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Maroufi SF, Habibi MA, Mirjani MS, Molla A, Pabarja N, Mehmandoost M, Sheehan JP, Iranmehr A. Repeat single-session stereotactic radiosurgery for arteriovenous malformation: a systematic review and meta-analysis. Neurosurg Rev 2024; 47:203. [PMID: 38702494 DOI: 10.1007/s10143-024-02438-5] [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: 02/07/2024] [Revised: 03/20/2024] [Accepted: 04/27/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Stereotactic radiosurgery is the preferred option for treating brain arteriovenous malformation (AVM) when the risks associated with surgery outweigh the potential benefits. However, some patients require repeat radiosurgery due to residual AVM after the first procedure. This systematic review and meta-analysis aimed to investigate the safety and efficacy of repeated procedure of radiosurgery for AVM. METHOD A systematic review was conducted according to the PRISMA guideline. The search was conducted on PubMed, Scopus, Embase, and Web of Science, using a pre-designed search string. Studies investigating the efficacy of repeat radiosurgery for residual AVM following initial single session radiosurgery were included. The risk of bias was assessed using the JBI tool. Meta-analysis and met-regression were performed to pool and inspect data. RESULTS Our meta-analysis, with a mean follow-up of 45.57 months, reveals repeat radiosurgery as a viable option for arteriovenous malformations (AVMs), achieving a 60.82% obliteration rate with a mean time to obliteration of 33.18 months. Meta-regression identifies AVM volume and Spetzler-Martin (SM) grade as factors influencing obliteration, with smaller volume and lower SM grades associated with higher rates. Complications include 10.33% radiation-induced changes, 5.26% post-radiosurgery hemorrhage, 2.56% neurologic deficits, and 0.67% cyst formation. Heterogeneity in complications is primarily attributed to male proportion and SM grade, while factors influencing post-radiosurgery hemorrhage remain unclear. The type of radiosurgery, whether Gamma Knife Radiosurgery (GKRS) or LINAC, does not significantly impact outcomes. CONCLUSION Repeat radiosurgery is a feasible, effective, and safe treatment for AVMs following failure of initial radiosurgery. When utilized in appropriate patient subgroups, it provides an acceptable risk-to-benefit profile. Feature studies are required to clarify its clear indications.
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Affiliation(s)
- Seyed Farzad Maroufi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran, Iran
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Amin Habibi
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Ayoob Molla
- School of Medicine, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Nafise Pabarja
- Student Research Committee, Qom University of Medical Sciences, Qom, Iran
| | - Mahdi Mehmandoost
- Student's Scientific Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, USA
| | - Arad Iranmehr
- Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
- Gamma Knife Radiosurgery Centre, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Nguyen TN. Management of Unruptured Intracranial Aneurysms and Brain Arteriovenous Malformations. Continuum (Minneap Minn) 2023; 29:584-604. [PMID: 37039411 DOI: 10.1212/con.0000000000001247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Managing a patient with an unruptured brain aneurysm or brain arteriovenous malformation (AVM) can lead to uncertainty about preventive treatment. While the bleeding risks are low, the morbidity or mortality associated with a hemorrhagic event is not insignificant. The objective of this article is to review the natural history of these vascular entities, the risk factors for hemorrhage, preventive treatment options, and the risks of treatment. LATEST DEVELOPMENTS Randomized trials to inform preventive treatment strategies for unruptured intracranial aneurysms and brain AVMs are ongoing. Higher angiographic obliteration rates of unruptured intracranial aneurysms have been reported with the flow-diversion technique compared with alternative standard techniques. One randomized trial for unruptured brain AVMs showed a higher rate of morbidity and mortality in patients who underwent interventional treatment compared with observation. ESSENTIAL POINTS The decision to treat a patient with a brain aneurysm should consider patient factors, the patient's life expectancy, aneurysm anatomical factors, and treatment risks. Patients with unruptured brain AVMs should be observed in light of recent clinical trial data or enrolled in an ongoing clinical trial.
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Kaya I, Çakır V, Cingoz ID, Atar M, Gurkan G, Sahin MC, Saygili SK, Yuceer N. Comparison of cerebral AVMs in patients undergoing surgical resection with and without prior endovascular embolization. Int J Neurosci 2021; 132:735-743. [PMID: 33866943 DOI: 10.1080/00207454.2021.1918689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM Brain arteriovenous malformations (AVMs) are congenital anomalies that present as intracranial hemorrhage or epilepsy. AVMs often remain clinically silent for extended periods. Although AVM treatment methods are controversial, three treatment strategies are usually combined or applied alone: surgical removal, embolization and stereotactic radiosurgery. We compared clinical and radiological outcomes in intracranial AVM patients treated via surgical resection with and without prior embolization. MATERIALS AND METHODS Patients who did (30 patients) and did not (30 patients) undergo endovascular embolization before surgical resection at the İzmir Katip Çelebi University Atatürk Training and Research Hospital Neurosurgery Clinic from 2011 to 2019 were included in this retrospective, cohort study. Symptoms at diagnosis, comorbidities and clinical (AVM and Spetzler-Martin grade) and morphological characteristics were assessed. RESULTS A mean one-year follow-up assessed outcomes using the modified Rankin score, and imaging studies assessed AVM obliteration post-procedure. Mean operation times for surgical resection with and without embolization were 166.50 ± 32.02 and 204.47 ± 26.66 min, respectively. Mean patient hospitalization periods for surgical resection with and without embolization were 8.43 ± 3.60 and 12.00 ± 5.51 days, respectively. CONCLUSION Among patients who underwent surgical resection, significant operation time and hospitalization time differences were observed in favor of patients who underwent embolization, indicating that preoperative embolization is a safe and beneficial method for treating ruptured and non-ruptured AVMs.
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Affiliation(s)
- Ismail Kaya
- Medical Faculty, Department of Neurosurgery, Usak University, Usak, Turkey
| | - Volkan Çakır
- Medical Faculty, Department of Interventional Radiology, Tınaztepe University, Izmir, Turkey
| | - Ilker Deniz Cingoz
- Medical Faculty, Department of Neurosurgery, Usak University, Usak, Turkey
| | - Murat Atar
- Department of Neurosurgery, Sultan 2.Abdulhamid Han Sample Training And Research Hospital, Istanbul, Turkey
| | - Gokhan Gurkan
- Medical Faculty, Department of Neurosurgery, Katip Çelebi University, Izmir, Turkey
| | - Meryem Cansu Sahin
- Training and Research Center, Kutahya Health Sciences University, Kutahya, Turkey
| | - Suna Karadeniz Saygili
- Medical Faculty, Department of Histology and Embryology, Kutahya Health Sciences University, Kutahya, Turkey
| | - Nurullah Yuceer
- Medical Faculty, Department of Neurosurgery, Katip Çelebi University, Izmir, Turkey
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Alshehri FD, Mail N, Okal F, Alzahrani A, Allehyani A, Samkari A, Alghamdi S. Assessment of Different Modalities and Their Impact on Patients with Ruptured Intracranial Arteriovenous Malformation Treated in King Abdulaiziz Medical City in Jeddah, Saudi Arabia. Cureus 2020; 12:e6969. [PMID: 32190515 PMCID: PMC7067571 DOI: 10.7759/cureus.6969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Intracranial arteriovenous malformation (AVM) is a rare congenital disease that is characterized by an abnormal tangle of blood vessels where arteries abnormally shunt into veins with no intervening capillary bed. Several treatment modalities, such as microsurgical removal, embolization, and stereotactic radiosurgery (SRS), are used to treat AVM either solely or in combination. We aimed to assess and compare the effect, morbidity, and mortality outcomes of mono-treatment with embolization and combined treatment for AVM obliteration. Methodology This retrospective cohort study was conducted in the National Guard Hospital Jeddah and reviewed all the AVM patients that visited the center between 2008 and 2017. We assessed presenting symptoms at diagnosis and any co-morbidities as the clinical characteristics and the patients’ AVM and Spetzler-Martin grade as the morphological characteristics. Moreover, we performed a three-year follow-up on suitable patients and assessed their outcomes using the modified Rankin Scale. In addition, we performed follow-up imaging on the patients to evaluate AVM obliteration after any of the procedures. Results We included 29 patients treated in our hospital (72.4%, males; 27.6%, females; mean age 40 years). About 65% of the patients underwent mono-therapy consisting of one or more embolization sessions while about 34% underwent combined treatment (embolization + surgery or embolization + SRS). We found more cases of complete obliteration among patients who underwent mono-therapy (52.6%) than among those who underwent combined treatment (30%). Patients who underwent mono-therapy showed better outcomes compared to those who underwent combined therapy; however, the difference did not reach statistical significance. Conclusions Embolization mono-therapy appears to be more effective with regards to the obliteration rate and outcome compared to combined therapy with either SRS or surgery in patients treated in our center.
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Affiliation(s)
- Fayez D Alshehri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Noor Mail
- Radiation Oncology, King Abdulaziz Medical City, Jeddah, SAU
| | - Fahad Okal
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Ahmed Alzahrani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Ahmed Allehyani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Abdulrauf Samkari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
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Patterns of Failure After Linear Accelerator Radiosurgery for Cerebral Arteriovenous Malformations. World Neurosurg 2019; 136:e141-e148. [PMID: 31874295 DOI: 10.1016/j.wneu.2019.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/07/2019] [Accepted: 12/09/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Numerous studies have assessed the predictive factors for the arteriovenous malformation (AVM) response to stereotactic radiosurgery (SRS). However, only a few have discussed the causes of failure. The aim of the present study was to evaluate the patterns of failure in patients with AVM who had undergone linear accelerator SRS. METHODS We performed a retrospective analysis of 288 patients who had undergone linear accelerator SRS in our institution from 1995 to 2011. Failure was defined from the findings of the follow-up angiogram at 5 years, with failure identified in 44 patients. The distribution of causes was estimated using a descriptive analysis of literature-based causes, including a minimal margin dose of <18 Gy, a residual nidus outside the initial targeted volume, previous embolization, recanalization, and the size of the target volume. We also analyzed the associations among the causes. RESULTS Incomplete nidus identification (41%) and previous embolization (77%) were the most frequently observed conditions in patients with failure. Patients who had undergone previous embolization, for whom the cause of failure had always been identified (P = 0.001), were younger (P = 0.004) and had had a larger nidus volume (P = 0.025). Recanalization was rare (5 of 34 patients) and had occurred exclusively in women (P = 0.048). Larger nidus volumes were less frequent (mean, 2.18 ± 2.2 cm3; range, 0.13-10.8 cm3) and had been observed mainly in women when >2 cm3 (P = 0.012). An insufficient dose was observed in 9 patients and had occurred in the case of a larger volume (P = 0.031), which had resulted in dosimetry constraints in 3 patients and treatment in the vicinity of eloquent zones in 6 patients. No known cause was found in 5 patients, 4 of whom had had a low Spetzler-Martin grade (I and II; P = 0.003), suggestive of radioresistance. CONCLUSION The results of our detailed analysis have highlighted the distribution of the causes of failure and the potential role of radioresistance in treatment failure.
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Alexander MD, Hippe DS, Cooke DL, Hallam DK, Hetts SW, Kim H, Lawton MT, Sekhar LN, Kim LJ, Ghodke BV. Targeted Embolization of Aneurysms Associated With Brain Arteriovenous Malformations at High Risk for Surgical Resection: A Case-Control Study. Neurosurgery 2019; 82:343-349. [PMID: 28419337 DOI: 10.1093/neuros/nyx167] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 03/10/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND High-risk components of brain arteriovenous malformations (BAVMs) can be targeted to reduce the risk of lesion rupture. OBJECTIVE To evaluate targeted embolization of aneurysms against other means of treatment with a case-control analysis; we previously investigated this approach associated with BAVMs. METHODS Retrospective analysis of patients with BAVMs was performed, identifying patients treated with intention to occlude only an aneurysm associated with a BAVM. For each targeted aneurysm embolization (TAE) patient identified, 4 control patients were randomly selected, controlling for rupture status, age, and Spetzler-Martin plus Lawton-Young supplemental score. Analysis was performed to compare rates of adverse events (hemorrhage, new seizure, and death) between the 2 groups. RESULTS Thirty-two patients met inclusion criteria, and 128 control patients were identified, out of 1103 patients treated during the study period. Thirty-four adverse events occurred (15 ruptures, 15 new seizures, and 11 deaths) during the follow-up period (mean 1157 d for the TAE cohort and 1036 d for the non-TAE cohort). Statistically lower associations were noted for the TAE group for any adverse event (hazard ratio 0.28, P = .037) and the composite outcome of hemorrhage or new seizure (hazard ratio 0.20, P = .029). CONCLUSION For BAVMs at high risk for surgical resection, TAE can be performed safely and effectively. Patients treated with TAE had better outcomes than matched patients undergoing other combinations of treatment. TAE can be considered for BAVMs with high operative risk prior to radiosurgery or when no other treatment options are available.
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Affiliation(s)
- Matthew D Alexander
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Daniel S Hippe
- Uni-versity Washington, Department of Radiology, Seattle, Washington
| | - Daniel L Cooke
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Danial K Hallam
- Uni-versity Washington, Department of Radiology, Seattle, Washington
| | - Steven W Hetts
- University of California San Francisco, Department of Radiology and Biomedical Imaging, San Francisco, California
| | - Helen Kim
- Univer-sity of California San Francisco, Depart-ment of Anesthesia and Perioperative Care, San Francisco, California
| | - Michael T Lawton
- University of California San Francisco, Department of Neurological Surgery, San Francisco, California
| | - Laligam N Sekhar
- University Washington, De-partment of Neurological Surgery, Seattle, Washington
| | - Louis J Kim
- University Washington, De-partment of Neurological Surgery, Seattle, Washington
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Dose Hypofractionated Stereotactic Radiotherapy for Intracranial Arteriovenous Malformations: A Case Series and Review of the Literature. World Neurosurg 2019; 126:e1456-e1467. [DOI: 10.1016/j.wneu.2019.03.119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 11/17/2022]
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Raman HS, Santanam L, Vellimana AK, Drzymala RE, Tsien CI, Zipfel GJ. Completion of Gamma Knife radiosurgery for AVM treatment after unplanned interruption-technical note. Acta Neurochir (Wien) 2018; 160:1343-1347. [PMID: 29455411 DOI: 10.1007/s00701-018-3493-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 02/10/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND IMPORTANCE Gamma Knife radiosurgery is an established technique for non-urgent treatment of various intracranial pathologies. Intra-procedural dislodgement of the stereotactic frame is an uncommon occurrence that could lead to abortion of ongoing treatment and necessitate more invasive treatment strategies. CLINICAL PRESENTATION In this case report, we describe a novel method for resumption of Gamma Knife treatment after an unplanned intra-procedural interruption. The case example involves a radiosurgical treatment of a Spetzler-Martin grade I arteriovenous malformation. CONCLUSION Our technique involves integration of scans and coordinate systems from two imaging sessions using the composite isodose line to resolve translational differences, thereby limiting delivery of remaining shots to the untreated region of the lesion. MRI follow-up at 13 months showed a reduction in the nidus size with no evidence of any radiation injury to the surrounding brain parenchyma. We believe this technique will allow care teams to effectively salvage interrupted Gamma Knife procedures and reduce progression to more invasive treatment options.
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Affiliation(s)
- Hari S Raman
- Department of Neurological Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8057, St. Louis, MO, 63110, USA
| | - Lakshmi Santanam
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Ananth K Vellimana
- Department of Neurological Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8057, St. Louis, MO, 63110, USA
| | - Robert E Drzymala
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Christina I Tsien
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Gregory J Zipfel
- Department of Neurological Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8057, St. Louis, MO, 63110, USA.
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Modern radiosurgical and endovascular classification schemes for brain arteriovenous malformations. Neurosurg Rev 2018; 43:49-58. [PMID: 29728873 DOI: 10.1007/s10143-018-0983-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/22/2018] [Accepted: 04/25/2018] [Indexed: 10/17/2022]
Abstract
Stereotactic radiosurgery (SRS) and endovascular techniques are commonly used for treating brain arteriovenous malformations (bAVMs). They are usually used as ancillary techniques to microsurgery but may also be used as solitary treatment options. Careful patient selection requires a clear estimate of the treatment efficacy and complication rates for the individual patient. As such, classification schemes are an essential part of patient selection paradigm for each treatment modality. While the Spetzler-Martin grading system and its subsequent modifications are commonly used for microsurgical outcome prediction for bAVMs, the same system(s) may not be easily applicable to SRS and endovascular therapy. Several radiosurgical- and endovascular-based grading scales have been proposed for bAVMs. However, a comprehensive review of these systems including a discussion on their relative advantages and disadvantages is missing. This paper is dedicated to modern classification schemes designed for SRS and endovascular techniques.
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Russell D, Peck T, Ding D, Chen CJ, Taylor DG, Starke RM, Lee CC, Sheehan JP. Stereotactic radiosurgery alone or combined with embolization for brain arteriovenous malformations: a systematic review and meta-analysis. J Neurosurg 2018; 128:1338-1348. [DOI: 10.3171/2016.11.jns162382] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEEmbolization of brain arteriovenous malformations (AVMs) prior to stereotactic radiosurgery (SRS) has been reported to negatively affect obliteration rates. The goal of this systematic review and meta-analysis was to compare the outcomes of AVMs treated with embolization plus SRS (E+SRS group) and those of AVMs treated with SRS alone (SRS group).METHODSA literature review was performed using PubMed to identify studies with 10 or more AVM patients and obliteration data for both E+SRS and SRS groups. A meta-analysis was performed to compare obliteration rates between the E+SRS and SRS groups.RESULTSTwelve articles comprising 1716 patients were eligible for analysis. Among the patients with radiological follow-up data, complete obliteration was achieved in 48.4% of patients (330/681) in the E+SRS group compared with 62.7% of patients (613/978) in the SRS group. A meta-analysis of the pooled data revealed that the obliteration rate was significantly lower in the E+SRS group (OR 0.51, 95% CI 0.41–0.64, p < 0.00001). Symptomatic adverse radiation effects were observed in 6.6% (27/412 patients) and 11.1% (48/433 patients) of the E+SRS and SRS groups, respectively. The annual post-SRS hemorrhage rate was 2.0%–6.5% and 0%–2.0% for the E+SRS and SRS groups, respectively. The rates of permanent morbidity were 0%–6.7% and 0%–13.5% for the E+SRS and SRS groups, respectively.CONCLUSIONSArteriovenous malformation treatment with combined embolization and SRS is associated with lower obliteration rates than those with SRS treatment alone. However, this comparison does not fully account for differences in the initial AVM characteristics in the E+SRS group as compared with those in the SRS group. Further studies are warranted to address these limitations.
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Affiliation(s)
| | | | - Dale Ding
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Ching-Jen Chen
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Davis G. Taylor
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Robert M. Starke
- 4Deparment of Neurological Surgery, University of Miami, Florida
| | - Cheng-Chia Lee
- 3Deparment of Neurological Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Jason P. Sheehan
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Feutren T, Huertas A, Salleron J, Anxionnat R, Bracard S, Klein O, Peiffert D, Bernier-Chastagner V. Modern robot-assisted radiosurgery of cerebral angiomas-own experiences, system comparisons, and comprehensive literature overview. Neurosurg Rev 2017; 41:787-797. [PMID: 29105011 DOI: 10.1007/s10143-017-0926-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 10/07/2017] [Accepted: 10/23/2017] [Indexed: 02/05/2023]
Abstract
Cerebral arteriovenous malformations (AVMs) are rare vascular lesions potentially responsible for substantial neurological morbidity and mortality. Over the past four decades, radiosurgery has become a valid therapeutic option for many patients with small intracranial AVMs, but reports describing the use of robotic stereotactic radiosurgery (SRS) are rare. The purposes of this study are to describe the efficacy and toxicity of robotic SRS for AVMs and to review the literature. The reports of 48 consecutive patients treated with SRS were reviewed. A total dose of 18 Gy in a single fraction was prescribed to the 70% isodose line. Efficacy (i.e., total obliteration of the AVM) and toxicity were analyzed. Literature search was performed on Embase and PubMed for the terms "Radiosurgery and AVMs", "Cyberknife and AVMs" and "Radiation therapy and AVMs." The median follow-up was 41 months. The median AVM volume was 2.62 cm3. The incidence of obliteration was 59% at 3 years. Regarding toxicity, 92% of patients remained symptom-free, 66% developed radiogenic edema on MRI, and none developed radionecrosis. Forty-one patients (85%) had embolization prior to SRS. Our study was incorporated in an exhaustive review of 25 trials categorized by SRS technique. In this review, the median follow-up was 60 months. The median nidus volume was 2 cm3. The median overall obliteration rate for SRS was 68% (range 36 to 92). The median embolization rate prior to SRS was 31% (range 8.23 to 90). Compared to other studies, tolerability was excellent and the obliteration rate was acceptable but probably affected by the high embolization rate prior to radiosurgery. Our study suggests that a higher dose is feasible. A larger cohort with a longer follow-up period will be needed to confirm the safety and effectiveness, and subsequently validate different prognosis and predictive scores with this treatment modality to maximize the benefits of this technology for selected patients in the long term.
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Affiliation(s)
- Thomas Feutren
- Department of Radiotherapy, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne, 54519, Vandœuvre-lès-Nancy, France.
| | - Andres Huertas
- Department of Radiotherapy, Hôpital Européen Georges Pompidou, Paris, France
| | - Julia Salleron
- Department of Biostatistics and Data Management, Institut de Cancérologie de Lorraine, Vandœuvre-lès-Nancy, France
| | - René Anxionnat
- Department of Neuroradiology, Hôpital Central CHU de Nancy, Nancy, France
| | - Serge Bracard
- Department of Neuroradiology, Hôpital Central CHU de Nancy, Nancy, France
| | - Olivier Klein
- Department of Neurosurgery, Hôpital Central CHU de Nancy, Nancy, France
| | - Didier Peiffert
- Department of Radiotherapy, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne, 54519, Vandœuvre-lès-Nancy, France
| | - Valérie Bernier-Chastagner
- Department of Radiotherapy, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne, 54519, Vandœuvre-lès-Nancy, France
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Impact of Onyx Embolization on Radiosurgical Management of Cerebral Arteriovenous Malformations: Treatment and Outcome. World Neurosurg 2017; 108:656-661. [PMID: 28890009 DOI: 10.1016/j.wneu.2017.08.188] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 08/28/2017] [Accepted: 08/30/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is a well-established treatment modality for cerebral arteriovenous malformations (AVMs). The main limiting factor in the radiosurgical treatment of AVMs is the volume of the nidus, with high-grade lesions often requiring combined treatment to reduce the SRS target volume. To overcome this limitation, we have been using a combined treatment approach consisting of endovascular embolization with Onyx followed by SRS. OBJECTIVE To evaluate our clinical experience for safety and feasibility of this multimodality treatment approach. METHODS This is a retrospective review of all adult patients with cerebral AVMs who received SRS treatment to their AVM after endovascular embolization with Onyx between June 2007 and June 2014. RESULTS Thirty-five consecutive patients were identified. The mean follow-up period was 52.4 ± 22.6 months (range 18-97 months). We confirmed 18 (51.4%) complete nidus closures at a median time of 49.5 months (range 6.5-81 months) from SRS. High-resolution Magnetic resonance imaging/magnetic resonance angiography was performed routinely in all patients until closure of the nidus. Digital subtraction angiography was performed to confirm complete obliteration in 5 of the patients (28%); 13 patients are either planned for digital subtraction angiography or have refused it. In 6 patients (17%) a significant flow reduction was noted after a mean of 32 ± 16 months. No significant improvement was observed in 9 patients (26%) during the follow-up period. Two patients were lost to follow-up. CONCLUSIONS The multimodality treatment of cerebral AVMs using embolization with Onyx followed by SRS is feasible and safe. The use of Onyx significantly reduced the SRS treatment target volume.
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Peres CMA, Souza ECD, Teixeira MJ, Figueiredo EG, Caldas JGM. Impact of Associated Nidal Lesions in Outcome of Brain Arteriovenous Malformations After Radiosurgery with or without Embolization. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Huang YJ, Hsu SW, Lee TF, Ho JT, Chen WF. Consistency between Targets Delineated by Angiography, Computed Tomography, and Magnetic Resonance Imaging in Stereotactic Radiosurgery for Arteriovenous Malformation. Stereotact Funct Neurosurg 2017; 95:236-242. [DOI: 10.1159/000469667] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 03/07/2017] [Indexed: 11/19/2022]
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Cenzato M, Boccardi E, Beghi E, Vajkoczy P, Szikora I, Motti E, Regli L, Raabe A, Eliava S, Gruber A, Meling TR, Niemela M, Pasqualin A, Golanov A, Karlsson B, Kemeny A, Liscak R, Lippitz B, Radatz M, La Camera A, Chapot R, Islak C, Spelle L, Debernardi A, Agostoni E, Revay M, Morgan MK. European consensus conference on unruptured brain AVMs treatment (Supported by EANS, ESMINT, EGKS, and SINCH). Acta Neurochir (Wien) 2017; 159:1059-1064. [PMID: 28389875 DOI: 10.1007/s00701-017-3154-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 03/13/2017] [Indexed: 11/30/2022]
Abstract
In December of 2016, a Consensus Conference on unruptured AVM treatment, involving 24 members of the three European societies dealing with the treatment of cerebral AVMs (EANS, ESMINT, and EGKS) was held in Milan, Italy. The panel made the following statements and general recommendations: (1) Brain arteriovenous malformation (AVM) is a complex disease associated with potentially severe natural history; (2) The results of a randomized trial (ARUBA) cannot be applied equally for all unruptured brain arteriovenous malformation (uBAVM) and for all treatment modalities; (3) Considering the multiple treatment modalities available, patients with uBAVMs should be evaluated by an interdisciplinary neurovascular team consisting of neurosurgeons, neurointerventionalists, radiosurgeons, and neurologists experienced in the diagnosis and treatment of brain AVM; (4) Balancing the risk of hemorrhage and the associated restrictions of everyday activities related to untreated unruptured AVMs against the risk of treatment, there are sufficient indications to treat unruptured AVMs grade 1 and 2 (Spetzler-Martin); (5) There may be indications for treating patients with higher grades, based on a case-to-case consensus decision of the experienced team; (6) If treatment is indicated, the primary strategy should be defined by the multidisciplinary team prior to the beginning of the treatment and should aim at complete eradication of the uBAVM; (7) After having considered the pros and cons of a randomized trial vs. a registry, the panel proposed a prospective European Multidisciplinary Registry.
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Affiliation(s)
- Marco Cenzato
- Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | | | - Ettore Beghi
- Neurology, Methodologist, IRCCS Istituto Mario Negri, Milan, Italy
| | - Peter Vajkoczy
- Neurosurgery, Charitè Universitatetsmedizin, Berlin, Germany
| | - Istvan Szikora
- Neuroradiology, National Institute of NeuroScience, Budapest, Hungary
| | - Enrico Motti
- Radiosurgery, Ospedale Villa Maria di Cotignola, Ravenna, Italy
| | - Luca Regli
- Neurosurgery, UniversitaetsSpital, Zurich, Switzerland
| | | | | | - Andreas Gruber
- Neurosurgery and Neuroradiology, University Hospital, Lintz, Austria
| | | | - Mika Niemela
- Neurosurgery, University Hospital, Helsinki, Finland
| | | | | | - Bengt Karlsson
- Radiosurgery, Singapore Gamma Knife Center, Singapore, Singapore
| | - Andras Kemeny
- Radiosurgery, Thornbury Radiosurgery Centre, Sheffield, UK
| | - Roman Liscak
- Radiosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Bodo Lippitz
- Radiosurgery, Bupa Cromwell Hospital, London, UK
| | | | | | - René Chapot
- Neuroradiology, Krupp Hospital, Hessen, Germany
| | - Civan Islak
- Neuroradiology, Cerrahpaşa Medical Faculty, İstanbul University, Istanbul, Turkey
| | - Laurent Spelle
- Neuroradiology, Bicetre University Hospital, Paris, France
| | | | - Elio Agostoni
- Neurology, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Martina Revay
- Neurosurgery, Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Alexander MD, Cooke DL, Hallam DK, Kim H, Hetts SW, Ghodke BV. Less can be more: Targeted embolization of aneurysms associated with arteriovenous malformations unsuitable for surgical resection. Interv Neuroradiol 2016; 22:445-51. [PMID: 27066813 DOI: 10.1177/1591019916641316] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 02/15/2016] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION To mitigate risks of hemorrhage, high-risk features of brain arteriovenous malformations (BAVMs) can be targeted to reduce the risk of rupture. Previous investigation has examined embolization of a pedicle supplying a high-risk feature; this study examines embolization targeted specifically at aneurysms associated with BAVMs. MATERIALS AND METHODS Patients with BAVMs treated at two high-volume neurointerventional services were retrospectively reviewed. Patients treated with intention to occlude only the associated aneurysm itself were analyzed. Demographic and lesion characteristics were identified, as were technical and clinical outcomes. Adverse events were defined as hemorrhage, new seizure, and death. RESULTS Thirty-two patients met inclusion criteria out of 1103 patients treated during the study period. Twenty-seven (84.4%) BAVMs were acutely ruptured, all with the aneurysm identified as the hemorrhage source. Twenty-four (75.0%) lesions involved eloquent territory. There were equal numbers of feeding artery and nidus aneurysms. Follow-up data were available for a total of 101.3 patient-years for a mean follow-up time of 2.9 years. One patient died; the remaining 31 patients had improved functional status at last contact. Annualized rate of hemorrhage after treatment was 1.0%; rate of adverse events after treatment was 3.0%. Excluding time after confirmed occlusion following radiosurgery, annualized rates were 1.4% and 4.8%, respectively. CONCLUSION In inoperable BAVMs, targeted embolization of associated aneurysms can be performed safely and effectively. This should be considered in high-risk lesions prior to radiosurgery or in cases when no other treatment options are available. Such intervention warrants further investigation.
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Affiliation(s)
- Matthew D Alexander
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, USA
| | - Daniel L Cooke
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, USA
| | | | - Helen Kim
- Department of Anesthesia and Perioperative Care, University of California San Francisco, USA
| | - Steven W Hetts
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, USA
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Cohen-Inbar O, Ding D, Chen CJ, Sheehan JP. Stereotactic radiosurgery for deep intracranial arteriovenous malformations, part 1: Brainstem arteriovenous malformations. J Clin Neurosci 2016; 24:30-6. [DOI: 10.1016/j.jocn.2015.11.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 11/21/2015] [Indexed: 11/30/2022]
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Darsaut TE, Magro E, Gentric JC, Batista AL, Chaalala C, Roberge D, Bojanowski MW, Weill A, Roy D, Raymond J. Treatment of Brain AVMs (TOBAS): study protocol for a pragmatic randomized controlled trial. Trials 2015; 16:497. [PMID: 26530856 PMCID: PMC4632683 DOI: 10.1186/s13063-015-1019-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 10/20/2015] [Indexed: 12/13/2022] Open
Abstract
Background The management of unruptured brain arteriovenous malformation (AVM) patients remains controversial. Furthermore, curative attempts to treat ruptured AVM patients have not been questioned so far, and there is a lack of prospective data on clinical results according to treatment modality. Endovascular treatment is often used aiming to improve the safety or efficacy of surgery or radiation therapy, but benefits have never been documented in a trial. A care trial context is needed to evaluate interventions at the same time they are practised. Methods/Trial design TOBAS is a pragmatic, prospective, multicenter, randomized, controlled trial and registry which offers a care trial context for brain AVM patients, including surgical resection, radiosurgery or endovascular embolization, alone or combined. The study includes two RCTs and a multimodality prospective registry. The objectives of the proposed study are to assess whether preventive interventions (surgery, embolization, radiation therapy, alone or combined), selected by the local treatment team and performed as locally practiced, randomly allocated and compared with conservative management, in unruptured brain AVM patients eligible for active or conservative management, can improve the proportion of patients having an independent outcome (modified Rankin Scale (mRS) < 3, as assessed by a standardized questionnaire administered by non-masked care personnel) at 10 years. All patients judged ineligible for randomized allocation are to be entered in a multimodal registry. The objective of a nested trial in patients with ruptured or unruptured AVMs to be treated by surgery or radiation therapy, is to assess whether pre-surgical or pre-radiation embolization, randomly allocated and compared with no embolization, can improve the proportion of patients with complete eradication of the AVM, as locally adjudicated, combined with a good clinical outcome (mRS < 3). The study will require up to 2000 patients in approximately 30 centers or more, followed for 10 years. TOBAS is registered at clinicaltrials.gov: NCT02098252 as of 25 March 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1019-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tim E Darsaut
- Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, Mackenzie Health Sciences Center, Edmonton, AB, Canada.
| | - Elsa Magro
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, QC, Canada. .,Service de Neurochirurgie, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest, France.
| | - Jean-Christophe Gentric
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada. .,Service de Radiologie, CHU Cavale Blanche, EA 3878 GETBO, Brest, France.
| | - André Lima Batista
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada.
| | - Chiraz Chaalala
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, QC, Canada.
| | - David Roberge
- Department of Radio-Oncology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, QC, Canada.
| | - Michel W Bojanowski
- Department of Surgery, Service of Neurosurgery, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Montreal, QC, Canada.
| | - Alain Weill
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada.
| | - Daniel Roy
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada.
| | - Jean Raymond
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Interventional Neuroradiology (NRI), 1560 Sherbrooke East, Pavillion Simard, room Z12909, Montreal, QC, H2L 4 M1, Canada.
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Serrone J, Zuccarello M. The role of microsurgical resection and radiosurgery for cerebral arteriovenous malformations. Methodist Debakey Cardiovasc J 2015; 10:240-4. [PMID: 25624979 DOI: 10.14797/mdcj-10-4-240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Cerebral arteriovenous malformations (AVMs) present unique challenges to cerebrovascular specialists. Management of these lesions begins with assessing their natural history. Intervention with the goal of complete obliteration requires some component of microsurgical techniques or radiosurgery. Clinicians must weigh observation and acceptance of the natural history of these lesions versus intervention on a case-by-case basis. Microsurgical resection and radiosurgery are both well-validated tools used in selectively treating cerebral AVMs. This manuscript offers a general review of the management of cerebral AVMs with multimodality treatment recommendations.
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Affiliation(s)
- Joseph Serrone
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mario Zuccarello
- University of Cincinnati College of Medicine, Cincinnati, Ohio ; Mayfield Clinic, Cincinnati, Ohio
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Sheth SA, Patel NS, Ismail AF, Freeman D, Duckwiler G, Tateshima S. Republished: Treatment of wide-necked basilar tip aneurysm not amenable to Y-stenting using the PulseRider device. J Neurointerv Surg 2015. [DOI: 10.1136/neurintsurg-2015-011836.rep] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Endovascular treatment of broad-necked bifurcation aneurysms remains challenging. Stent-assisted coiling has been successful but requires catheterization of the branches off the parent vessel. We present the case of a patient who failed primary and stent-assisted coiling of a large basilar tip aneurysm because the morphology of the aneurysm precluded successful distal catheterization of the posterior cerebral artery (PCA) branches. Using the PulseRider device, which does not require catheterization of bifurcation branches, we were able to treat the aneurysm successfully.
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21
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Sheth SA, Patel NS, Ismail AF, Freeman D, Duckwiler G, Tateshima S. Treatment of wide-necked basilar tip aneurysm not amenable to Y-stenting using the PulseRider device. BMJ Case Rep 2015. [PMID: 26199295 DOI: 10.1136/bcr-2015-011836] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Endovascular treatment of broad-necked bifurcation aneurysms remains challenging. Stent-assisted coiling has been successful but requires catheterization of the branches off the parent vessel. We present the case of a patient who failed primary and stent-assisted coiling of a large basilar tip aneurysm because the morphology of the aneurysm precluded successful distal catheterization of the posterior cerebral artery (PCA) branches. Using the PulseRider device, which does not require catheterization of bifurcation branches, we were able to treat the aneurysm successfully.
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Affiliation(s)
- Sunil A Sheth
- Division of Interventional Neuroradiology, University of California, Los Angeles, California, USA
| | - Nirav S Patel
- Long Beach Memorial Medical Center, Long Beach, California, USA
| | - Ameera F Ismail
- Long Beach Memorial Medical Center, Long Beach, California, USA
| | - Dena Freeman
- MemorialCare Research, Long Beach Memorial, Long Beach, California, USA
| | - Gary Duckwiler
- Division of Interventional Neuroradiology, University of California, Los Angeles, California, USA
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, University of California, Los Angeles, California, USA
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22
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Cohen-Inbar O, Lee CC, Xu Z, Schlesinger D, Sheehan JP. A quantitative analysis of adverse radiation effects following Gamma Knife radiosurgery for arteriovenous malformations. J Neurosurg 2015; 123:945-53. [PMID: 25909572 DOI: 10.3171/2014.10.jns142264] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors review outcomes following Gamma Knife radiosurgery (GKRS) of cerebral arteriovenous malformations (AVMs) and their correlation to postradiosurgery adverse radiation effects (AREs). METHODS From a prospective institutional review board-approved database, the authors identified patients with a minimum of 2 years of follow-up and thin-slice T2-weighted MRI sequences for volumetric analysis. A total of 105 AVM patients were included. The authors analyzed the incidence and quantitative changes in AREs as a function of time after GKRS. Statistical analysis was performed to identify factors related to ARE development and changes in the ARE index. RESULTS The median clinical follow-up was 53.8 months (range 24-212.4 months), and the median MRI follow-up was 36.8 months (range 24-212.4 months). 47.6% of patients had an AVM with a Spetzler-Martin grade ≥ III. The median administered margin and maximum doses were 22 and 40 Gy, respectively. The overall obliteration rate was 70.5%. Of patients who showed complete obliteration, 74.4% developed AREs within 4-6 months after GKRS. Late-onset AREs (i.e., > 12 months) correlated to a failure to obliterate the nidus. 58.1% of patients who developed appreciable AREs (defined as ARE index > 8) proceeded to have a complete nidus obliteration. Appreciable AREs were found to be influenced by AVM nidus volume > 3 ml, lobar location, number of draining veins and feeding arteries, prior embolization, and higher margin dose. On the other hand, a minimum ARE index > 8 predicted obliteration (p = 0.043). CONCLUSIONS ARE development after radiosurgery follows a temporal pattern peaking at 7-12 months after stereotactic radiosurgery. The ARE index serves as an important adjunct tool in patient follow-up and outcome prediction.
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Affiliation(s)
- Or Cohen-Inbar
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia;,Neurological Institute, Taipei Veteran General Hospital; and.,National Yang-Ming University, Taipei, Taiwan
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - David Schlesinger
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Abstract
Background:We report the results of a consecutive series of patients treated with Gamma Knife (GK) Surgery for cerebral arteriovenous malformations (AVMs).Methods:We retrospectively reviewed 69 patients treated with GK for cerebral AVMs between November 2003 and April 2009, recording clinical data, treatment parameters, and AVM obliteration rates in order to assess our effectiveness with GK in treating these lesions.Results:Ten patients were lost to follow-up. Presentations included: seizure (24), hemorrhage (18), persistent headache (12), progressing neurological signs (10), and incidental (9). In 24 patients (34.8%) treatment planning consisted of digital subtraction angiography (DSA), magnetic resonance imaging (MRI), and computed tomogram (CT) angiography (CTA). Currently we rely predominantly on CTA and/or MRI scanning only. Fourty-one patients have been followed for a minimum of 3 years; average age 40.9yr., 58.5% males. Average dose at the 50% isodose line was 20.3 Gy (range 16 to 26.4 Gy). Obliteration was observed in 87.8% by MRI, CT, or DSA. Not all obliteration was confirmed by DSA. Complications occurred in 12 of 59 (20.3%) patients, and in 11 of 41 (26.8%) with 3 year follow-up. Major (temporary) complications for the 59 included symptomatic cerebral edema (7), seizure (2), and hemorrhage (1). Major permanent complications occurred in one patient suffering a cranial nerve V deafferentation, and in two patients suffering a hemorrhage.Conclusion:GKS for cerebral AVM's offers an effective and safe method of treatment, with low permanent complication rate.
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Elhammady MS, Heros RC. Editorial. Management of incidental cerebral AVMs in the post-ARUBA era. J Neurosurg 2014; 121:1011-4. [DOI: 10.3171/2014.3.jns14135] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Flores BC, Klinger DR, Rickert KL, Barnett SL, Welch BG, White JA, Batjer HH, Samson DS. Management of intracranial aneurysms associated with arteriovenous malformations. Neurosurg Focus 2014; 37:E11. [DOI: 10.3171/2014.6.focus14165] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intracranial or brain arteriovenous malformations (BAVMs) are some of the most interesting and challenging lesions treated by the cerebrovascular neurosurgeon. It is generally believed that the combination of BAVMs and intracranial aneurysms (IAs) is associated with higher hemorrhage rates at presentation and higher rehemorrhage rates and thus with a more aggressive course and natural history. There is wide variation in the literature on the prevalence of BAVM-associated aneurysms (range 2.7%–58%), with 10%–20% being most often cited in the largest case series. The risk of intracranial hemorrhage in patients with unruptured BAVMs and coexisting IAs has been reported to be 7% annually, compared with 2%–4% annually for those with BAVM alone. Several different classification systems have been applied in an attempt to better understand the natural history of this combination of lesions and implications for treatment. Independent of the classification used, it is clear that a few subtypes of aneurysms have a direct hemodynamic correlation with the BAVM itself. This is exemplified by the fact that the presence of a distal flow-related or an intranidal aneurysm appears to be associated with an increased hemorrhage risk, when compared with an aneurysm located on a vessel with no direct supply to the BAVM nidus. Debate still exists regarding the etiology of the association between those two vascular lesions, the subsequent implications for patients’ risk of hemorrhagic stroke, and finally the determination of which patients warrant treatment and when. The ultimate goals of the treatment of a BAVM associated with an IA are to prevent hemorrhage, avoid stepwise neurological deterioration, and eliminate the mortality risk associated with recurrent hemorrhagic events. The treatment is only justifiable if the risks associated with an intervention are lower than or equivalent to the long-term risks of disability or mortality caused by the lesion itself. When faced with this difficult decision, a few questions need to be answered by the treating neu-rosurgeon: What is the mode of presentation? What is the symptomatic lesion? Which one of the lesions bled? What is the relationship between the BAVM and IA? Is it possible to safely treat both BAVM and IA? The objective of this review is to discuss the demographics, natural history, classification, and strategies for management of BAVMs associated with IAs.
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Affiliation(s)
- Bruno C. Flores
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Daniel R. Klinger
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kim l. Rickert
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
- 2 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samuel l. Barnett
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Babu G. Welch
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
- 2 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jonathan A. White
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
- 2 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - H. Hunt Batjer
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Duke S. Samson
- 1 Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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Nabavizadeh SA, Edgar JC, Vossough A. Utility of susceptibility-weighted imaging and arterial spin perfusion imaging in pediatric brain arteriovenous shunting. Neuroradiology 2014; 56:877-84. [DOI: 10.1007/s00234-014-1408-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 07/16/2014] [Indexed: 10/25/2022]
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Meinel FG, Fischer J, Pomschar A, Wöhrle N, Koerte IK, Steffinger D, Laubender RP, Muacevic A, Reiser MF, Alperin N, Ertl-Wagner B. MRI evidence for preserved regulation of intracranial pressure in patients with cerebral arteriovenous malformations. Eur J Radiol 2014; 83:1442-7. [PMID: 24932847 DOI: 10.1016/j.ejrad.2014.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 05/06/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of this study was to investigate intracranial pressure and associated hemo- and hydrodynamic parameters in patients with cerebral arteriovenous malformations AVMs. METHODS Thirty consecutive patients with arteriovenous malformations (median age 38.7 years, 27/30 previously treated with radiosurgery) and 30 age- and gender-matched healthy controls were investigated on a 3.0T MR scanner. Nidus volume was quantified on dynamic MR angiography. Total arterial cerebral blood flow (tCBF), venous outflow as well as aqueductal and craniospinal stroke volumes were obtained using velocity-encoded cine-phase contrast MRI. Intracranial volume change during the cardiac cycle was calculated and intracranial pressure (ICP) was derived from systolic intracranial volume change (ICVC) and pulse pressure gradient. RESULTS TCBF was significantly higher in AVM patients as compared to healthy controls (median 799 vs. 692 mL/min, p=0.007). There was a trend for venous flow to be increased in both the ipsilateral internal jugular vein (IJV, 282 vs. 225 mL/min, p=0.16), and in the contralateral IJV (322 vs. 285 mL/min, p=0.09), but not in secondary veins. There was no significant difference in median ICP between AVM patients and control subjects (6.9 vs. 8.6 mmHg, p=0.30) and ICP did not correlate with nidus volume in AVM patients (ρ=-0.06, p=0.74). There was a significant positive correlation between tCBF and craniospinal CSF stroke volume (ρ=0.69, p=0.02). CONCLUSIONS The elevated cerebral blood flow in patients with AVMs is drained through an increased flow in IJVs but not secondary veins. ICP is maintained within ranges of normal and does not correlate with nidus volume.
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Affiliation(s)
- Felix G Meinel
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Judith Fischer
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Andreas Pomschar
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Natalie Wöhrle
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Inga K Koerte
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Denise Steffinger
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Rüdiger P Laubender
- Institute of Medical Informatics, Biometry and Epidemiology, Ludwig-Maximilians-University, Marchioninistr. 15, 81377 Munich, Germany
| | | | - Maximilian F Reiser
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Noam Alperin
- Department of Radiology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Birgit Ertl-Wagner
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany.
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Wang YC, Huang YC, Chen HC, Wei KC, Chang CN, Lee ST, Wu CT, Tseng CK, Wang CC, Chen YL, Hsu PW. Linear accelerator stereotactic radiosurgery in the management of intracranial arteriovenous malformations: long-term outcome. Cerebrovasc Dis 2014; 37:342-9. [PMID: 24941898 DOI: 10.1159/000360756] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 02/18/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Arteriovenous malformation (AVM) is one of the cerebrovascular diseases that bear a high risk of hemorrhage. The treatment modalities include microsurgical resection, endovascular embolization, stereotactic radiosurgery, or combinations that vary widely. Several large series have been reported, while data from Asian populations were few. The aim of this study was to examine the efficacy of linear accelerator stereotactic radiosurgery (LINAC SRS) for the treatment of intracranial AVMs, to evaluate the hemorrhage rate and to analyze associated factors. METHODS One hundred and sixteen patients with AVM were treated with LINAC SRS in a single institute between September 1994 and May 2005 and were retrospectively evaluated. The demographics of patients, clinical characteristics of AVM, the treatment modalities, and the parameters of the LINAC SRS were analyzed. Delayed toxicity and hemorrhage rate after treatment were also evaluated. The AVM obliteration and bleed rates were calculated using the Kaplan-Meier method and Cox regression analyses. RESULTS The efficacy rate with total obliteration after treatment was 81.9% (95 of 116 patients). The median interval to achieve total obliteration was 49 months. Microsurgical resection combined with SRS for residual AVMs achieved better obliteration rates compared to SRS alone (statistically significant, p = 0.001), while no significant difference was found between the embolization group and the group with no prior treatment (p = 0.895). The Spetzler-Martin grade of AVM is a relative factor of obliteration, higher grades resulting in a worse outcome (p = 0.009). Obliteration was significantly influenced by AVM volume in univariate analysis (p = 0.034), and volume <5 cm(3) contributed to improved obliteration (p = 0.01). There was no statistically significant difference in the hemorrhagic rate and the complication rate between ruptured and unruptured AVMs, while the unruptured group had a higher obliteration rate (p = 0.024). The annual hemorrhage rate after LINAC SRS treatment was 1.9%. The bleeding rate was 3.3% in the first year after radiosurgery, 2.1% in the second year, 1.9% between the second and fifth year, and 1.5% between the fifth and tenth year. Patients with hemorrhagic events before radiosurgery appeared to have a higher rebleeding risk during the latency period. Twenty-three patients (19.8%) had late adverse effects with regard to posttreatment radiological follow-up, but only 1 (0.8%) had newly developed neurological deficits. CONCLUSION LINAC SRS achieved a high obliteration rate and reduced the risk of hemorrhage effectively in ruptured and unruptured intracranial AVMs. Prior microsurgical resection provided better outcome, while embolization showed no benefit. Adverse effects after treatment are acceptable and require long-term follow-up.
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Affiliation(s)
- Yu-Chi Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan, ROC
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Hattangadi-Gluth JA, Chapman PH, Kim D, Niemierko A, Bussière MR, Stringham A, Daartz J, Ogilvy C, Loeffler JS, Shih HA. Single-Fraction Proton Beam Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations. Int J Radiat Oncol Biol Phys 2014; 89:338-46. [DOI: 10.1016/j.ijrobp.2014.02.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 02/13/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
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Sheehan JP, Starke RM. Aneurysm formation associated with ionizing radiation. World Neurosurg 2013; 81:487-9. [PMID: 24215869 DOI: 10.1016/j.wneu.2013.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 11/02/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
| | - Robert M Starke
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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Kalani MYS, Albuquerque FC, Fiorella D, McDougall CG. Endovascular Treatment of Cerebral Arteriovenous Malformations. Neuroimaging Clin N Am 2013; 23:605-24. [DOI: 10.1016/j.nic.2013.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Starke RM, Yen CP, Ding D, Sheehan JP. A practical grading scale for predicting outcome after radiosurgery for arteriovenous malformations: analysis of 1012 treated patients. J Neurosurg 2013; 119:981-7. [DOI: 10.3171/2013.5.jns1311] [Citation(s) in RCA: 162] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors performed a study to review outcomes following Gamma Knife radiosurgery for cerebral arteriovenous malformations (AVMs) and to create a practical scale to predict long-term outcome.
Methods
Outcomes were reviewed in 1012 patients who were followed up for more than 2 years. Favorable outcome was defined as AVM obliteration and no posttreatment hemorrhage or permanent, symptomatic, radiation-induced complication. Preradiosurgery patient and AVM characteristics predictive of outcome in multivariate analysis were weighted according to their odds ratios to create the Virginia Radiosurgery AVM Scale.
Results
The mean follow-up time was 8 years (range 2–20 years). Arteriovenous malformation obliteration occurred in 69% of patients. Postradiosurgery hemorrhage occurred in 88 patients, for a yearly incidence of 1.14%. Radiation-induced changes occurred in 387 patients (38.2%), symptoms in 100 (9.9%), and permanent deficits in 21 (2.1%). Favorable outcome was achieved in 649 patients (64.1%). The Virginia Radiosurgery AVM Scale was created such that patients were assigned 1 point each for having an AVM volume of 2–4 cm3, eloquent AVM location, or a history of hemorrhage, and 2 points for having an AVM volume greater than 4 cm3. Eighty percent of patients who had a score of 0–1 points had a favorable outcome, as did 70% who had a score of 2 points and 45% who had a score of 3–4 points. The Virginia Radiosurgery AVM Scale was still predictive of outcome after controlling for predictive Gamma Knife radiosurgery treatment parameters, including peripheral dose and number of isocenters, in a multivariate analysis. The Spetzler-Martin grading scale and the Radiosurgery-Based Grading Scale predicted favorable outcome, but the Virginia Radiosurgery AVM Scale provided the best assessment.
Conclusions
Gamma Knife radiosurgery can be used to achieve long-term AVM obliteration and neurological preservation in a predictable fashion based on patient and AVM characteristics.
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Schwyzer L, Yen CP, Evans A, Zavoian S, Steiner L. Long-term results of gamma knife surgery for partially embolized arteriovenous malformations. Neurosurgery 2013; 71:1139-47; discussion 1147-8. [PMID: 22986603 DOI: 10.1227/neu.0b013e3182720280] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The effectiveness and risk of gamma knife surgery (GKS) in the management of partially embolized cerebral arteriovenous malformations (AVMs) remain to be elucidated. OBJECTIVE To evaluate the long-term imaging and clinical outcomes of GKS in AVM patients who had undergone previous partial embolization and compare the results with patients treated with GKS alone. METHODS A total of 215 embolized AVMs were analyzed. The mean patient age was 32.9 years. The mean volume of the nidus was 4.6 mL (range, 0.1-29.4 mL), and the mean prescription dose was 19.6 Gy (range, 4-28 Gy). This group was compared with 729 nonembolized AVMs. RESULTS After embolization and GKS, angiographically confirmed total obliteration of the AVMs was significantly lower (33%) compared with patients in whom GKS was used alone (60.9%; P < .001). However, the mean nidus size was larger and the Spetzler-Martin grade was higher for the embolized AVMs compared with the nonembolized AVMs. Radiation-induced changes occurred more often in the embolized (43.4%) than the nonembolized (33.4%) AVMs (P = .028). Permanent neurological deficits associated with radiation-induced changes occurred in 2.7% of the embolized compared with 1.3% of the nonembolized patients (P = .14). CONCLUSION In our retrospective and historical series, the long-term results suggest that the obliteration rate is significantly lower in embolized AVMs compared with nonembolized AVMs, also because of the fact that the combined treatment is applied to higher grade AVMs; the percentage of grade III-V AVMs was 58.6% and 48.8% for nonembolized AVMs.
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Affiliation(s)
- Lucia Schwyzer
- Lars Leksell Center for Gamma Surgery, Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia 22908, USA.
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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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Preuss M, Hirsch W, Hoffmann KT, Bernhard MK, Siekmeyer M, Kiess W, Meixensberger J, Wurm RE, Merkenschlager A. Effectiveness of bevacizumab for radiation-induced cerebral necrosis in children. Pediatr Neurosurg 2013; 49:81-5. [PMID: 24435068 DOI: 10.1159/000357447] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 11/15/2013] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Bevacizumab has been reported to effectively reduce cerebral edema caused by radiation therapy. However, only limited data with a short follow-up in tumor patients are available so far. PATIENTS AND METHODS Two children suffering from hemorrhage from arteriovenous malformation (AVM) have been treated with stereotactic radiotherapy and developed radiation-induced cerebral edema with deteriorating neurological status despite maximized steroid therapy. Bevacizumab administration at 5 mg/kg body weight was initiated every 2 weeks. RESULTS Bevacizumab treatment rapidly ameliorated the neurological deficits, malignant edema and prevented catastrophic complications. Corticoid therapy could be reduced and discontinued. However, after 18 months, both patients showed identical or worse neurological status than before bevacizumab therapy. AVM radiation therapy had been successful to completely obliterate AVMs. DISCUSSION In our limited experience, bevacizumab may be an effective and safe option for rescue therapy for malignant cerebral edema on the basis of radiation-induced necrosis especially in patients who experience rapid deterioration despite corticoid therapy and/or intolerable steroid side effects. Despite the fact that functional improvement could not be achieved in long-term outcome patients significantly stabilized and improved during periods of acute deterioration. In order to determine the long-term effectiveness of bevacizumab further investigation in placebo-controlled studies with a higher number of patients are required.
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Affiliation(s)
- M Preuss
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
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Planned Two-Fraction Proton Beam Stereotactic Radiosurgery for High-Risk Inoperable Cerebral Arteriovenous Malformations. Int J Radiat Oncol Biol Phys 2012; 83:533-41. [DOI: 10.1016/j.ijrobp.2011.08.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 07/22/2011] [Accepted: 08/08/2011] [Indexed: 11/23/2022]
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Application of susceptibility weighted imaging (SWI) for evaluation of draining veins of arteriovenous malformation: utility of magnitude images. Neuroradiology 2012; 54:1221-7. [DOI: 10.1007/s00234-012-1029-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 03/09/2012] [Indexed: 11/26/2022]
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See AP, Raza S, Tamargo RJ, Lim M. Stereotactic radiosurgery of cranial arteriovenous malformations and dural arteriovenous fistulas. Neurosurg Clin N Am 2012; 23:133-46. [PMID: 22107864 DOI: 10.1016/j.nec.2011.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Cranial arteriovenous malformations (AVM) and cranial dural arteriovenous fistulas (AVF) carry a significant risk of morbidity and mortality when they hemorrhage. Current treatment options include surgery, embolization, radiosurgery, or a combination of these treatments. Radiosurgery is thought to reduce the risk hemorrhage in AVMs and AVFs by obliterating of the nidus of abnormal vasculature over the course of 2 to 3 years. Success in treating AVMs is variable depending on the volume of the lesion, the radiation dose, and the pattern of vascular supply and drainage. This article discusses the considerations for selecting radiosurgery as a treatment modality in patients who present with AVMs and AVFs.
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Affiliation(s)
- Alfred P See
- Department of Neurosurgery, The Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287, USA
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Gerigk L, Schmitt B, Stieltjes B, Röder F, Essig M, Bock M, Schlemmer HP, Röthke M. 7 tesla imaging of cerebral radiation necrosis after arteriovenous malformations treatment using amide proton transfer (APT) imaging. J Magn Reson Imaging 2012; 35:1207-9. [DOI: 10.1002/jmri.23534] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 11/11/2011] [Indexed: 11/06/2022] Open
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Colby GP, Coon AL, Huang J, Tamargo RJ. Historical Perspective of Treatments of Cranial Arteriovenous Malformations and Dural Arteriovenous Fistulas. Neurosurg Clin N Am 2012; 23:15-25. [DOI: 10.1016/j.nec.2011.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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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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Zhao J, Yu T, Wang S, Zhao Y, Yang WY. Surgical treatment of giant intracranial arteriovenous malformations. Neurosurgery 2011; 67:1359-70; discussion 1370. [PMID: 20948402 DOI: 10.1227/neu.0b013e3181eda216] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The treatment of giant arteriovenous malformations (AVMs) remains a challenge in the neurosurgical field. Microsurgery is one of the most effective ways for eliminating giant cerebral AVMs. OBJECTIVE To review surgical outcomes in treating the disease, and form conclusions regarding the indications for and outcomes of surgical treatment in giant intracranial AVMs. METHODS We studied 40 consecutive cases of giant AVMs treated in Beijing Tiantan Hospital between 2000 and 2008. The radiologic and clinical features were analyzed. The Spetzler-Martin grading system was used to classify the patients. All patients were surgically treated, and the final outcomes of the patients were gathered for analysis. RESULTS The major presenting symptoms were seizures, headaches, hemorrhage, and neurological deficits. The mean AVM diameter was 6.3 cm. According to the Spetzler-Martin grading system, 5 patients had grade III lesions, 21 had grade IV lesions, and 14 had grade V lesions. Out of the total 40 patients, 31 (77.5%) demonstrated excellent or good outcome. Complications included hemiparalysis, aphasia, hemianopia, cranial nerve dysfunction, and seizures. After follow-up, 27 of 30 (90%) surviving patients presented normal function or minimal symptoms. CONCLUSION Presurgical evaluation of every candidate and treatment choice is the determining factor in therapy for giant AVMs. For giant cerebral AVMs located superficially or not involving critical components, a good outcome can be expected through surgical resection. The obliteration and recurrence rates were satisfying, and the complication rate was acceptable.
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Affiliation(s)
- Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Koga T, Shin M, Terahara A, Saito N. Outcomes of Radiosurgery for Brainstem Arteriovenous Malformations. Neurosurgery 2011; 69:45-51; discussion 51-2. [DOI: 10.1227/neu.0b013e31821421d1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND:
Arteriovenous malformations (AVMs) in the brainstem yield a high risk of hemorrhage. Although stereotactic radiosurgery (SRS) is accepted, because of high surgical morbidity and mortality, outcomes are still unclear.
OBJECTIVE:
We previously reported the early results of SRS for brainstem AVMs. Here, we obtained data from a longer follow-up for a larger number of patients and present precise outcomes based on the latest follow-up data.
METHODS:
Forty-four patients with brainstem AVMs were treated by SRS. Outcomes such as the rates of obliteration, hemorrhage after treatment, and adverse effects were retrospectively analyzed.
RESULTS:
The annual hemorrhage rate before SRS was 17.5%. The mean follow-up period after SRS was 71 months (range, 2-168 months). The actuarial obliteration rate confirmed by angiography was 52% at 5 years. Factors associated with higher obliteration rate were previous hemorrhage (P = .048) and higher margin dose (P = .048). For patients treated with a margin dose of ≥ 18 Gy, the obliteration rate was 71% at 5 years. Persistent worsening of neurological symptoms was observed in 5%. The annual hemorrhage rate after SRS was 2.4%. Four patients died of rebleeding, and disease-specific survival rate was 86% at 10 years after treatment.
CONCLUSION:
Nidus obliteration must be achieved for brainstem AVMs because they possibly cause lethal hemorrhage even after SRS. Treatment with a high margin dose is desirable to obtain favorable outcomes for these lesions. Additional treatment should be considered for an incompletely obliterated nidus.
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Affiliation(s)
- Tomoyuki Koga
- Departments of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
| | - Masahiro Shin
- Departments of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
| | - Atsuro Terahara
- Departments of Radiology, University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Departments of Neurosurgery, University of Tokyo Hospital, Tokyo, Japan
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Strahlentherapie bei arteriovenösen Malformationen assoziierten Epilepsien. ZEITSCHRIFT FUR EPILEPTOLOGIE 2010. [DOI: 10.1007/s10309-010-0135-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Koga T, Shin M, Maruyama K, Terahara A, Saito N. Long-term Outcomes of Stereotactic Radiosurgery for Arteriovenous Malformations in the Thalamus. Neurosurgery 2010; 67:398-403. [PMID: 20644425 DOI: 10.1227/01.neu.0000371989.90956.6f] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Arteriovenous malformations (AVMs) in the thalamus carry a high risk of hemorrhage. Although stereotactic radiosurgery (SRS) is widely accepted because of the high surgical morbidity and mortality of these lesions, precise long-term outcomes are largely unknown.
OBJECTIVE
To review our experience with SRS for thalamic AVMs based on the latest follow-up data.
METHODS
Forty-eight patients with thalamic AVMs were treated by SRS using the Leksell Gamma Knife and were followed. Long-term outcomes including the obliteration rate, hemorrhage after treatment, and adverse effects were retrospectively analyzed.
RESULTS
The annual hemorrhage rate before SRS was 14%. The mean follow-up period after SRS was 66 months (range 6–198 months). The actuarial obliteration rate confirmed by angiography was 82% at 5 years after treatment, and the annual hemorrhage rate after SRS was 0.36%. Factors associated with higher obliteration rates were previous hemorrhage (P = .004) and treatment using new planning software (P = .001). Persistent worsening of neurological symptoms was observed in 17% and more frequently seen in patients who were treated using older planning software (P = .04) and a higher margin dose (P = .02). The morbidity rate for patients who received treatment planned using new software with a margin dose not more than 20 Gy was 12%.
CONCLUSION
SRS for thalamic AVMs achieved a high obliteration rate and effectively decreased the risk of hemorrhage, with less morbidity compared with other modalities. Longer follow-up to evaluate the risk of delayed complications and the effort to minimize the morbidity is necessary.
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Affiliation(s)
- Tomoyuki Koga
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Keisuke Maruyama
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Atsuro Terahara
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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Sun DQ, Carson KA, Raza SM, Batra S, Kleinberg LR, Lim M, Huang J, Rigamonti D. The radiosurgical treatment of arteriovenous malformations: obliteration, morbidities, and performance status. Int J Radiat Oncol Biol Phys 2010; 80:354-61. [PMID: 20400239 DOI: 10.1016/j.ijrobp.2010.01.049] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 01/26/2010] [Accepted: 01/31/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study examined the single-center treatment outcomes of arteriovenous malformations (AVMs) of the brain using stereotactic radiosurgery, with regard to obliteration, predictive factors, morbidities, and patient performance status. PATIENTS AND METHODS 127 patients were treated between 1990 and 2008 by use of linear accelerator or Gamma Knife. Their median age was 37 years, the median AVM volume was 7.3 cc (range, 0.014-113.13 cc), and the median follow-up duration was 42 months (range, 6-209 months). Forty-two percent of patients presented with intracranial hemorrhage, 31% received embolization, and 8% underwent prior resection. Thirty-one percent of patients received more than one round of radiosurgery. RESULTS 64% of patients had complete obliteration confirmed by magnetic resonance imaging or angiography. Positive predictors of obliteration included pretreatment hemorrhage (p = 0.042), smaller AVM volume (odds ratio = 1.25; 95% CI, 1.03-1.52), and larger marginal dose (odds ratio = 0.292; 95% CI, 0.100-0.820), whereas embolization (p < 0.001) was a negative predictor . The annual risk of hemorrhage after radiosurgery was 2.2%, and the risk of death as a result of hemorrhage was 0.6-1.3%. Eleven percent of patients reported new or worsened neurologic symptoms. Radiosurgery was effective in treating AVM-related headaches (p < 0.001) but did not improve the performance status of patients. CONCLUSIONS Stereotactic radiosurgery is an effective tool in the treatment of AVMs and amelioration of AVM-related headaches, but it did not affect the patients' performance status. Factors affecting obliteration include prior hemorrhage, marginal dose, prior embolization, and AVM volume. Risk of hemorrhage persists in the latency period after radiosurgery, and it remains finite even after complete obliteration.
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Affiliation(s)
- Daniel Q Sun
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD, USA
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Hernesniemi J, Romani R, Lehecka M, Isarakul P, Dashti R, Celik O, Navratil O, Niemelä M, Laakso A. Present state of microneurosurgery of cerebral arteriovenous malformations. ACTA NEUROCHIRURGICA. SUPPLEMENT 2010; 107:71-6. [PMID: 19953374 DOI: 10.1007/978-3-211-99373-6_11] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Microneurosurgical excision is known to be the definitive treatment for brain arteriovenous malformation (AVMs). The most important factors governing the operability of an AVM are location, size, age of the patient, and the neurosurgeon's and team's experience. We present in this review the surgical experience of the senior author (JH) in microneurosurgical treatment of brain AVMs. This consists of the following steps: (1) accurate preoperative embolization; (2) optimal selection of the surgical approach; (3) accurate definition and preservation of the normal arterial vessels of passage; (4) temporary clipping of the feeding arteries; (5) a special method of coagulation called "dirty coagulation" of the deep small difficult vessels inside apparently normal brain around the AVM; (6) removal of all AVM; (7) meticulous hemostasis; (8) intra- and postoperative digital subtraction angiography (DSA); (9) clinical and radiological follow-up. These steps are not possible in AVMs lying entirely within central eloquent areas. Nine out of ten small- and medium-sized arteriovenous malformations (AVMs) are suitable for direct surgery, but surgical complications increase drastically with the size of the AVM. Nevertheless, the actual results of combined treatment with preoperative Onyx embolization followed by microsurgery have decreased these risks.
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Affiliation(s)
- Juha Hernesniemi
- Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland.
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External beam radiotherapy in the treatment of extensive vascular malformation of the lower extremity refractory to surgery and interventional embolisation therapy. JOURNAL OF RADIOTHERAPY IN PRACTICE 2009. [DOI: 10.1017/s1460396909990069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractThis patient case-study represents the introduction of radiotherapy in the management of extra-cranial vascular malformations, a topic with virtually no supported literature before our case study. In those patients refractory to established therapies and facing the inevitability of mutilating amputation, radiotherapy may be a viable option to preserve the limb.
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Achrol AS, Guzman R, Varga M, Adler JR, Steinberg GK, Chang SD. Pathogenesis and radiobiology of brain arteriovenous malformations: implications for risk stratification in natural history and posttreatment course. Neurosurg Focus 2009; 26:E9. [PMID: 19409010 DOI: 10.3171/2009.2.focus0926] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Brain arteriovenous malformations (BAVMs) are an important cause of intracerebral hemorrhage (ICH) in young adults. Biological predictors of future ICH risk are lacking, and controversy exists over previous studies of natural history risk among predominantly ruptured BAVM cohorts. Recent studies have suggested that the majority of BAVMs are now diagnosed as unruptured lesions, and that the risk according to natural history among these lesions may be less than previously assumed. In the first part of this review, the authors discuss available data on the natural history of BAVMs and highlight the need for future studies that aim to develop surrogate biomarkers of disease progression that accurately predict future risk of ICH in BAVMs. The etiology of BAVM remains unknown. Recent studies have suggested a role for genetic factors in the pathogenesis of sporadic BAVM, which is further supported by reports of familial occurrence of BAVM and association with known systemic genetic disorders (such as Osler-Weber-Rendu disease, Sturge-Weber disease, and Wyburn-Mason syndrome). Molecular characterization of BAVM tissue demonstrates a highly angiogenic milieu with evidence of increased endothelial cell turnover. Taken together with a number of reports of de novo BAVM formation, radiographic growth after initial BAVM diagnosis, and regrowth after successful treatment of BAVM, these findings challenge the long-held assumption that BAVMs are static lesions of congenital origin. In the second part of this review, the authors discuss available data on the origins of BAVM and offer insights into future investigations into genetics and endothelial progenitor cell involvement in the pathogenesis of BAVM. Current treatment options for BAVM focus on removal or obliteration of the lesion in an attempt to protect against future ICH risk, including microsurgical resection, endovascular embolization, and stereotactic radiosurgery (SRS). In the third part of this review, the authors discuss available data on SRS in BAVMs and highlight the need for future studies on the radiobiology of BAVMs, especially in regard to biomarker detection for tracking SRS response during the latency period. Insights from future investigations in BAVM may not only prove important for the development of novel therapies and relevant biomarkers for BAVM, but could also potentially benefit a variety of other disorders involving new vessel formation in the CNS, including stroke, tumors, moyamoya disease, and other cerebrovascular malformations.
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Affiliation(s)
- Achal S Achrol
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305-5487, USA
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Surgical Management of Acute Intracranial Hemorrhage, Surgical Aneurysmal and Arteriovenous Malformation Ablation, and Other Surgical Principles. Neurol Clin 2008; 26:987-1005, ix. [DOI: 10.1016/j.ncl.2008.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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