underwent repeated radiosurgery. The mean bAVM volume at first radiosurgery (S1) was 4.6 +/- 4.3 ml and that at second radiosurgery (S2) was 2.1 +/- 2.5 ml. The median marginal dose was 18 Gy at S1, and 21 Gy at S2. Modified Rankin Scale (MRS) score was determined in all patients at last follow-up (FU). RESULTS Complete obliteration was reached in nine patients (60%). Median time to obliteration was 50 months after S2. An excellent outcome (no new neurologic deficiencies, complete obliteration) was reached in seven patients (47%). Eleven patients (73%) showed a MRS1. Radiation-induced complications occurred in 20%, of which 13% occurred after S2. Radiological complications included cyst formation (n = 1), radiation-related edema (n = 4), and radiation necrosis (n = 1), resulting in an increasing mean MRS of 0.5 at S1, 0.6 at S2, to 0.8 at FU. No (re-)bleedings were encountered during 137-patient years at risk. DISCUSSION Repeated radiosurgery is a viable option for the treatment of small remnant bAVMs. We report 20% permanent radiation-induced complications. Such complications were mainly seen in relatively large, and therefore difficult to treat, bAVMs.
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Vesper J, Bölke B, Wille C, Gerber PA, Matuschek C, Peiper M, Steiger HJ, Budach W, Lammering G. Current concepts in stereotactic radiosurgery - a neurosurgical and radiooncological point of view. Eur J Med Res 2009; 14:93-101. [PMID: 19380278 PMCID: PMC3352064 DOI: 10.1186/2047-783x-14-3-93] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Stereotactic radiosurgery is related to the history of "radiotherapy" and "stereotactic neurosurgery". The concepts for neurosurgeons and radiooncologists have been changed during the last decade and have also transformed neurosurgery. The gamma knife and the stereotactically modified linear accelerator (LINAC) are radiosurgical equipments to treat predetermined intracranial targets through the intact skull without damaging the surrounding normal brain tissue. These technical developments allow a more precise intracranial lesion control and offer even more conformal dose plans for irregularly shaped lesions. Histological determination by stereotactic biopsy remains the basis for any otherwise undefined intracranial lesion. As a minimal approach, it allows functional preservation, low risk and high sensitivity. Long-term results have been published for various indications. The impact of radiosurgery is presented for the management of gliomas, metastases, brain stem lesions, benign tumours and vascular malformations and selected functional disorders such as trigeminal neuralgia. In AVM's it can be performed as part of a multimodality strategy including resection or endovascular embolisation. Finally, the technological advances in radiation oncology as well as stereotactic neurosurgery have led to significant improvements in radiosurgical treatment opportunities. Novel indications are currently under investigation. The combination of both, the neurosurgical and the radiooncological expertise, will help to minimize the risk for the patient while achieving a greater treatment success.
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Affiliation(s)
- Jan Vesper
- Department of Neurosurgery, University of Düsseldorf, Germany.
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Chung WY, Shiau CY, Wu HM, Liu KD, Guo WY, Wang LW, Pan DHC. Staged radiosurgery for extra-large cerebral arteriovenous malformations: method, implementation, and results. J Neurosurg 2009; 109 Suppl:65-72. [PMID: 19123890 DOI: 10.3171/jns/2008/109/12/s11] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The effectiveness and safety of radiosurgery for small- to medium-sized cerebral arteriovenous malformations (AVMs) have been well established. However, the management for large cerebral AVMs remains a great challenge to neurosurgeons. In the past 5 years the authors performed preplanned staged radiosurgery to treat extra-large cerebral AVMs. METHODS An extra-large cerebral AVM is defined as one with nidus volume > 40 ml. The nidus volume of cerebral AVM is measured from the dose plan-that is, as being the volume contained within the best-fit prescription isodose. From January 2003 to December 2007, the authors treated 6 patients with extra-large AVMs by preplanned staged GKS. Staged radiosurgery is implemented by rigid transformation with translation and rotation of coordinates between 2 stages. The average radiation-targeted volume was 60 ml (range 47-72 ml). The presenting symptoms were seizure in 4 patients and a bleeding episode in 2. One patient had undergone a previous craniotomy and evacuation of hematoma. The mean interval between the 2 radiosurgical sessions was 6.9 months (range 4.5-9.1 months). The prescribed marginal dose given to the nidus volume in each stage ranged from 16 to 18.6 Gy. The expected marginal dose of total nidus was 17-19 Gy. Regular follow-up MR imaging was performed every 6 months. The mean follow-up period was 28 months (range 12-54 months). RESULTS Most of the patients exhibited clinical improvement: relief of headache and reduced frequency of seizure attack. All patients had significant regression of nidus observed on MR imaging follow-up. Two patients had angiogram-confirmed complete obliteration of the nidus 45 and 60 months after the second-stage radiosurgical session. One patient experienced minor bleeding 8 months after the second-stage radiosurgery with mild headache. She had satisfactory recovery without clinical neurological deficit after conservative treatment. CONCLUSIONS These preliminary results indicate that staged radiosurgery is a practical strategy to treat patients with extra-large cerebral AVMs. It takes longer to obliterate the AVMs. The observed high signal T2 changes after the radiosurgery appeared clinically insignificant in 6 patients followed up for an average of 28 months. Longer follow-up is necessary to confirm its long-term safety.
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Affiliation(s)
- Wen-Yuh Chung
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan.
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Arrese I, Alday R, González P, Fernández-Letón J, Pérez-Núñez A, Lobato R, Campollo J, Ramos A, Dominguez P. Hiperintensidad en secuencias T2 y tamaño como factores pronósticos de obliteración en malformaciones arteriovenosas tratadas mediante radiocirugía. Neurocirugia (Astur) 2009. [DOI: 10.1016/s1130-1473(09)70174-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Berger MO, Anxionnat R, Kerrien E, Picard L, Söderman M. A methodology for validating a 3D imaging modality for brain AVM delineation: application to 3DRA. Comput Med Imaging Graph 2008; 32:544-53. [PMID: 18640005 DOI: 10.1016/j.compmedimag.2008.06.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Accepted: 06/10/2008] [Indexed: 11/17/2022]
Abstract
A general methodology is described to validate a 3D imaging modality with respect to 2D digital subtracted angiography (DSA) for brain AVMs (BAVM) delineation. It relies on the assessment of the statistical compatibility of the radiosurgical target delineated in 3D with its delineations in 2D. This methodology is demonstrated through a preliminary evaluation of 3D rotational angiography (3DRA). Generally speaking, BAVM delineation cannot be performed on 3DRA alone. However, in our study, 3DRA showed similar performances to DSA for rather easy cases, and even better for three patients. Conversely, three problematic cases are identified and discussed.
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Affiliation(s)
- Marie-Odile Berger
- Projet Magrit, Bâtiment C, LORIA & INRIA Nancy-Grand Est, 615, rue du Jardin Botanique-BP 101, 65602 Villers-lès-Nancy Cedex, France.
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Andrade-Souza YM, Ramani M, Beachey DJ, Scora D, Tsao MN, Terbrugge K, Schwartz ML. Liquid embolisation material reduces the delivered radiation dose: a physical experiment. Acta Neurochir (Wien) 2008; 150:161-4; discussion 164. [PMID: 18213438 DOI: 10.1007/s00701-007-1482-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Accepted: 12/04/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To test a new hypothesis that the glue/contrast admixture used for embolisation reduces the dose delivered to AVMs using an experimental model. METHOD A model was created using a block of "solid water" (6 x 5 x 2 cm) with twelve wells of different depths. Different concentrations of the glue admixture (Enbucrilate + Lipiodol) were used. The model was irradiated using a 5MV beam with a clinical LINAC system and the dose was checked upstream and downstream. Dose was measured using Kodak XV film, a Vidar 16 bit film scanner and software for therapeutic film dosimetry measurements (RIT software). RESULTS The radiation dose varied with the distance beyond the glue solid water interface. For distances of 0, 2 and 5 mm to the film, the mean reduction was 13.65% (SD = 2.94), 6.87% (SD = 1.95) and 1.75% (SD = 1.14), respectively. There was also correlation with the Lipiodol concentration in the mixture. The maximum reductions for 80, 50 and 20% Lipiodol concentrations were 16.1% (SD = 1.32), 14.85% (SD = 0.98) and 10% (SD = 1.21), respectively. There was no correlation between the glue depth and the dose delivered. CONCLUSION The hypothesis that the glue mixture used for embolisation reduces the radiation dose delivered was experimentally confirmed with this study.
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Moreno-Jiménez S, Celis MA, Lárraga-Gutiérrez JM, de Jesús Suárez-Campos J, García-Garduño A, Hernández-Bojórquez M. Intracranial arteriovenous malformations treated with linear accelerator–based conformal radiosurgery: clinical outcome and prediction of obliteration. ACTA ACUST UNITED AC 2007; 67:487-91; discussion 491-2. [DOI: 10.1016/j.surneu.2006.08.076] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2006] [Accepted: 08/16/2006] [Indexed: 11/16/2022]
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Cover KS, Lagerwaard FJ, van den Berg R, Buis DR, Slotman BJ. Color intensity projection of digitally subtracted angiography for the visualization of brain arteriovenous malformations. Neurosurgery 2007; 60:511-4; discussion 514-5. [PMID: 17327796 DOI: 10.1227/01.neu.0000255331.49791.b4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Reliable and rapid delineation of arteriovenous malformations enables the application of effective treatments such as stereotactic radiosurgery. We describe a new method to improve the speed and reliability of visualizing the flow of contrast images with digital subtraction angiography. METHODS In line with current practices, digital subtraction angiography was used to produce a sequence of grayscale images. The new method combines the standard grayscale images produced by digital subtraction angiography into a single composite color image that encodes the contrast arrival time at each point of the brain's circulatory system. The algorithm is simple, fast, and easy to implement. RESULTS The technique allows the flow of contrast from a series of angiography images to be summarized in a single color image. CONCLUSION This visualization method promises to improve the speed of manual delineation of arteriovenous malformations. Further studies are required to evaluate the clinical value of the use of color intensity projection images, supplemented by grayscale images as necessary, in comparison with contouring on grayscale images only.
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Affiliation(s)
- Keith S Cover
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands.
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Stancanello J, Cavedon C, Francescon P, Causin F, Avanzo M, Colombo F, Cerveri P, Ferrigno G, Uggeri F. BOLD FMRI integration into radiosurgery treatment planning of cerebral vascular malformations. Med Phys 2007; 34:1176-84. [PMID: 17500448 DOI: 10.1118/1.2710326] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Functional magnetic resonance imaging (fMRI) is used to distinguish areas of the brain responsible for different tasks and functions. It is possible, for example, by using fMRI images, to identify particular regions in the brain which can be considered as "functional organs at risk" (fOARs), i.e., regions which would cause significant patient morbidity if compromised. The aim of this study is to propose and validate a method to exploit functional information for the identification of fOARs in CyberKnife (Accuray, Inc., Sunnyvale, CA) radiosurgery treatment planning; in particular, given the high spatial accuracy offered by the CyberKnife system, local nonrigid registration is used to reach accurate image matching. Five patients affected by arteriovenous malformations (AVMs) and scheduled to undergo radiosurgery were scanned prior to treatment using computed tomography (CT), three-dimensional (3D) rotational angiography (3DRA), T2 weighted and blood oxygenation level dependent echo planar imaging MRI. Tasks were chosen on the basis of lesion location by considering those areas which could be potentially close to treatment targets. Functional data were superimposed on 3DRA and CT used for treatment planning. The procedure for the localization of fMRI areas was validated by direct cortical stimulation on 38 AVM and tumor patients undergoing conventional surgery. Treatment plans studied with and without considering fOARs were significantly different, in particular with respect to both maximum dose and dose volume histograms; consideration of the fOARs allowed quality indices of treatment plans to remain almost constant or to improve in four out of five cases compared to plans with no consideration of fOARs. In conclusion, the presented method provides an accurate tool for the integration of functional information into AVM radiosurgery, which might help to minimize undesirable side effects and to make radiosurgery less invasive.
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Andrade-Souza YM, Ramani M, Scora D, Tsao MN, terBrugge K, Schwartz ML. EMBOLIZATION BEFORE RADIOSURGERY REDUCES THE OBLITERATION RATE OF ARTERIOVENOUS MALFORMATIONS. Neurosurgery 2007; 60:443-51; discussion 451-2. [PMID: 17327788 DOI: 10.1227/01.neu.0000255347.25959.d0] [Citation(s) in RCA: 197] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
To evaluate the arteriovenous malformation (AVM) obliteration rate and the clinical outcome after radiosurgery in patients with and without previous embolization.
METHODS
Of 244 patients who underwent linear accelerator radiosurgery for AVMs at the Sunnybrook Health Sciences Centre between 1989 and 2000, 61 patients had embolization before radiosurgery and complete follow-up for at least 3 years. For 47 of these 61 patients (Group A, embolization plus radiosurgery), we were able to find 47 matching patients without previous embolization (Group B, radiosurgery alone). This group of matching patients had the same AVM volume (after embolization in Group A), location, and marginal dose. The radiosurgery-based AVM score and the obliteration prediction index were calculated.
RESULTS
The median follow-up period was 44 months. Nidus obliteration was achieved in 22 patients in Group A (47%) and 33 patients in Group B (70%, P = 0.036). Permanent deficit related to hemorrhage or radiation occurred in three patients (6%) in Group A and three patients (6%) in Group B. During the first 3 years after radiosurgery, two patients (4%) in Group A experienced hemorrhage; in Group B, five patients (11%) experienced hemorrhage (P = 0.2). In Group B, two patients (4%) died and two patients (4%) had their AVM surgically removed. Both deaths were related to hemorrhage during the latency period. The excellent outcome (obliteration plus no deficit) in Group A was 47% compared with 64% in Group B (P = 0.146). There was no difference in the obliteration prediction index and the radiosurgery-based AVM score between Groups A and B. The predicted rates of obliteration and excellent outcome were 55 and 62.5%, respectively, according to the obliteration prediction index and the radiosurgery-based AVM score.
CONCLUSION
Embolization before radiosurgery significantly decreases the obliteration rate, even in AVMs with the same volume, location, and marginal dose. Although an excellent outcome rate was higher in the group without embolization, this was not statistically significant.
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Affiliation(s)
- Yuri M Andrade-Souza
- Division of Neurosurgery, University of Toronto, Sunnybrook Health Sciences Centre, Toronto Western Hospital, Toronto, Canada
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Andrade-Souza YM, Ramani M, Scora D, Tsao MN, TerBrugge K, Schwartz ML. Radiosurgical treatment for rolandic arteriovenous malformations. J Neurosurg 2006; 105:689-97. [PMID: 17121129 DOI: 10.3171/jns.2006.105.5.689] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors reviewed the radiosurgical outcomes in patients with arteriovenous malformations (AVMs) located in the rolandic area, including the primary motor and sensory gyri.
Methods
The study population consisted of 38 patients with rolandic-area AVMs who underwent linear accelerator radiosurgery at the University of Toronto between 1989 and 2000. Obliteration rate, risk of hemorrhage during the latency period, radiation-induced complications, seizure control, and functional status were evaluated. Patients were also divided into two subgroups according to AVM volume (< 3 cm3 and ≥ 3 cm3).
Patients were followed up for a median of 42.4 months (range 30–103 months), and the median age of the patients was 40 years (range 12–67 years). The median AVM volume was 8.1 cm3 (range 0.32–21, mean 8.32 cm3), and the median dose at the tumor margin was 15 Gy (range 15–22, mean 16.8 Gy). The risk of hemorrhage after radiosurgery was 5.3% for the 1st year, 2.6% for the 2nd, and 0% for the 3rd. Two patients (5.3%) sustained adverse effects related to radiation for more than 6 months. Complete nidus obliteration after a single radiosurgical treatment was achieved in 23 patients (60.5%). The obliteration rate for AVMs smaller than 3 cm3 was 83.3% (10 of 12) and that for AVMs larger than or equal to 3 cm3 was 50% (13 of 26). Among the patients who had seizures as the initial presentation, 51.8% were free of seizures after radiosurgery and the seizure pattern improved in 40.7% during the 3rd and last year of follow up. Overall, excellent results (obliteration and no new or worsening neurological deficit) can be achieved in approximately 60% of patients. This percentage varies according to the AVM size and can reach 83% in patients with AVMs smaller than 3 cm3.
Conclusions
Radiosurgery is a safe and effective treatment for people with rolandic AVMs. The low rate of morbidity associated with radiosurgery, compared with other treatments, indicates that this method may be the first choice for patients with AVMs located in this area.
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Affiliation(s)
- Yuri M Andrade-Souza
- Division of Neurosurgery, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada.
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Tu J, Stoodley MA, Morgan MK, Storer KP. Responses of arteriovenous malformations to radiosurgery: ultrastructural changes. Neurosurgery 2006; 58:749-58; discussion 749-58. [PMID: 16575339 DOI: 10.1227/01.neu.0000192360.87083.90] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To examine the ultrastructural changes in arteriovenous malformations (AVMs) after radiosurgery and to explore the possible mechanisms of posttreatment obliteration and hemorrhage. METHODS Twenty-two specimens, among them three irradiated AVMs (size, 3-6 cm), 15 nonirradiated AVMs, and four normal controls were processed for ultrastructural study immediately after removal. Transmission electron microscopy was used to compare the vasculature of irradiated AVMs with nonirradiated AVMs and normal controls. RESULTS Thirty-three months postradiosurgery, partial vaso-occlusion (36-74% lumen) occurred by coagulation of cytoplasmic debris and proteinaceous material leaking from the endothelium. Forty-eight months postradiosurgery, heterogeneous thrombus formation (86-96% lumen) with fibrinoid and proteinaceous materials was observed. Sixty-four months postradiosurgery, complete luminal closure (90-100% lumen) by a fibrin thrombus was seen in vessels with diameters up to 5.5 mm including feeding arteries and draining veins. In occluded vessels, there was extensive degeneration of endothelial cells, subendothelial fibroblasts, and myofibroblasts. Neoproliferation and endothelialization of smooth muscle cells with Weibel-Palade bodies was observed in arteries. CONCLUSION Radiosurgery causes irreversible cellular damage of the vascular wall. Partial vaso-occlusion that increases blood flow in remaining vessels and degenerative changes on the blood-brain barrier may contribute to hemorrhage at early stage postradiosurgery. Radiosurgery stimulates neoproliferating and endothelializing smooth muscle cells in vessel walls, which might lead to narrowing of the vessel lumina. Complete vaso-occlusion achieved 64 months postradiosurgery suggested a minimum follow-up duration of 5 years to determine final outcome of radiosurgery. Histological end point of vaso-occlusion of AVMs takes longer time than neuroimaging endpoint of complete obliteration.
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Affiliation(s)
- Jian Tu
- Prince of Wales Medical Research Institute, University of New South Wales, Randwick, Australia
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40
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Luo CB, Guo WY, Teng MMH, Chang FC, Pan DH. Embolization of arteriovenous fistula after radiosurgery for multiple cerebral arteriovenous malformations. Kaohsiung J Med Sci 2006; 21:571-7. [PMID: 16670050 DOI: 10.1016/s1607-551x(09)70210-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cerebral arteriovenous malformation (CAVM) associated with arteriovenous fistula (AVF) is rare. It may be difficult to identify hemodynamic details of mixed CAVM and AVF, even when using x-ray cerebral angiography (digital subtraction angiography). We report on a 37-year-old male patient with headache that led to an initial diagnosis of deep frontotemporal CAVM. The first DSA revealed engorged, tortuous, and high-flow venous drainage in addition to clusters of vasculature niduses. The patient was initially treated using gamma-knife radiosurgery (GKRS), which resulted in partial nidus obliteration, documented by a series of follow-up magnetic resonance imaging (MRI). However, the high-flow venous drainage remained, seen on MRI as engorged venous pouches. Clinically, the patient was bothered by persistent headache and bruits after GKRS. Follow-up DSA 3 years after GKRS confirmed a small remnant CAVM nidus and a nearby AVF, separated from and lateral to the original CAVM nidus in the ipsilateral deep temporal lobe. When the initial DSA was reviewed, it revealed that the AVF was difficult to define because of superimposition of the nidus and engorged drainage vessels. Embolization of the AVF using electrodetachable coils resulted in total occlusion of the AVF. The patient's symptoms resolved immediately after embolization. This case suggests that superselective angiography using a microcatheter may be necessary for the initial diagnosis of CAVM associated with AVF with high-flow and engorged venous drainage. For CAVM patients with persistent symptoms after radiosurgery and engorged venous drainage when CAVM is expected to be cured, a microcatheter and superselective endovascular approach may offer diagnosis. Immediate embolization for associated AVF in the same angiographic session may thereby improve neurologic deficits and reduce hemorrhagic risk during the latency after GKRS.
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Affiliation(s)
- Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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41
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Moreno-Jiménez S, Celis-López M, Herrera-Gómez L, Lárraga-Gutiérrez J, Suárez-Campos J, García-Garduño A, Hernández-Bojórquez M. Malformaciones arteriovenosas intracraneales y radiocirugía con LINAC: artículo de revisión. Neurocirugia (Astur) 2006. [DOI: 10.1016/s1130-1473(06)70332-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Stancanello J, Cavedon C, Francescon P, Cerveri P, Ferrigno G, Causin F, Colombo F. CT—3D rotational angiography automatic registration: A sensitivity analysis. Med Biol Eng Comput 2005; 43:667-71. [PMID: 16411640 DOI: 10.1007/bf02351041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Preprocessing, binning and dataset subsampling are investigated with regard to simultaneous maximisation of the speed, accuracy and robustness of CT-3D rotational angiography (3DRA) registration. Clinical diagnosis and treatment can both take advantage of this integration, because 3DRA allows the shape of vessel structures to be evaluated three-dimensionally with respect to standard 2D projective angiography. The method for optimising preprocessing, binning and subsampling consisted of independent variation of the corresponding parameters to maximise robustness and speed while maintaining subvoxel accuracy; the latter was computed as the sum of the mean squared errors initially present in the registrations with the errors relative to both binning and subsampling. The results suggest the choice of 256 bins, steps between 14 mm (coarse optimisation) and 2.5 mm (fine optimisation) and bone segmentation by threshold, for binning, subsampling and preprocessing, respectively. The application of this parameter set-up to 50 CT-3DRA registrations resulted in a saving, on average, of 40% of the time with respect to the method previously used, while registration error was maintained within 2 mm (1.97 mm, 90% confidence interval) and robustness was increased, so that no manual initial realignment was needed in 48 registrations. Validation by the registration of images acquired for a head phantom showed subvoxel residual errors. In conclusion, the proposed procedure can be considered a satisfactory strategy to optimise CT-3DRA registration.
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Affiliation(s)
- J Stancanello
- Department of Medical Physics, San Bortolo Hospital, Vicenza, Italy.
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Buis DR, Lagerwaard FJ, Barkhof F, Dirven CMF, Lycklama GJ, Meijer OWM, van den Berg R, Langendijk HA, Slotman BJ, Vandertop WP. Stereotactic radiosurgery for brain AVMs: role of interobserver variation in target definition on digital subtraction angiography. Int J Radiat Oncol Biol Phys 2005; 62:246-52. [PMID: 15850928 DOI: 10.1016/j.ijrobp.2004.12.080] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2004] [Revised: 12/02/2004] [Accepted: 12/16/2004] [Indexed: 11/23/2022]
Abstract
PURPOSE We evaluated the extent of interobserver variation in contouring arteriovenous malformations (AVMs) on digital subtraction angiography (DSA) with respect to volume, spatial localization, and dosimetry and correlated our findings with the clinical outcome. METHODS AND MATERIALS Thirty-one patients who had undergone radiosurgery for brain AVMs were studied. Six clinicians independently contoured the nidus on the original DSA. As a measure of variation, the ratio between the volumes of agreement and the corresponding encompassing volumes, as well as the absolute positional shift between the individual target volumes were derived. Using the original treatment plan, the dosimetric coverage of the individually contoured volumes with standard collimators was compared with a similar plan using dynamic conformal arcs. RESULTS The mean contoured nidus volume was 3.6 +/- 5.6 cm3. The mean agreement ratio was 0.45 +/- 0.18 for all possible pairs of observers. The mean absolute positional shift between individually contoured volumes was 2.8 +/- 2.6 mm. These differences were more marked in previously treated groups and tended to be more pronounced in those with treatment failure. The mean coverage of the individual volumes by the 80% prescription isodose was 88.1% +/- 3.2% using conventional collimators and 78.9% +/- 4.4% using dynamic conformal arcs (p = 0.001). CONCLUSION Substantial interobserver variations exist when contouring brain AVMs on DSA for the purpose of radiosurgical planning. Such variations may result in underdosage to the AVM and, thereby, contribute to treatment failure. The consequences of contouring variations may increase with the use of more conformal radiosurgical techniques.
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Affiliation(s)
- Dennis R Buis
- Department of Neurosurgery, VU University Medical Center, Amsterdam, The Netherlands.
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Unsgaard G, Ommedal S, Rygh OM, Lindseth F. Operation of Arteriovenous Malformations Assisted by Stereoscopic Navigation-controlled Display of Preoperative Magnetic Resonance Angiography and Intraoperative Ultrasound Angiography. Oper Neurosurg (Hagerstown) 2005; 56:281-90; discussion 281-90. [PMID: 15794825 DOI: 10.1227/01.neu.0000157005.51053.41] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2004] [Accepted: 12/02/2004] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To study the application of navigated stereoscopic display of preoperative three-dimensional (3-D) magnetic resonance angiography and intraoperative 3-D ultrasound angiography in a clinical setting. METHODS Preoperative magnetic resonance angiography and intraoperative ultrasound angiography are presented as stereoscopic images on the monitor during the operation by a simple red/blue technique. Two projections are generated, one for each eye, according to a simple ray casting method. Because of integration with a navigation system, it is possible to identify vessels with a pointer. The system has been applied during operations on nine patients with arteriovenous malformations (AVMs). Seven of the patients had AVMs in an eloquent area. RESULTS The technology makes it easier to understand the vascular architecture during the operation, and it offers a possibility to identify and clip AVM feeders both on the surface and deep in the tissue at the beginning of the operation. All 28 feeders identified on the preoperative angiograms were identified by intraoperative navigated stereoscopy. Twenty-five were clipped at the beginning of the operation. The other three were clipped at a later phase of the operation. 3-D ultrasound angiography was useful to map the size of the nidus, to detect the degree of brain shift, and to identify residual AVM. CONCLUSION Stereoscopic visualization enhances the surgeon's perception of the vascular architecture, and integrated with navigation technology, this offers a reliable system for identification and clipping of AVM feeders in the initial phase of the operation.
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Affiliation(s)
- Geirmund Unsgaard
- Department of Neurosurgery, Trondheim University Hospital, Norwegian University of Science and Technology, Trondheim, Norway.
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Andrade-Souza YM, Zadeh G, Scora D, Tsao MN, Schwartz ML. Radiosurgery for Basal Ganglia, Internal Capsule, and Thalamus Arteriovenous Malformation: Clinical Outcome. Neurosurgery 2005; 56:56-63; discussion 63-4. [PMID: 15617586 DOI: 10.1227/01.neu.0000145797.35968.ed] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2004] [Accepted: 09/10/2004] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
Radiosurgery is accepted as the first option for treating deep arteriovenous malformations (AVMs), although the clinical outcome in this subgroup of brain AVMs is not well studied. The objective of this study is to review our experience with radiosurgical treatment for these AVMs.
METHODS:
Between October 1989 and December 2000, 45 patients with deep AVMs (including basal ganglia, internal capsule, and thalamus) underwent stereotactic radiosurgery. Three patients were lost to follow-up and therefore were excluded from this study. Patient characteristics and outcomes were collected and analyzed. The obliteration prediction index and the radiosurgery-based AVM score were calculated and tested.
RESULTS:
Forty-two patients were followed up for a median of 39 months (range, 25–90 mo; mean, 45.8 mo). The median maximum AVM diameter during the radiosurgery was 1.8 cm (range, 0.9–4.0 cm; mean, 2.07 cm), and the median AVM volume was 2.8 cm3 (range, 0.2–18.3 cm3; mean, 4.74 cm3). The mean marginal dose was 16.2 Gy (median, 15 Gy), and the median maximum dose was 22.4 Gy (range, 16.6–30 Gy). The AVM cure rate after the first radiosurgical treatment, using angiography- and magnetic resonance imaging-confirmed obliteration, was 61.9%. The predicted obliteration using the obliteration prediction index was 60%. Eight patients developed radiation-induced complications (19%). The deficit was transient in three patients (7.1%) and permanent in five patients (11.9%). The risk of postradiosurgical hemorrhage in this cohort was 9.5% for the first year, 4.7% for the second year, and 0% thereafter. Excellent outcome (obliteration plus no new deficit) was achieved in 70% of the patients in the group with radiosurgery-based AVM score less than 1.5 compared with 40.9% in the group with radiosurgery-based AVM score greater than 1.5% (P = 0.059).
CONCLUSION:
Radiosurgery for deep AVMs has a satisfactory obliteration rate and acceptable morbidity, considering the risk of hemorrhage without treatment and the risk of morbidity associated with other treatment modalities.
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Affiliation(s)
- Yuri M Andrade-Souza
- Division of Neurosurgery, Sunnybrook and Women's College, Health Science Centre,University of Toronto, Toronto, Ontario, Canada
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Zipfel GJ, Bradshaw P, Bova FJ, Friedman WA. Do the morphological characteristics of arteriovenous malformations affect the results of radiosurgery? J Neurosurg 2004; 101:393-401. [PMID: 15352595 DOI: 10.3171/jns.2004.101.3.0393] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors sought to determine which morphological features of arteriovenous malformations (AVMs) are statistically predictive of preradiosurgical hemorrhage, postradiosurgical hemorrhage, and neuroimaging-defined failure of radiosurgical treatment. In addition, correlation between computerized tomography (CT) scanning and angiography for the identification of AVM structures was investigated. METHODS Archived CT dosimetry and available angiographic and clinical data for 268 patients in whom AVMs were treated with linear accelerator radiosurgery were retrospectively reviewed. Many of the morphological features of AVMs, including location, volume, compact or diffuse nidus, neovascularity, ease of nidus identification, number of feeding arteries, location (deep or superficial) of feeding arteries, number of draining veins, deep or superficial venous drainage, venous stenoses, venous ectasias, and the presence of intranidal aneurysms, were analyzed. In addition, a number of patient and treatment factors, including patient age, presenting symptoms, radiation dose, repeated treatment, and radiological outcome, were subjected to multivariate analyses. Two hundred twenty-seven patients were treated with radiosurgery for the first time and 41 patients underwent repeated radiosurgery. Eighty-one patients presented with a history of AVM hemorrhage and 91 patients had AVMs in a periventricular location. Twenty-six patients (10%) experienced a hemorrhage following radiosurgery. Of the 268 patients, 81 (30%) experienced angiographically defined cures, and 37 (14%) experienced MR imaging-defined cures. Eighty-six patients (32%) experienced neuroimaging-defined treatment failure, and 64 underwent insufficiently long follow up. A larger AVM volume (odds ratio [OR] 0.349; p = 0.004) was associated with a decreased rate of pretreatment hemorrhage, whereas periventricular location (OR 6.358; p = 0.000) was associated with an increased rate of pretreatment hemorrhage. None of the analyzed factors was predictive of hemorrhage following radiosurgery. A higher radiosurgical dose was strongly correlated with neuroimaging-defined success (OR 3.743; p = 0.006), whereas a diffuse nidus structure (OR 0.246; p = 0.008) and associated neovascularity (OR 0.428; p = 0.048) were each associated with a lower neuroimaging-defined cure rate. A strong correlation between CT scanning and angiography was noted for both nidus structure (p = 0.000; Fisher exact test) and neovascularity (p = 0.002; Fisher exact test). CONCLUSIONS Patients presenting with AVMs that are small or periventricular were at higher risk for experiencing hemorrhage. A higher radiosurgical dose correlated strongly with neuroimaging-defined success. Patients in whom the AVM had a diffuse structure or associated neovascularity were at higher risk for neuroimaging-defined failure of radiosurgery. A strong correlation between CT scanning and angiography in the assessment of AVM structure was demonstrated.
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Affiliation(s)
- Gregory J Zipfel
- Department of Neurosurgery, University of Miami, Miami, Florida, USA
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Veznedaroglu E, Andrews DW, Benitez RP, Downes MB, Werner-Wasik M, Rosenstock J, Curran WJ, Rosenwasser RH. Fractionated Stereotactic Radiotherapy For the Treatment of Large Arteriovenous Malformations with or without Previous Partial Embolization. Neurosurgery 2004; 55:519-30; discussion 530-1. [PMID: 15335419 DOI: 10.1227/01.neu.0000134285.41701.83] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2003] [Accepted: 05/06/2004] [Indexed: 11/19/2022] Open
Abstract
AbstractOBJECTIVE:Despite the success of stereotactic radiosurgery, large inoperable arteriovenous malformations (AVMs) of 14 cm3 or more have remained largely refractory to stereotactic radiosurgery, with much lower obliteration rates. We review treatment of large AVMs either previously untreated or partially obliterated by embolization with fractionated stereotactic radiotherapy (FSR) regimens using a dedicated linear accelerator (LINAC).METHODS:Before treatment, all patients were discussed at a multidisciplinary radiosurgery board and found to be suitable for FSR. All patients were evaluated for pre-embolization. Those who had feeding pedicles amenable to glue embolization were treated. LINAC technique involved acquisition of a stereotactic angiogram in a relocatable frame that was also used for head localization during treatment. The FSR technique involved the use of six 7-Gy fractions delivered on alternate days over a 2-week period, and this was subsequently dropped to 5-Gy fractions after late complications in one of seven patients treated with 7-Gy fractions. Treatments were based exclusively on digitized biplanar stereotactic angiographic data. We used a Varian 600SR LINAC (Varian Medical Systems, Inc., Palo Alto, CA) and XKnife treatment planning software (Radionics, Inc., Burlington, MA). In most cases, one isocenter was used, and conformality was established by non-coplanar arc beam shaping and differential beam weighting.RESULTS:Thirty patients with large AVMs were treated between January 1995 and August 1998. Seven patients were treated with 42-Gy/7-Gy fractions, with one patient lost to follow-up and the remaining six with previous partial embolization. Twenty-three patients were treated with 30-Gy/5-Gy fractions, with two patients lost to follow-up and three who died as a result of unrelated causes. Of 18 evaluable patients, 8 had previous partial embolization. Mean AVM volumes at FSR treatment were 23.8 and 14.5 cm3, respectively, for the 42-Gy/7-Gy fraction and 30-Gy/5-Gy fraction groups. After embolization, 18 patients still had AVM niduses of 14 cm3 or more: 6 in the 7-Gy cohort and 12 in the 5-Gy cohort. For patients with at least 5-year follow-up, angiographically documented AVM obliteration rates were 83% for the 42-Gy/7-Gy fraction group, with a mean latency of 108 weeks (5 of 6 evaluable patients), and 22% for the 30-Gy/5-Gy fraction group, with an average latency of 191 weeks (4 of 18 evaluable patients) (P = 0.018). For AVMs that remained at 14 cm3 or more after embolization (5 of 6 patients), the obliteration rate remained 80% (4 of 5 patients) for the 7-Gy cohort and dropped to 9% for the 5-Gy cohort. A cumulative hazard plot revealed a 7.2-fold greater likelihood of obliteration with the 42-Gy/7-Gy fraction protocol (P = 0.0001), which increased to a 17-fold greater likelihood for postembolization AVMs of 14 cm3 or more (P = 0.003).CONCLUSION:FSR achieves obliteration for AVMs at a threshold dose, including large residual niduses after embolization. With significant treatment-related morbidities, further investigation warrants a need for better three-dimensional target definition with higher dose conformality.
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Affiliation(s)
- Erol Veznedaroglu
- Department of Neurosurgery, Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
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Nataf F, Ghossoub M, Schlienger M, Moussa R, Meder JF, Roux FX. Bleeding after Radiosurgery for Cerebral Arteriovenous Malformations. Neurosurgery 2004; 55:298-305; discussion 305-6. [PMID: 15271235 DOI: 10.1227/01.neu.0000129473.52172.b5] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2003] [Accepted: 03/24/2004] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
Obliteration is progressive after radiosurgery (RS) for cerebral arteriovenous malformation (AVM), and until it is complete, there is still a risk of hemorrhage. The aim of our study was to evaluate the severity of hemorrhage after RS, the actuarial risk of hemorrhage, and the parameters associated with hemorrhage.
METHODS:
Of 756 patients treated by linear accelerator RS for AVM, 51 (6.5%) had one or more hemorrhages after the RS. We studied the clinical, anatomic, and dosimetric parameters and obliteration rate before hemorrhage and then calculated the actuarial risk per patient and per hemorrhage before and after RS. Correlations between parameters and risk were studied by univariate and multivariate analysis using Kaplan-Meier hemorrhage-free survival curves and the Cox model.
RESULTS:
Apart from one exclusively ventricular hemorrhage, which caused the death of the patient, only parenchymal hemorrhages were associated with morbidity and neurological deficits (64.5% of all cases of hemorrhage had neurological deficits, 45% had a permanent deficit). The overall mortality rate per hemorrhage was 7.14%. The overall morbidity rate was 47.6%, 26.2% with a permanent deficit. In all but one patient, the AVM was not cured before hemorrhage; thus, the mean obliteration rate before hemorrhage was 24%. The actuarial hemorrhage rates were 3.08% per year per patient and 3.31% per year per hemorrhage. The actuarial rate per patient increased from 1.66% the 1st year to 3.87% in the 5th year after RS but was not statistically different from the rate before radiosurgery. The parameters found to be correlated with hemorrhage risk after RS using multivariate analysis were intranidal or paranidal aneurysms, complete coverage, and minimum dose.
CONCLUSION:
The risk of hemorrhage after RS would seem to be the sum of hemorrhage risk factors of the AVM and factors predicting a poor level of obliteration. These factors can be predicted in some cases but rarely avoided.
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Affiliation(s)
- François Nataf
- Department of Neurosurgery, Centre Hospitalier Sainte-Anne, Paris, France.
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Shin M, Maruyama K, Kurita H, Kawamoto S, Tago M, Terahara A, Morita A, Ueki K, Takakura K, Kirino T. Analysis of nidus obliteration rates after gamma knife surgery for arteriovenous malformations based on long-term follow-up data: the University of Tokyo experience. J Neurosurg 2004; 101:18-24. [PMID: 15255246 DOI: 10.3171/jns.2004.101.1.0018] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object. A large number of clinical studies have been made on treatment outcomes of radiosurgery for arteriovenous malformations (AVMs), but the reported obliteration rates following this treatment vary significantly, perhaps reflecting the different methods and timings of the imaging studies used.
Methods. The authors retrospectively analyzed their experience with gamma knife surgery in 400 patients with AVMs (follow-up period 1–135 months, median 65 months), with special reference to the imaging modality used in each case. The calculated obliteration rates varied from 68.2 to 92%, depending on imaging modality and timing of evaluation. When only unquestionable imaging data such as demonstrations of a residual nidus on computerized tomography (CT) or magnetic resonance (MR) images or findings on angiograms were used in the calculation, the obliteration rates were 72% at 3 years and 87.3% at 5 years. Factors leading to a better obliteration rate were previous hemorrhage (p = 0.0084), smaller nidus (p = 0.0023), and higher radiation dose to the lesion's margin (p = 0.0495), as determined in a multivariate analysis. Factors leading to an earlier obliteration of the nidus were male sex (p = 0.0001), previous hemorrhage (p = 0.0039), smaller nidus diameter (p = 0.0006), and dose planning using angiography alone (p = 0.0201).
Conclusions. After the introduction of CT and MR images into dose planning, the conformity and selectivity of dosimetry improved remarkably, although the latency intervals until obliteration were prolonged. Imaging outcomes for AVMs should be evaluated using data provided by longer follow-up periods. The timing of additional treatments for residual AVMs should be decided cautiously, considering the size of the AVM, the patient age and sex, and the history of hemorrhage before radiosurgery.
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Affiliation(s)
- Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan.
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Stancanello J, Cavedon C, Francescon P, Cerveri P, Ferrigno G, Colombo F, Perini S. Development and validation of a CT-3D rotational angiography registration method for AVM radiosurgery. Med Phys 2004; 31:1363-71. [PMID: 15259640 DOI: 10.1118/1.1751252] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In this paper a novel technique is proposed and validated for radiosurgery treatment planning of arteriovenous malformations (AVMs). The technique was developed for frameless radiosurgery by means of the CyberKnife, a nonisocentric, linac-based system which allows highly conformed isodose surfaces to be obtained, while also being valid for other treatment strategies. The technique is based on registration between computed tomography (CT) and three-dimensional rotational angiography (3DRA). Tests were initially performed on the effectiveness of the correction method for distortion offered by the angiographic system. These results determined the registration technique that was ultimately chosen. For CT-3DRA registration, a twelve-parameter affine transformation was selected, based on a mutual information maximization algorithm. The robustness of the algorithm was tested by attempting to register data sets increasingly distant from each other, both in translation and rotation. Registration accuracy was estimated by means of the "full circle consistency test." A registration quality index (expressed in millimeters) based on these results was also defined. A hybrid subtraction between CT and 3DRA is proposed in order to improve 3D reconstruction. Preprocessing improved the ability of the algorithm to find an acceptable solution to the registration process. The robustness tests showed that data sets must be manually prealigned within approximately 15 mm and 20 degrees with respect to all three directions simultaneously. Results of the consistency test showed agreement between the quality index and registration accuracy stated by visual inspection in 20 good and 10 artificially worsened registration processes. The quality index showed values smaller than the maximum voxel size (mean 0.8 mm compared to 2 mm) for all successful registrations, while it resulted in much greater values (mean 20 mm) for unsuccessful registrations. Once registered, the two data sets can be used for CyberKnife treatment planning. Target delineation is performed on 3DRA while dose calculation and DRR generation are performed on CT. In conclusion, a method was developed for using 3DRA images for AVM frameless radiosurgery treatment planning. The method proved to be feasible, robust, and accurate for clinical use. 3DRA can be performed at different times or locations compared to standard, frame based stereotactic angiography. Unlike two-dimensional angiography, 3DRA allows examination of the shape of the AVM and of the surrounding target from any arbitrary point of view during treatment planning. The method can be applied to any case of intermodality registration, is operator-independent, and allows estimation of registration quality. Further research is desirable to improve time resolution in order to distinguish between feeding and draining vessels.
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