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Taguchi A, Ohba S, Taniyama D, Kuraoka K, Yamasaki F. A chronic encapsulated expanding hematoma that developed 15 years after gamma knife surgery for a cerebral arteriovenous malformation: A case report and review of the literature. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:40-45. [PMID: 34998491 DOI: 10.1016/j.neucie.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 09/30/2020] [Indexed: 06/14/2023]
Abstract
We report a case of gamma knife surgery (GKS)-induced chronic encapsulated expanding hematoma with extensive literature review. A 17-year-old young man underwent GKS after embolization for arteriovenous malformation (AVM) in the right frontal lobe and the AVM completely disappeared. He developed a generalized convulsion 15 years after GKS. MRI showed a small oedematous change at the AVM site. His epileptic seizure was controlled with anticonvulsant. His epilepsy recurred after three years, and MRI revealed an intracerebral hematoma with extensive surrounding edema at the same lesion. He underwent cerebral angiography and a recurrence of AVM was prevented. The hematoma was surgically removed, and intraoperative finding confirmed an old hematoma with a capsule and capillary hyperplasia, without developing cavernous angioma. The final diagnosis was a secondary chronic encapsulated expanding hematoma after GKS. This is the first report to show the early-stage imaging findings of this late effect after GKS.
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Affiliation(s)
- Akira Taguchi
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi, Minamiku, Hiroshima, Japan
| | - Shinji Ohba
- Department of Neurosurgery, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Aoyama-cho, Kureshi, Hiroshima, Japan
| | - Daiki Taniyama
- Department of Molecular Pathology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi, Minamiku, Hiroshima, Japan
| | - Kazuya Kuraoka
- Department of Diagnostic Pathology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, 3-1, Aoyama-cho, Kureshi, Hiroshima 737-0023, Japan
| | - Fumiyuki Yamasaki
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi, Minamiku, Hiroshima, Japan.
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2
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Shimizu A, Yamaguchi K, Okada Y, Funatsu T, Ishikawa T, Hayashi M, Tamura N, Horiba A, Kawamata T. Results of surgical treatment after Gamma Knife radiosurgery for cerebral arteriovenous malformations: patient series. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE21181. [PMID: 35855079 PMCID: PMC9245776 DOI: 10.3171/case21181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 04/01/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Gamma Knife radiosurgery (GKRS) is a safe and effective treatment, but it has a risk of bleeding. Herein, the authors describe their experience with some patients who required surgical removal of cerebral arteriovenous malformations (AVMs) located mainly in eloquent areas of the brain after GKRS, and they consider the advantages of surgical removal after GKRS. OBSERVATIONS Twelve patients who had undergone surgical removal of AVMs after GKRS at Tokyo Women’s Medical University between April 2013 and July 2019 were selected for analysis. All participants underwent GKRS as first-line therapy for AVMs located in an eloquent region or if requested by the patient. Complete obliteration was achieved in 7 patients, and the size of the nidus decreased in 3 patients during the follow-up period. The Spetzler-Martin grade decreased in 11 patients. Three patients experienced symptomatic intracerebral hemorrhage before and after confirmation of complete obliteration of the nidus via GKRS, and 7 patients experienced some neurological deficits because of an encapsulated expanding hematoma. All patients underwent resection of the nidus without complications. The preoperative neurological deficits improved in 6 patients and remained unchanged in 6 patients. LESSONS This report indicates that performing GKRS before surgery may be useful for future multimodal therapy.
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Affiliation(s)
- Atsushi Shimizu
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Koji Yamaguchi
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yoshikazu Okada
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Takayuki Funatsu
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Tatsuya Ishikawa
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Motohiro Hayashi
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Noriko Tamura
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Ayako Horiba
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
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Taguchi A, Ohba S, Taniyama D, Kuraoka K, Yamasaki F. A chronic encapsulated expanding hematoma that developed 15 years after gamma knife surgery for a cerebral arteriovenous malformation: A case report and review of the literature. Neurocirugia (Astur) 2020; 33:S1130-1473(20)30131-7. [PMID: 33317925 DOI: 10.1016/j.neucir.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 09/30/2020] [Indexed: 11/22/2022]
Abstract
We report a case of gamma knife surgery (GKS)-induced chronic encapsulated expanding hematoma with extensive literature review. A 17-year-old young man underwent GKS after embolization for arteriovenous malformation (AVM) in the right frontal lobe and the AVM completely disappeared. He developed a generalized convulsion 15 years after GKS. MRI showed a small oedematous change at the AVM site. His epileptic seizure was controlled with anticonvulsant. His epilepsy recurred after three years, and MRI revealed an intracerebral hematoma with extensive surrounding edema at the same lesion. He underwent cerebral angiography and a recurrence of AVM was prevented. The hematoma was surgically removed, and intraoperative finding confirmed an old hematoma with a capsule and capillary hyperplasia, without developing cavernous angioma. The final diagnosis was a secondary chronic encapsulated expanding hematoma after GKS. This is the first report to show the early-stage imaging findings of this late effect after GKS.
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Affiliation(s)
- Akira Taguchi
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi, Minamiku, Hiroshima, Japan
| | - Shinji Ohba
- Department of Neurosurgery, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Aoyama-cho, Kureshi, Hiroshima, Japan
| | - Daiki Taniyama
- Department of Molecular Pathology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi, Minamiku, Hiroshima, Japan
| | - Kazuya Kuraoka
- Department of Diagnostic Pathology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, 3-1, Aoyama-cho, Kureshi, Hiroshima 737-0023, Japan
| | - Fumiyuki Yamasaki
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi, Minamiku, Hiroshima, Japan.
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4
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Hasegawa H, Yamamoto M, Shin M, Barfod BE. Gamma Knife Radiosurgery For Brain Vascular Malformations: Current Evidence And Future Tasks. Ther Clin Risk Manag 2019; 15:1351-1367. [PMID: 31819462 PMCID: PMC6874113 DOI: 10.2147/tcrm.s200813] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 10/22/2019] [Indexed: 12/25/2022] Open
Abstract
Gamma Knife radiosurgery (GKRS) has long been used for treating brain vascular malformations, including arteriovenous malformations (AVMs), dural arteriovenous fistulas (DAVFs), and cavernous malformations (CMs). Herein, current evidence and controversies regarding the role of stereotactic radiosurgery for vascular malformations are described. 1) It has already been established that GKRS achieves 70–85% obliteration rates after a 3–5-year latency period for small to medium-sized AVMs. However, late radiation-induced adverse events (RAEs) including cyst formation, encapsulated hematoma, and tumorigenesis have recently been recognized, and the associated risks, clinical courses, and outcomes are under investigation. SRS-based therapeutic strategies for relatively large AVMs, including staged GKRS and a combination of GKRS and embolization, continue to be developed, though their advantages and disadvantages warrant further investigation. The role of GKRS in managing unruptured AVMs remains controversial since a prospective trial showed no benefit of treatment, necessitating further consideration of this issue. 2) Regarding DAVFs, GKRS achieves 41–90% obliteration rates at the second post-GKRS year with a hemorrhage rate below 5%. Debate continues as to whether GKRS might serve as a first-line solo therapeutic modality given its latency period. Although the post-GKRS outcomes are thought to differ among lesion locations, further outcome analyses regarding DAVF locations are required. 3) GKRS is generally accepted as an alternative for small or medium-sized CMs in which surgery is considered to be too risky. The reported hemorrhage rates ranged from 0.5–5% after GKRS. Higher dose treatments (>15 Gy) were performed during the learning curve, while, with the current standard treatment, a dose range of 12–15 Gy is generally selected, and has resulted in acceptable complication rates (< 5%). Nevertheless, further elucidation of long-term outcomes is essential.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Bierta E Barfod
- Katsuta Hospital Mito Gamma House, Hitachinaka, Ibaraki, Japan
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5
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Meneghelli P, Pasqualin A, Nicolato A. In Reply to "Surgery for Intractable Seizures After Successful Radiosurgery of Cerebral Arteriovenous Malformation". World Neurosurg 2018; 122:725. [PMID: 30481623 DOI: 10.1016/j.wneu.2018.11.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 11/16/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Pietro Meneghelli
- Institute of Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy.
| | - Alberto Pasqualin
- Section of Vascular Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Antonio Nicolato
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
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Aizawa R, Uto M, Takehana K, Arakawa Y, Miyamoto S, Mizowaki T. Radiation-induced cystic brain necrosis developing 10 years after linac-based stereotactic radiosurgery for brain metastasis. Oxf Med Case Reports 2018; 2018:omy090. [PMID: 30364384 PMCID: PMC6194183 DOI: 10.1093/omcr/omy090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 08/09/2018] [Accepted: 08/20/2018] [Indexed: 12/30/2022] Open
Abstract
Cystic brain necrosis (CBN) is a rare form of BN. It typically occurs as a very late complication, and no standard treatment has been established. We report a case of a 59-year-old man who developed CBN 10 years after radiation therapy for metastatic brain tumors. The therapy consisted of whole brain radiotherapy followed by linac-based stereotactic radiosurgery as a boost. Initially, the CBN continued to expand despite treatment with corticosteroids and bevacizumab. Therefore, we resected the tumor and implanted an Ommaya reservoir, which successfully stabilized the lesion. Although the prognosis of patients with brain metastases is generally poor, some patients, like the one reported here, achieve long survival. Therefore, we should follow such cases carefully, considering the possibility of developing CBN as a late complication.
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Affiliation(s)
- Rihito Aizawa
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Megumi Uto
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Keiichi Takehana
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshiki Arakawa
- Department of Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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A Comprehensive Study of Symptomatic Late Radiation-Induced Complications After Radiosurgery for Brain Arteriovenous Malformation: Incidence, Risk Factors, and Clinical Outcomes. World Neurosurg 2018; 116:e556-e565. [DOI: 10.1016/j.wneu.2018.05.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 05/04/2018] [Accepted: 05/05/2018] [Indexed: 11/20/2022]
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Hasegawa H, Hanakita S, Shin M, Kawashima M, Takahashi W, Ishikawa O, Koizumi S, Nakatomi H, Saito N. Comparison of the Long-term Efficacy and Safety of Gamma Knife Radiosurgery for Arteriovenous Malformations in Pediatric and Adult Patients. Neurol Med Chir (Tokyo) 2018; 58:231-239. [PMID: 29769453 PMCID: PMC6002683 DOI: 10.2176/nmc.st.2018-0008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
It is debated whether the efficacy and long-term safety of gamma knife radiosurgery (GKRS) for arteriovenous malformations (AVMs) differs between adult and pediatric patients. We aimed to clarify the long-term outcomes of GKRS in pediatric patients and how they compare to those in adult patients. We collected data for 736 consecutive patients with AVMs treated with GKRS between 1990 and 2014 and divided the patients into pediatric (age < 20 years, n = 144) and adult (age ≥ 20 years, n = 592) cohorts. The mean follow-up period in the pediatric cohort was 130 months. Compared to the adult patients, the pediatric patients were significantly more likely to have a history of hemorrhage (P < 0.001). The actuarial rates of post-GKRS nidus obliteration in the pediatric cohort were 36%, 60%, and 87% at 2, 3, and 6 years, respectively. Nidus obliteration occurred earlier in the pediatric cohort than in the adult cohort (P = 0.015). The actuarial rates of post-GKRS hemorrhage in the pediatric cohort were 0.7%, 2.5%, and 2.5% at 1, 5, and 10 years, respectively. Post-GKRS hemorrhage was marginally less common in the pediatric cohort than in the adult cohort (P = 0.056). Cyst formation/encapsulated hematoma were detected in seven pediatric patients (4.9%) at a median post-GKRS timepoint of 111 months, which was not significantly different from the rate in the adult cohort. Compared to adult patients, pediatric patients experience earlier therapeutic effects from GKRS for AVMs, and this improves long-term outcomes.
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Affiliation(s)
| | | | - Masahiro Shin
- Department of Neurosurgery, University of Tokyo Hospital
| | | | | | - Osamu Ishikawa
- Department of Neurosurgery, University of Tokyo Hospital
| | | | | | - Nobuhito Saito
- Department of Neurosurgery, University of Tokyo Hospital
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9
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Meneghelli P, Pasqualin A, Zampieri P, Longhi M, Foroni R, Sini A, Tommasi N, Nicolato A. Surgical Management of Adverse Radiation Effects After Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformations: A Population-Based Cohort Study. World Neurosurg 2018; 114:e840-e850. [PMID: 29572169 DOI: 10.1016/j.wneu.2018.03.097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 03/12/2018] [Accepted: 03/14/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The goal of this study is to report our experience in the surgical treatment of cerebral arteriovenous malformations (cAVMs) related permanent symptomatic adverse radiation effects (PSAREs), to clarify an appropriate surgical management and to identify the risk factors related to their development. METHODS We evaluated 549 patients treated with Gamma Knife radiosurgery (GKRS) for cAVMs with a follow-up of at least 8 years. Univariate and multivariate analyses were used to test different risk factors related to the development of PSARE. We retrospectively reviewed the records of these patients to analyze the clinical outcome. RESULTS Fourteen patients (2.5%) developed PSARE and were submitted to surgery. Higher average treated volume represents a significant risk factors for the development of PSARE (P < 0.05); on the other hand, older age and higher average dose reduce the risk of PSARE (P < 0.05). A favorable clinical outcome was achieved in 13 patients (93%) after surgery; in 1 patient, the unfavorable outcome was due to hemorrhage that occurred months after GKRS. Serial MRI scans following either surgical removal of the nodule or Ommaya reservoir positioning showed progressive reduction of brain edema in all cases. CONCLUSIONS The management of PSARE is controversial, especially for cAVMs treated with SRS. Surgical removal is rarely needed, but-if unavoidable-it can be a valuable option in experienced hands. A careful preoperative planning is always necessary to detect pathologic blood flow through the PSARE.
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Affiliation(s)
- Pietro Meneghelli
- Institute of Neurosurgery, University and City Hospital, Verona, Italy.
| | - Alberto Pasqualin
- Section of Vascular Neurosurgery, Institute of Neurological Surgery, University and City Hospital, Verona, Italy
| | - Piergiuseppe Zampieri
- Section of Neuroradiology, Department of Diagnosis and Pathology, University and City Hospital, Verona, Italy
| | - Michele Longhi
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Roberto Foroni
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Antonio Sini
- Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Nicola Tommasi
- Centro interdipartimentale di documentazione economica, University of Verona, Verona, Italy
| | - Antonio Nicolato
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
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10
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Pomeraniec IJ, Ding D, Starke RM, Liu KC, Mrachek EK, Lopes MB, Sheehan JP. Delayed cyst formation after stereotactic radiosurgery for brain arteriovenous malformations. J Neurosurg 2017; 129:937-946. [PMID: 29192860 DOI: 10.3171/2017.6.jns17559] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is a commonly employed treatment modality for brain arteriovenous malformations (AVMs). However, due to the low frequency of delayed cyst formation after AVM SRS, as well as the prolonged time interval between treatment and its occurrence, the characteristics of post-SRS cyst formation are not well defined. Therefore, the aims of this retrospective cohort study are to determine the rate of cyst formation after SRS for AVMs, identify predictive factors, and evaluate the clinical sequelae of post-SRS cysts. METHODS The authors analyzed an SRS database for AVM patients who underwent SRS at the University of Virginia and identified those who developed post-SRS cysts. Statistical analyses were performed to determine predictors of post-SRS cyst formation and the effect of cyst formation on new or worsening seizures after SRS. RESULTS The study cohort comprised 1159 AVM patients treated with SRS; cyst formation occurred in 17 patients (post-SRS cyst rate of 1.5%). Compared with patients who did not develop post-SRS cysts, those with cyst formation were treated with a greater number of radiosurgical isocenters (mean 3.8 vs 2.8, p = 0.047), had a longer follow-up (mean 132 vs 71 months, p < 0.001), were more likely to develop radiological radiation-induced changes (RIC) (64.7% vs 36.1%, p = 0.021), and had a longer duration of RIC (57 vs 21 months, p < 0.001). A higher number of isocenters (p = 0.014), radiological RIC (p = 0.002), and longer follow-up (p = 0.034) were found to be independent predictors of post-SRS cyst formation in the multivariate analysis. There was a trend toward a significant association between cyst formation and new or worsening seizures in univariate analysis (p = 0.054). CONCLUSIONS Patients with greater nidal complexity appear to be more prone to post-SRS cyst formation. The findings of this study emphasize the importance of long-term follow-up for patients who have undergone AVM SRS, even after nidal obliteration is achieved. Post-SRS cysts may be epileptogenic, although seizure outcomes after AVM SRS are multifactorial.
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Affiliation(s)
| | | | - Robert M Starke
- 5Departments of Neurosurgery and Radiology, Jackson Memorial Hospital and University of Miami Hospital, Miami, Florida
| | | | - E Kelly Mrachek
- 4Neuropathology, University of Virginia Health System, Charlottesville, Virginia; and
| | - M Beatriz Lopes
- 4Neuropathology, University of Virginia Health System, Charlottesville, Virginia; and
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11
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Dho YS, Kim DG, Chung HT. Ruptured de novo Aneurysm following Gamma Knife Surgery for Arteriovenous Malformation: Case Report. Stereotact Funct Neurosurg 2017; 95:379-384. [PMID: 29190619 DOI: 10.1159/000481666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 09/19/2017] [Indexed: 11/19/2022]
Abstract
Stereotactic radiosurgery is a well-known treatment tool for arteriovenous malformations (AVMs). The method has high validity and minimal invasiveness, but late-onset problems involving tumor formation and vasculopathy induced by radiation have been reported. We present a rare case of a radiation-induced ruptured de novo aneurysm following Gamma Knife surgery (GKS) for an AVM. A 17-year-old, right-handed male underwent GKS for AVM at the left parietal lobe. After 3 years, a follow-up angiogram showed a residual AVM at the angular gyrus. Then, a 2nd GKS was performed for the residual lesion. Six years after the 1st GKS, the AVM disappeared on the angiogram. Seven years later, he suffered a sudden onset of headache. A left carotid angiogram revealed a ruptured aneurysm at the M2-M3 junction of the middle cerebral artery parietal branch. Coil embolization was performed, and the aneurysm was occluded. The patient was discharged without any neurologic deficits.
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Affiliation(s)
- Yun-Sik Dho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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12
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Majewska P, Tsui A, Adamides AA. Delayed symptomatic haemorrhage from the remnants of a thalamic arteriovenous malformation after previous angiographic cure with radiotherapy. Acta Neurochir (Wien) 2017; 159:2123-2125. [PMID: 28681273 DOI: 10.1007/s00701-017-3259-0] [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: 03/01/2017] [Accepted: 06/21/2017] [Indexed: 10/19/2022]
Abstract
In 1995 a 16-year old girl was diagnosed with a large left thalamic AVM that was considered unsuitable for microsurgical resection and was treated with radiotherapy twice, which led to angiographic cure. She re-presented 19 years after initial treatment with a symptomatic acute thalamic haemorrhage. Her digital subtraction angiography was negative for arterio-venous shunting. MRI/MRA showed cystic change with adjacent contrast enhancement in the region of the previously irradiated arteriovenous malformation. The patient underwent an interhemispheric transcallosal resection of the left thalamic haemorrhagic lesion via a contralateral craniotomy. Intra-operatively there was a cystic cavity filled with blood products in association with thrombosed, calcified vessels as well as actively filling vessels. Histologically there were aggregated abnormal blood vessels with a dilated lumen and surrounded by brain parenchyma. Some of the vessel walls were thickened with fibrosis and some were arterialised with presence of elastin fibres. Potential mechanisms for the delayed haemorrhage are discussed.
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13
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Grady C, Tanweer O, Zagzag D, Jafar JJ, Huang PP, Kondziolka D. Delayed hemorrhage from the tissue of an occluded arteriovenous malformation after stereotactic radiosurgery: report of 3 cases. J Neurosurg 2016; 126:1899-1904. [DOI: 10.3171/2016.4.jns152320] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Stereotactic radiosurgery is widely used to treat cerebral arteriovenous malformations (AVMs), with the goal of complete angiographic obliteration. A number of case series have challenged the assumption that absence of residual AVM on follow-up angiograms is consistent with elimination of the risk of hemorrhage. The authors describe 3 cases in which patients who had angiographic evidence of AVM occlusion presented with late hemorrhage in the area of their prior lesions. They compare the radiographic, angiographic, and histological features of these patients with those previously described in the literature.Delayed hemorrhage from the tissue of occluded AVMs has been reported as early as 4 and as late as 11 years after initial stereotactic radiosurgery. In all cases for which data are available, hemorrhage occurred in the area of persistent imaging findings despite negative findings on conventional angiography. The hemorrhagic lesions that were resected demonstrated a number of distinct histological findings.While rare, delayed hemorrhage from the tissue of occluded AVMs may occur from a number of distinct, angiographically occult postirradiation changes. The hemorrhages in the authors' 3 cases were symptomatic and localized. The correlation of histological and imaging findings in delayed hemorrhage from occluded AVMs is an area requiring further investigation.
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Affiliation(s)
| | | | - David Zagzag
- Departments of 1Neurosurgery and
- 2Neuropathology, NYU Langone Medical Center, New York University, New York, New York
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14
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Shekhtman OD, Maryashev SA, Eliava SS, Yakovlev SB, Golanov AV, Shishkina LV, Pilipenko YV, Okishev DN, Bocharov AV, Bukharin EY, Mikeladze KG, Kisar'ev SA, Vinogradov EV, Kaftanov AN, Konovalov AN. [Combined treatment of cerebral arteriovenous malformations. Experience of the Burdenko Neurosurgical Institute]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2015; 79:4-18. [PMID: 26529618 DOI: 10.17116/neiro20157944-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Despite the achievements of recent years, cerebral AVMs continue to pose a challenge to treatment. The objective of this work was the development of recommendations for combined treatment of AVMs based on analysis of the available material and published data. MATERIAL AND METHODS The study included 93 patients hospitalized at the Neurosurgical Institute for combined treatment of cerebral AVMs in 2010-2014. A group of combined surgery (removal of an AVM with preoperative embolization) consisted of 40 patients, and a group of combined radiotherapy (radiation after partial embolization or partial removal of an AVM) included 53 patients. 36 patients underwent radiosurgery, and 17 patients received stereotactic radiation therapy. Both groups were analyzed in terms of outcomes, complications, and follow-up results. RESULTS In the group of combined surgery, according to the Glasgow outcome scale, good results (grade 4-5) were achieved in 35 (87.5%) patients at discharge and in 27 (90%) patients during follow-up. Treatment outcomes, surgery duration, and the amount of blood loss were not significantly different from those in the control group. Complete AVM obliteration was achieved in 29 (80.6%) patients 3 years after radiosurgery and in 8 (47%) patients after stereotactic radiotherapy. In discussion, these findings are compared to the published data, and recommendations for AVM treatment are suggested. CONCLUSION The combined treatment of AVMs is effective management for patients with complex AVMs (Spetzler-Martin grade III-IV AVMs). Successful treatment of AVMs requires careful planning and teamwork of vascular and endovascular neurosurgeons, radiologists, and neurologists.
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Affiliation(s)
| | | | - Sh Sh Eliava
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - S B Yakovlev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A V Golanov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | - D N Okishev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A V Bocharov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | - S A Kisar'ev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - A N Kaftanov
- Burdenko Neurosurgical Institute, Moscow, Russia
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Park JC, Ahn JS, Kwon DH, Kwun BD. Growing Organized Hematomas Following Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformation : Five Cases of Surgical Excision. J Korean Neurosurg Soc 2015; 58:83-8. [PMID: 26279820 PMCID: PMC4534746 DOI: 10.3340/jkns.2015.58.1.83] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 06/27/2014] [Accepted: 06/29/2014] [Indexed: 12/02/2022] Open
Abstract
Organized hematoma is a rare complication that can develop following gamma knife radiosurgery (GKS) for cerebral arteriovenous malformation (AVM). Here, we describe 5 patients with growing organized hematomas that developed from completely obliterated AVMs several years after GKS. The patients were 15, 16, 30, 36, and 38 years old at the time of GKS, respectively, and 3 patients were female. Four AVMs were located in the lobe of the brain, and the remaining AVM were in the thalamus. Between 2-12 years after GKS, patients developed progressive symptoms such intractable headache or hemiparesis and enhancing mass lesions were identified. Follow-up visits revealed the slow expansion of the hematomas and surrounding edema. Steroids were ineffective, and thus surgery was performed. Histology revealed organized hematomas with a capsule, but there was no evidence of residual AVMs or vascular malformation. After surgery, the neurological symptoms of all patients improved and the surrounding edema resolved. However, the hematoma continued to expand and intraventricular hemorrhage developed in 1 patient whose hematoma was only partially removed. GKS for cerebral AVM can be complicated by growing, organized hematomas that develop after complete obliteration. Growing hematomas should be surgically evacuated if they are symptomatic. Radical resection of the hematoma capsule is also strongly recommended.
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Affiliation(s)
- Jung Cheol Park
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Do Hoon Kwon
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Byung Duk Kwun
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Akai T, Torigoe K, Fukushima M, Iizuka H, Hayashi Y. De Novo Aneurysm Formation Following Gamma Knife Surgery for Arteriovenous Malformation: A Case Report. J Neurol Surg Rep 2015; 76:e105-8. [PMID: 26251783 PMCID: PMC4520975 DOI: 10.1055/s-0035-1549223] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 01/13/2015] [Indexed: 10/26/2022] Open
Abstract
Background Stereotactic radiosurgery plays a critical role in the treatment of central nervous system neoplasm and cerebrovascular malformations. This procedure is purportedly less invasive, but problems occurring later including tumor formation, necrosis, and vasculopathy-related diseases have been reported. Clinical Presentation We report on a 65-year-old man who had experienced a de novo aneurysm in an irradiated field and an acute onset of right hemiparesis and aphasia. He had undergone gamma knife radiosurgery to treat an arteriovenous malformation 15 and 12 years prior, with 18 and 22 Gy marginal doses. At current admission, radiologic studies showed a de novo aneurysm in the irradiated field without recurrence of malformation. The aneurysm was resected. Histologic findings showed a disruption of the internal elastic lamina accompanied by fibrous degeneration. Conclusion Stereotactic radiosurgery is a promising treatment tool, but long-term risks have not been fully researched. The treatment procedure for benign lesions should be chosen prudently.
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Affiliation(s)
- Takuya Akai
- Department of Neurosurgery, Kanazawa Medical University, Kanazawa, Japan
| | - Keiichiro Torigoe
- Department of Neurosurgery, Kanazawa Medical University, Kanazawa, Japan
| | - Manna Fukushima
- Pathology and Laboratory Medicine, Kanazawa Medical University, Kanazawa, Japan
| | - Hideaki Iizuka
- Department of Neurosurgery, Kanazawa Medical University, Kanazawa, Japan
| | - Yasuhiko Hayashi
- Department of Neurosurgery, Kanazawa University, Kanazawa, Japan
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17
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Lee CC, Chen CJ, Ball B, Schlesinger D, Xu Z, Yen CP, Sheehan J. Stereotactic radiosurgery for arteriovenous malformations after Onyx embolization: a case-control study. J Neurosurg 2015; 123:126-35. [PMID: 25658780 DOI: 10.3171/2014.12.jns141437] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Onyx, an ethylene-vinyl alcohol copolymer mixed in a dimethyl sulfoxide solvent, is currently one of the most widely used liquid materials for embolization of intracranial arteriovenous malformations (AVMs). The goal of this study was to define the risks and benefits of stereotactic radiosurgery (SRS) for patients who have previously undergone partial AVM embolization with Onyx. METHODS Among a consecutive series of 199 patients who underwent SRS between January 2007 and December 2012 at the University of Virginia, 25 patients had Onyx embolization prior to SRS (the embolization group). To analyze the obliteration rates and complications, 50 patients who underwent SRS without prior embolization (the no-embolization group) were matched by propensity score method. The matched variables included age, sex, nidus volume before SRS, margin dose, Spetzler-Martin grade, Virginia Radiosurgery AVM Scale score, and median imaging follow-up period. RESULTS After Onyx embolization, 18 AVMs were reduced in size. Total obliteration was achieved in 6 cases (24%) at a median of 27.5 months after SRS. In the no-embolization group, total obliteration was achieved in 20 patients (40%) at a median of 22.4 months after SRS. Kaplan-Meier analysis demonstrated obliteration rates of 17.7% and 34.1% in the embolization group at 2 and 4 years, respectively. In the no-embolization group, the corresponding obliteration rates were 27.0% and 55.9%. The between-groups difference in obliteration rates after SRS did not achieve statistical significance. The difference in complications, including adverse radiation effects, hemorrhage episodes, seizure control, and patient mortality also did not reach statistical significance. CONCLUSIONS Onyx embolization can effectively reduce the size of many AVMs. This case-control study did not show any statistically significant difference in the rates of embolization or complications after SRS in patients who had previously undergone Onyx embolization and those who had not.
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Affiliation(s)
- Cheng-Chia Lee
- Departments of 1 Neurological Surgery, and.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital; and.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | | | | | - David Schlesinger
- Departments of 1 Neurological Surgery, and.,Radiation Oncology, University of Virginia, Charlottesville, Virginia
| | - Zhiyuan Xu
- Departments of 1 Neurological Surgery, and
| | | | - Jason Sheehan
- Departments of 1 Neurological Surgery, and.,Radiation Oncology, University of Virginia, Charlottesville, Virginia
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Pathological characteristics of cyst formation following gamma knife surgery for arteriovenous malformation. Acta Neurochir (Wien) 2015; 157:293-8. [PMID: 25503297 DOI: 10.1007/s00701-014-2298-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 11/28/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The pathological characteristics of cyst development after gamma knife surgery (GKS) for arteriovenous malformation (AVM) were analysed. METHOD Sixteen male and 12 female patients aged 17-67 years (mean 31.3 years) were retrospectively identified among 868 patients who underwent GKS for AVM at our hospital. The pathological characteristics of the reddish nodular lesion and chronic encapsulated expanding haematoma associated with cyst following GKS for AVM were examined. RESULTS Cyst was associated with chronic encapsulated expanding haematoma in 13, and with nodular lesion in 12 patients. The nidus volume at GKS was 0.1-36 ml (median 6.0 ml), and the prescription dose at the nidus margin was 18-25 Gy (median 20 Gy). Cyst formation was detected from 1.1 to 16 years (mean 7.3 years) after GKS. Seven of the 12 patients with nodular lesion underwent surgery. Ten of the 13 patients with expanding haematoma underwent surgical removal of expanding haematoma. Histological examination was possible in 17 cases. Dilated capillary vessels with wall damage such as hyalinisation and fibrinoid necrosis, marked protein exudation and haemorrhage were the most common findings. Brain parenchyma was observed among the dilated vessels in some cases. Structureless necrotic tissue was not evident. CONCLUSIONS The present study suggests that enhanced nodular lesion on magnetic resonance imaging and chronic encapsulated expanding haematoma associated with cyst may have common aetiopathology caused by late radiation effects, mainly consisting of dilated capillary vessels with wall damage. Massive protein exudation from such damaged capillary vessels is important in cyst development.
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Parkhutik V, Lago A, Aparici F, Vazquez JF, Tembl JI, Guillen L, Mainar E, Vazquez V. Late clinical and radiological complications of stereotactical radiosurgery of arteriovenous malformations of the brain. Neuroradiology 2012. [DOI: 10.1007/s00234-012-1115-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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