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Mollier O, Dupin C, Marnat G, Benech J, Vendrely V, Giraud N, Trouette R, Barreau X, Huchet A. [Stereotactic radiotherapy of non-tumoral brain pathologies: Arteriovenous malformations and trigeminal neuralgias]. Cancer Radiother 2022; 26:779-783. [PMID: 36030190 DOI: 10.1016/j.canrad.2022.06.023] [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: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 10/15/2022]
Abstract
Stereotactic radiotherapy and radiosurgery allow delivery of high irradiation doses in a limited volume. These techniques are specially adapted to brain and nervous pathologies. Indication are not only cancers and tumors but also non tumor tissues such as arteriovenous malformations. In some case purpose of stereotactic radiotherapy is solely functional, for example for trigeminal neuralgia. We detail the questions that raise treatment of these non-tumor pathologies. These pathologies imply a multidisciplinary approach that associate radiation oncologists, neuro-radiologist and neurosurgeons.
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Affiliation(s)
- O Mollier
- Service de neurochirurgie A, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - C Dupin
- Service d'oncologie-radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, Bordeaux, France; U1312-BRIC, eq BioGO, Inserm, université de Bordeaux, 33000 Bordeaux, France
| | - G Marnat
- Service de radiologie et de neuro-imagerie diagnostique et thérapeutique, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - J Benech
- Service d'oncologie-radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, Bordeaux, France
| | - V Vendrely
- Service d'oncologie-radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, Bordeaux, France; U1312-BRIC, eq BioGO, Inserm, université de Bordeaux, 33000 Bordeaux, France
| | - N Giraud
- Service d'oncologie-radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, Bordeaux, France
| | - R Trouette
- Service d'oncologie-radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, Bordeaux, France
| | - X Barreau
- Service de radiologie et de neuro-imagerie diagnostique et thérapeutique, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - A Huchet
- Service d'oncologie-radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, Bordeaux, France.
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Ogino A, Lunsford LD, Long H, Johnson S, Faramand A, Niranjan A, Flickinger JC, Kano H. Stereotactic radiosurgery as the first-line treatment for intracanalicular vestibular schwannomas. J Neurosurg 2021; 135:1051-1057. [PMID: 34600434 DOI: 10.3171/2020.9.jns202818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This report evaluates the outcomes of stereotactic radiosurgery (SRS) as the first-line treatment of intracanalicular vestibular schwannomas (VSs). METHODS Between 1987 and 2017, the authors identified 209 patients who underwent SRS as the primary intervention for a unilateral intracanalicular VS. The median patient age was 54 years (range 22-85 years); 94 patients were male and 115 were female. Three patients had facial neuropathy at the time of SRS. One hundred fifty-five patients (74%) had serviceable hearing (Gardner-Robertson [GR] grades I and II) at the time of SRS. The median tumor volume was 0.17 cm3 (range 0.015-0.63 cm3). The median margin dose was 12.5 Gy (range 11.0-25.0 Gy). The median maximum dose was 24.0 Gy (range 15.7-50.0 Gy). RESULTS The progression-free survival rates of all patients with intracanalicular VS were 97.5% at 3 years, 95.6% at 5 years, and 92.1% at 10 years. The rates of freedom from the need for any additional intervention were 99.4% at 3 years, 98.3% at 5 years, and 98.3% at 10 years. The serviceable hearing preservation rates in GR grade I and II patients at the time of SRS were 76.6% at 3 years, 63.5% at 5 years, and 27.3% at 10 years. In univariate analysis, younger age (< 55 years, p = 0.011), better initial hearing (GR grade I, p < 0.001), and smaller tumor volumes (< 0.14 cm3, p = 0.016) were significantly associated with improved hearing preservation. In multivariate analysis, better hearing (GR grade I, p = 0.001, HR 2.869, 95% CI 1.569-5.248) and smaller tumor volumes (< 0.14 cm3, p = 0.033, HR 2.071, 95% CI 1.059-4.047) at the time of SRS were significantly associated with improved hearing preservation. The hearing preservation rates of patients with GR grade I VS were 88.1% at 3 years, 77.9% at 5 years, and 38.1% at 10 years. The hearing preservation rates of patients with VSs smaller than 0.14 cm3 were 85.5% at 3 years, 77.7% at 5 years, and 42.6% at 10 years. Facial neuropathy developed in 1.4% from 6 to 156 months after SRS. CONCLUSIONS SRS provided sustained tumor control in more than 90% of patients with intracanalicular VS at 10 years and freedom from the need for additional intervention in more than 98% at 10 years. Patients with initially better hearing and smaller VSs had enhanced serviceable hearing preservation during an observation interval up to 10 years after SRS.
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Affiliation(s)
- Akiyoshi Ogino
- Departments of1Neurological Surgery and.,3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and.,4Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - L Dade Lunsford
- Departments of1Neurological Surgery and.,3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Hao Long
- Departments of1Neurological Surgery and.,3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | | | - Andrew Faramand
- Departments of1Neurological Surgery and.,3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Ajay Niranjan
- Departments of1Neurological Surgery and.,3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - John C Flickinger
- 2Radiation Oncology, and.,3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Hideyuki Kano
- Departments of1Neurological Surgery and.,3Center for Image-Guided Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
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Chagoya G, Hardigan AA, Fox BM, Laskay N, Salehani AA, Rotman LE, Elsayed GA, Bernstock JD, Omar NB, Tabibian BE, Ilyas A, Hackney J, Fisher WS. Cerebellar Arteriovenous Malformation Rupture Despite Apparent Angiographic Obliteration. World Neurosurg 2019; 134:25-32. [PMID: 31629928 DOI: 10.1016/j.wneu.2019.10.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Arteriovenous malformations (AVMs) can occur in all regions of the brain and spinal cord, with clinical consequences and risks varying by location. Delayed AVM rupture despite digital subtraction angiography-confirmed obliteration post-radiation is exceedingly rare. CASE DESCRIPTION To our knowledge, we present the first documented case of delayed hemorrhage associated with a cerebellar AVM 5 years after linear accelerator-based radiation in a man aged 31 years despite apparent angiographic obliteration. CONCLUSIONS Intracranial hemorrhage after radiosurgery in digital subtraction angiography-confirmed obliterated AVMs is rare, with limited understanding of risk factors, appropriate preventative management, and mechanisms of occurrence. This case serves to demonstrate the need for greater awareness of this rare complication, as well as the need for appropriate surveillance and management strategies.
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Affiliation(s)
- Gustavo Chagoya
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Andrew A Hardigan
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama; Department Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brandon M Fox
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama; Department Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham, Alabama
| | - Nicholas Laskay
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Arsalaan A Salehani
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lauren E Rotman
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Galal A Elsayed
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nidal B Omar
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - B Ethan Tabibian
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James Hackney
- Department Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Winfield S Fisher
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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Marciscano AE, Huang J, Tamargo RJ, Hu C, Khattab MH, Aggarwal S, Lim M, Redmond KJ, Rigamonti D, Kleinberg LR. Long-term Outcomes With Planned Multistage Reduced Dose Repeat Stereotactic Radiosurgery for Treatment of Inoperable High-Grade Arteriovenous Malformations: An Observational Retrospective Cohort Study. Neurosurgery 2018; 81:136-146. [PMID: 28201783 DOI: 10.1093/neuros/nyw041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 11/12/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There is no consensus regarding the optimal management of inoperable high-grade arteriovenous malformations (AVMs). This long-term study of 42 patients with high-grade AVMs reports obliteration and adverse event (AE) rates using planned multistage repeat stereotactic radiosurgery (SRS). OBJECTIVE To evaluate the efficacy and safety of multistage SRS with treatment of the entire AVM nidus at each treatment session to achieve complete obliteration of high-grade AVMs. METHODS Patients with high-grade Spetzler-Martin (S-M) III-V AVMs treated with at least 2 multistage SRS treatments from 1989 to 2013. Clinical outcomes of obliteration rate, minor/major AEs, and treatment characteristics were collected. RESULTS Forty-two patients met inclusion criteria (n = 26, S-M III; n = 13, S-M IV; n = 3, S-M V) with a median follow-up was 9.5 yr after first SRS. Median number of SRS treatment stages was 2, and median interval between stages was 3.5 yr. Twenty-two patients underwent pre-SRS embolization. Complete AVM obliteration rate was 38%, and the median time to obliteration was 9.7 yr. On multivariate analysis, higher S-M grade was significantly associated ( P = .04) failure to achieve obliteration. Twenty-seven post-SRS AEs were observed, and the post-SRS intracranial hemorrhage rate was 0.027 events per patient year. CONCLUSION Treatment of high-grade AVMs with multistage SRS achieves AVM obliteration in a meaningful proportion of patients with acceptable AE rates. Lower obliteration rates were associated with higher S-M grade and pre-SRS embolization. This approach should be considered with caution, as partial obliteration does not protect from hemorrhage.
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Affiliation(s)
- Ariel E Marciscano
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chen Hu
- Department of Oncology, Division of Biostatistics and Bioinformatics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohamed H Khattab
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sameer Aggarwal
- The George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kristin J Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniele Rigamonti
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lawrence R Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
In this work, we studied the possibility of merging proton therapy with grid therapy. We hypothesized that patients with larger targets containing solid tumor growth could benefit from being treated with this method, proton grid therapy. We performed treatment planning for 2 patients with abdominal cancer with the suggested proton grid therapy technique. The proton beam arrays were cross-fired over the target volume. Circular or rectangular beam element shapes (building up the beam grids) were evaluated in the planning. An optimization was performed to calculate the fluence from each beam grid element. The optimization objectives were set to create a homogeneous dose inside the target volume with the constraint of maintaining the grid structure of the dose distribution in the surrounding tissue. The proton beam elements constituting the grid remained narrow and parallel down to large depths in the tissue. The calculation results showed that it is possible to produce target doses ranging between 100% and 130% of the prescribed dose by cross-firing beam grids, incident from 4 directions. A sensitivity test showed that a small rotation or translation of one of the used grids, due to setup errors, had only a limited influence on the dose distribution produced in the target, if 4 beam arrays were used for the irradiation. Proton grid therapy is technically feasible at proton therapy centers equipped with spot scanning systems using existing tools. By cross-firing the proton beam grids, a low tissue dose in between the paths of the elemental beams can be maintained down to the vicinity of a deep-seated target. With proton grid therapy, it is possible to produce a dose distribution inside the target volume of similar uniformity as can be created with current clinical methods.
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Affiliation(s)
- Thomas Henry
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, Sweden
| | - Ana Ureba
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, Sweden
| | - Alexander Valdman
- Department of Oncology and Pathology, Karolinska University Hospital, Stockholm, Sweden
| | - Albert Siegbahn
- Medical Radiation Physics, Department of Physics, Stockholm University, Stockholm, Sweden
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Zhao Z, Johnson MS, Chen B, Grace M, Ukath J, Lee VS, McRobb LS, Sedger LM, Stoodley MA. Live-cell imaging to detect phosphatidylserine externalization in brain endothelial cells exposed to ionizing radiation: implications for the treatment of brain arteriovenous malformations. J Neurosurg 2015; 124:1780-7. [PMID: 26430846 DOI: 10.3171/2015.4.jns142129] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Stereotactic radiosurgery (SRS) is an established intervention for brain arteriovenous malformations (AVMs). The processes of AVM vessel occlusion after SRS are poorly understood. To improve SRS efficacy, it is important to understand the cellular response of blood vessels to radiation. The molecular changes on the surface of AVM endothelial cells after irradiation may also be used for vascular targeting. This study investigates radiation-induced externalization of phosphatidylserine (PS) on endothelial cells using live-cell imaging. METHODS An immortalized cell line generated from mouse brain endothelium, bEnd.3 cells, was cultured and irradiated at different radiation doses using a linear accelerator. PS externalization in the cells was subsequently visualized using polarity-sensitive indicator of viability and apoptosis (pSIVA)-IANBD, a polarity-sensitive probe. Live-cell imaging was used to monitor PS externalization in real time. The effects of radiation on the cell cycle of bEnd.3 cells were also examined by flow cytometry. RESULTS Ionizing radiation effects are dose dependent. Reduction in the cell proliferation rate was observed after exposure to 5 Gy radiation, whereas higher radiation doses (15 Gy and 25 Gy) totally inhibited proliferation. In comparison with cells treated with sham radiation, the irradiated cells showed distinct pseudopodial elongation with little or no spreading of the cell body. The percentages of pSIVA-positive cells were significantly higher (p = 0.04) 24 hours after treatment in the cultures that received 25- and 15-Gy doses of radiation. This effect was sustained until the end of the experiment (3 days). Radiation at 5 Gy did not induce significant PS externalization compared with the sham-radiation controls at any time points (p > 0.15). Flow cytometric analysis data indicate that irradiation induced growth arrest of bEnd.3 cells, with cells accumulating in the G2 phase of the cell cycle. CONCLUSIONS Ionizing radiation causes remarkable cellular changes in endothelial cells. Significant PS externalization is induced by radiation at doses of 15 Gy or higher, concomitant with a block in the cell cycle. Radiation-induced markers/targets may have high discriminating power to be harnessed in vascular targeting for AVM treatment.
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Affiliation(s)
- Zhenjun Zhao
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University
| | | | - Biyi Chen
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University
| | - Michael Grace
- Genesis Cancer Care, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Jaysree Ukath
- Genesis Cancer Care, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Vivienne S Lee
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University
| | - Lucinda S McRobb
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University
| | - Lisa M Sedger
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University
| | - Marcus A Stoodley
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University
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Abstract
An arteriovenous malformation is a tangle of dysplastic vessels (nidus) fed by arteries and drained by veins without intervening capillaries, forming a high-flow, low-resistance shunt between the arterial and venous systems. Arteriovenous malformations in the brain have a low estimated prevalence but are an important cause of intracerebral haemorrhage in young adults. For previously unruptured malformations, bleeding rates are approximately 1% per year. Once ruptured, the subsequent risk increases fivefold, depending on associated aneurysms, deep locations, deep drainage and increasing age. Recent findings from novel animal models and genetic studies suggest that arteriovenous malformations, which were long considered congenital, arise from aberrant vasculogenesis, genetic mutations and/or angiogenesis after injury. The phenotypical characteristics of arteriovenous malformations differ among age groups, with fistulous lesions in children and nidal lesions in adults. Diagnosis mainly involves imaging techniques, including CT, MRI and angiography. Management includes observation, microsurgical resection, endovascular embolization and stereotactic radiosurgery, alone or in any combination. There is little consensus on how to manage patients with unruptured malformations; recent studies have shown that patients managed medically fared better than those with intervention at short-term follow-up. By contrast, interventional treatment is preferred following a ruptured malformation to prevent rehaemorrhage. Management continues to evolve as new mechanistic discoveries and reliable animal models raise the possibility of developing drugs that might prevent the formation of arteriovenous malformations, induce obliteration and/or stabilize vessels to reduce rupture risk. For an illustrated summary of this Primer, visit: http://go.nature.com/TMoAdn.
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Abstract
OPINION STATEMENT Arteriovenous malformations (AVMs) pose a risk of morbidity and mortality throughout an affected patient's lifetime. Over the course of a patient's life, the risk of hemorrhage is approximately 1-4 % per year, and after an initial hemorrhage occurs, this risk may be higher. Other causes of morbidity include seizures, headaches, or progressive neurologic deficits. Once an AVM has been discovered, the utility of attempted obliteration or surgical resection compared to the risk of intervention should be entertained. The characteristics of the malformation as well as the patient's overall health status contribute to the decision to intervene on these lesions. For small lesions located in superficial areas without high-risk surgical characteristics (low-grade Spetzler-Martin grades), it is reasonable to consider surgical resection. In lesions that pose high-risk of complications from surgical removal, intra-arterial embolization, radiosurgery, or a combination of the two may be reasonable treatment options. Some AVMs at traditional high surgical risk may be amenable to partial embolization, allowing initially high-risk lesions to become better candidates for surgical resection. In some patients, particularly those who are older or who have multiple medical comorbidities, the risk of intervention as compared to the annual hemorrhage risk may warrant conservative management as opposed to intervention. The overall treatment strategy must be based on patient and AVM characteristics and careful risk-benefit ratio analysis.
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Rossmeisl JH. New treatment modalities for brain tumors in dogs and cats. Vet Clin North Am Small Anim Pract 2014; 44:1013-38. [PMID: 25441624 DOI: 10.1016/j.cvsm.2014.07.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Despite advancements in standard therapies, intracranial tumors remain a significant source of morbidity and mortality in veterinary and human medicine. Several newer approaches are gaining more widespread acceptance or are currently being prepared for translation from experimental to routine therapeutic use. Clinical trials in dogs with spontaneous brain tumors have contributed to the development and human translation of several novel therapeutic brain tumor approaches.
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Affiliation(s)
- John H Rossmeisl
- Neurology and Neurosurgery, Department of Small Animal Clinical Sciences, VA-MD Regional College of Veterinary Medicine, Virginia Tech, 215 Duckpond Drive, Mail Code 0442, Blacksburg, VA 24061, USA.
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Rubin BA, Brunswick A, Riina H, Kondziolka D. Advances in Radiosurgery for Arteriovenous Malformations of the Brain. Neurosurgery 2014; 74 Suppl 1:S50-9. [DOI: 10.1227/neu.0000000000000219] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Arteriovenous malformations of the brain are a considerable source of morbidity and mortality for patients who harbor them. Although our understanding of this disease has improved, it remains in evolution. Advances in our ability to treat these malformations and the modes by which we address them have also improved substantially. However, the variety of patient clinical and disease scenarios often leads us into challenging and complex management algorithms as we balance the risks of treatment against the natural history of the disease. The goal of this article is to provide a focused review of the natural history of cerebral arteriovenous malformations, to examine the role of stereotactic radiosurgery, to discuss the role of endovascular therapy as it relates to stereotactic radiosurgery, and to look toward future advances.
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