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Maroufi SF, Fallahi MS, Khorasanizadeh M, Waqas M, Sheehan JP. Radiosurgery With Prior Embolization Versus Radiosurgery Alone for Intracranial Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2024; 94:478-496. [PMID: 37796184 DOI: 10.1227/neu.0000000000002699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/02/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The addition of adjuvant embolization to radiosurgery has been proposed as a means of improving treatment outcomes of intracranial arteriovenous malformations (AVMs). However, the relative efficacy and safety of radiosurgery with adjuvant embolization vs radiosurgery alone remain uncertain. Moreover, previous systematic reviews and meta-analyses have included a limited number of studies and did not consider the effects of baseline characteristics, including AVM volume, on the outcomes. This systematic review aimed to evaluate the efficacy of preradiosurgery embolization for intracranial AVMs with consideration to matching status between participants in each treatment group. METHODS A systematic review and meta-analysis were conducted by searching electronic databases, including PubMed, Scopus, and Cochrane Library, up to January 2023. All studies evaluating the utilization of preradiosurgery embolization were included. RESULTS A total of 70 studies (9 matched and 71 unmatched) with a total of 12 088 patients were included. The mean age of the included patients was 32.41 years, and 48.91% of the patients were female. Preradiosurgery embolization was used for larger AVMs and patients with previous hemorrhage ( P < .01, P = .02, respectively). The obliteration rate for preradiosurgery embolization (49.44%) was lower compared with radiosurgery alone (61.42%, odds ratio = 0.56, P < .01), regardless of the matching status of the analyzed studies. Although prior embolization was associated higher rate of cyst formation ( P = .04), it lowered the odds of radiation-induced changes ( P = .04). The risks of minor and major neurological deficits, postradiosurgery hemorrhage, and mortality were comparable between groups. CONCLUSION This study provides evidence that although preradiosurgery embolization is a suitable option to reduce the AVM size for future radiosurgical interventions, it may not be useful for same-sized AVMs eligible for radiosurgery. Utilization of preradiosurgery embolization in suitable lesions for radiosurgery may result in the added cost and burden of an endovascular procedure.
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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 Sadegh Fallahi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran , Iran
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran , Iran
| | - MirHojjat Khorasanizadeh
- Department of Neurosurgery, Mount Sinai Hospital, Icahn School of Medicine, New York City , New York , USA
| | - Muhammad Waqas
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo , New York , USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
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LINAC stereotactic radiosurgery for brain arteriovenous malformations: An updated single centre analysis of outcomes. J Clin Neurosci 2022; 102:54-59. [PMID: 35728395 DOI: 10.1016/j.jocn.2022.06.003] [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: 11/11/2021] [Revised: 06/03/2022] [Accepted: 06/05/2022] [Indexed: 10/18/2022]
Abstract
Arteriovenous malformations (AVM) of the brain are congenital, high pressure vascular malformations, which are at risk of haemorrhage. Stereotactic radiosurgery (SRS) can obliterate the nidus by delivering a precise high dose of ionising radiation in a single fraction. This paper updates long term AVM obliteration rates, time to obliteration and retreatment outcomes in LINAC delivered SRS treatment at the Royal Adelaide Hospital. A retrospective review of a prospectively maintained AVM SRS database supplemented by clinical case notes, patient correspondence and electronic medical records was performed. 89 AVMs received primary SRS treatment for which the crude obliteration rate was 61% (68% for 79 patients with adequate follow up). Higher marginal dose, smaller nidus size and lower Pollock-Flickinger (PF) score were significantly associated with AVM obliteration. The crude obliteration rates for patients with adequate follow-up and AVM diameter < 3 cm vs ≥ 3 cm were 76% vs 48%, respectively, and 93% with PF score < 1.0. Median time to obliteration was 36 months. Higher dose and lower PF score were associated with earlier obliteration. The crude obliteration rate after second SRS was 56% (9/16 patients) and no significant associations were found. These obliteration rates after primary and retreatment LINAC SRS are comparable to other studies. Marginal dose and PF score were the main predictors of obliteration overall as well as early (<36 months) obliteration.
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Erickson N, Mooney J, Salehani A, Thomas E, Ilyas A, Rahm S, Maleknia P, Yousuf O, Fiveash J, Dobelbower C, Fisher WS. Predictive Factors for AVM Obliteration after Stereotactic Radiosurgery: A Single Center Study. World Neurosurg 2022; 160:e529-e536. [PMID: 35077887 DOI: 10.1016/j.wneu.2022.01.060] [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: 11/08/2021] [Revised: 01/13/2022] [Accepted: 01/15/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND SRS is particularly useful for deep AVMs in eloquent territory with a high associated surgical risk. Prior studies have demonstrated high rates of AVM obliteration with SRS typically ranging 60-80% in a latency period of 2-4 years for complete obliteration. Studies have identified several factors associated with successful obliteration of the AVM nidus, however, these present inconsistent and conflicting data. OBJECTIVE To present a single center study examining factors associated with successful obliteration of AVMs treated with SRS. METHODS We performed a retrospective review of 210 consecutive patients undergoing SRS for brain AVMs between 2010 and 2019 at our institution. Chi square and logistic regression analyses were utilized to identify patient and AVM factors associated with successful obliteration. RESULTS Younger age (p=0.034) and prior embolization (p=0.012) were associated with complete obliteration. Figure 2 demonstrates survival curves for those with complete obliteration comparing those with prior embolization (n = 6) to those without prior embolization (n = 182). The presence of coronary artery disease (CAD) was associated with incomplete obliteration (p=0.04). There were no AVM characteristics statistically associated with complete obliteration although superficial venous drainage (p=0.08) and frontal location (p=0.06) trended towards significance. CONCLUSIONS Successful obliteration of the AVM nidus was significantly associated with younger age and prior embolization. The presence of coronary artery disease negatively affected obliteration rates. These results add to the mixed results seen in the literature and emphasize the need for continued studies to delineate more specific patient and AVM factors that contribute to successful obliteration.
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Affiliation(s)
- Nicholas Erickson
- Department of Neurosurgery, University of Alabama at Birmingham, AL, USA.
| | - James Mooney
- Department of Neurosurgery, University of Alabama at Birmingham, AL, USA
| | - Arsalaan Salehani
- Department of Neurosurgery, University of Alabama at Birmingham, AL, USA
| | - Evan Thomas
- Department of Radiation Oncology, University of Alabama at Birmingham, AL, USA
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, AL, USA
| | - Sage Rahm
- Department of Neurosurgery, University of Alabama at Birmingham, AL, USA
| | - Pedram Maleknia
- School of Medicine, University of Alabama at Birmingham, AL, USA
| | - Omer Yousuf
- School of Medicine, University of Alabama at Birmingham, AL, USA
| | - John Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, AL, USA
| | - Chris Dobelbower
- Department of Radiation Oncology, University of Alabama at Birmingham, AL, USA
| | - Winfield S Fisher
- Department of Neurosurgery, University of Alabama at Birmingham, AL, USA
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Scullen T, Mathkour M, Dumont AS. Commentary: Systematic Review and Meta-Analysis of the Dose-Response and Risk Factors for Obliteration of Arteriovenous Malformations Following Radiosurgery: An Update Based on the Last 20 Years of Published Clinical Evidence. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okab019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Liu R, Zhan Y, Piao J, Yang Z, Wei Y, Liu P, Chen X, Jiang Y. Treatments of unruptured brain arteriovenous malformations: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e26352. [PMID: 34160402 PMCID: PMC8238300 DOI: 10.1097/md.0000000000026352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/10/2021] [Accepted: 05/28/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The best therapeutic option for unruptured brain arteriovenous malformations (bAVMs) patients is disputed. OBJECTIVE To assess the occurrence of obliteration and complications of patients with unruptured bAVMs after various treatments. METHODS A systematic literature search was performed in PubMed, EMBASE, Web of Science, and so on to identify studies fulfilling predefined inclusion criteria. Baseline, treatment, and outcomes data were extracted for statistical analysis. RESULTS We identified 28 eligible studies totaling 5852 patients. The obliteration rates were 98% in microsurgery group (95% confidence interval (CI): 96%-99%, I2 = 74.5%), 97% in surgery group (95%CI: 95%-99%, I2 = 18.3%), 87% in endovascular treatment group (95%CI: 80%-93%, I2 = 0.0%), and 68% in radiosurgery group (95%CI: 66%-69%, I2 = 92.0%). The stroke or death rates were 1% in microsurgery group (95%CI: 0%-2%, I2 = 0.0%), 0% in surgery group (95%CI: 0%-1%, I2 = 0.0%), 4% in endovascular treatment group (95%CI: 0%-8%, I2 = 85.8%), and 3% in radiosurgery group (95%CI: 3%-4%, I2 = 82.9%). In addition, the proportions of hemorrhage were 2% in microsurgery group (95%CI: 1%-4%, I2 = 0.0%), 23% in endovascular treatment group (95%CI: 7%-39%), and 12% in radiosurgery group (95%CI: 12%-13%, I2 = 99.2%). As to neurological deficit, the occurrence was 9% in microsurgery group (95%CI: 6%-11%, I2 = 94.1%), 20% in surgery group (95%CI: 13%-27%, I2 = 0.0%), 14% in endovascular treatment group (95%CI: 10%-18%, I2 = 64.0%), and 8% in radiosurgery group (95%CI: 7%-9%, I2 = 66.6%). CONCLUSIONS We found that microsurgery might provide lasting clinical benefits in some unruptured bAVMs patients for its high obliteration rates and low hemorrhage. These findings are helpful to provide a reference basis for neurosurgeons to choose the treatment of patients with unruptured bAVMs.
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Affiliation(s)
- Renjie Liu
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Yongle Zhan
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jianmin Piao
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Zhongxi Yang
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Yun Wei
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Pengcheng Liu
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Xuan Chen
- Department of Neurovascular Surgery, The First Bethune Hospital of Jilin University, Changchun 130021, Jilin Province
| | - Yu Jiang
- Department of Epidemiology and Biostatistics, School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Hsu PW. Fractionated stereotactic radiosurgery in treating the complex intracranial arteriovenous malformations. FORMOSAN JOURNAL OF SURGERY 2021. [DOI: 10.4103/fjs.fjs_88_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
BACKGROUND Dysphagia (swallowing problems), which is common after stroke, is associated with increased risk of death or dependency, occurrence of pneumonia, poor quality of life, and longer hospital stay. Treatments provided to improve dysphagia are aimed at accelerating recovery of swallowing function and reducing these risks. This is an update of the review first published in 1999 and updated in 2012. OBJECTIVES To assess the effects of swallowing therapy on death or dependency among stroke survivors with dysphagia within six months of stroke onset. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (26 June 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 6) in the Cochrane Library (searched 26 June 2018), MEDLINE (26 June 2018), Embase (26 June 2018), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (26 June 2018), Web of Science Core Collection (26 June 2018), SpeechBITE (28 June 2016), ClinicalTrials.Gov (26 June 2018), and the World Health Organization International Clinical Trials Registry Platform (26 June 2018). We also searched Google Scholar (7 June 2018) and the reference lists of relevant trials and review articles. SELECTION CRITERIA We sought to include randomised controlled trials (RCTs) of interventions for people with dysphagia and recent stroke (within six months). DATA COLLECTION AND ANALYSIS Two review authors independently applied the inclusion criteria, extracted data, assessed risk of bias, used the GRADE approach to assess the quality of evidence, and resolved disagreements through discussion with the third review author (PB). We used random-effects models to calculate odds ratios (ORs), mean differences (MDs), and standardised mean differences (SMDs), and provided 95% confidence intervals (CIs) for each.The primary outcome was functional outcome, defined as death or dependency (or death or disability), at the end of the trial. Secondary outcomes were case fatality at the end of the trial, length of inpatient stay, proportion of participants with dysphagia at the end of the trial, swallowing ability, penetration aspiration score, or pneumonia, pharyngeal transit time, institutionalisation, and nutrition. MAIN RESULTS We added 27 new studies (1777 participants) to this update to include a total of 41 trials (2660 participants).We assessed the efficacy of swallowing therapy overall and in subgroups by type of intervention: acupuncture (11 studies), behavioural interventions (nine studies), drug therapy (three studies), neuromuscular electrical stimulation (NMES; six studies), pharyngeal electrical stimulation (PES; four studies), physical stimulation (three studies), transcranial direct current stimulation (tDCS; two studies), and transcranial magnetic stimulation (TMS; nine studies).Swallowing therapy had no effect on the primary outcome (death or dependency/disability at the end of the trial) based on data from one trial (two data sets) (OR 1.05, 95% CI 0.63 to 1.75; 306 participants; 2 studies; I² = 0%; P = 0.86; moderate-quality evidence). Swallowing therapy had no effect on case fatality at the end of the trial (OR 1.00, 95% CI 0.66 to 1.52; 766 participants; 14 studies; I² = 6%; P = 0.99; moderate-quality evidence). Swallowing therapy probably reduced length of inpatient stay (MD -2.9, 95% CI -5.65 to -0.15; 577 participants; 8 studies; I² = 11%; P = 0.04; moderate-quality evidence). Researchers found no evidence of a subgroup effect based on testing for subgroup differences (P = 0.54). Swallowing therapy may have reduced the proportion of participants with dysphagia at the end of the trial (OR 0.42, 95% CI 0.32 to 0.55; 1487 participants; 23 studies; I² = 0%; P = 0.00001; low-quality evidence). Trial results show no evidence of a subgroup effect based on testing for subgroup differences (P = 0.91). Swallowing therapy may improve swallowing ability (SMD -0.66, 95% CI -1.01 to -0.32; 1173 participants; 26 studies; I² = 86%; P = 0.0002; very low-quality evidence). We found no evidence of a subgroup effect based on testing for subgroup differences (P = 0.09). We noted moderate to substantial heterogeneity between trials for these interventions. Swallowing therapy did not reduce the penetration aspiration score (i.e. it did not reduce radiological aspiration) (SMD -0.37, 95% CI -0.74 to -0.00; 303 participants; 11 studies; I² = 46%; P = 0.05; low-quality evidence). Swallowing therapy may reduce the incidence of chest infection or pneumonia (OR 0.36, 95% CI 0.16 to 0.78; 618 participants; 9 studies; I² = 59%; P = 0.009; very low-quality evidence). AUTHORS' CONCLUSIONS Moderate- and low-quality evidence suggests that swallowing therapy did not have a significant effect on the outcomes of death or dependency/disability, case fatality at the end of the trial, or penetration aspiration score. However, swallowing therapy may have reduced length of hospital stay, dysphagia, and chest infections, and may have improved swallowing ability. However, these results are based on evidence of variable quality, involving a variety of interventions. Further high-quality trials are needed to test whether specific interventions are effective.
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Affiliation(s)
- Philip M Bath
- University of Nottingham, City HospitalStroke Trials Unit, Division of Clinical NeuroscienceNottinghamUKNG5 1PB
| | - Han Sean Lee
- University of Nottingham, City HospitalStroke Trials Unit, Division of Clinical NeuroscienceNottinghamUKNG5 1PB
| | - Lisa F Everton
- University of Nottingham, City HospitalStroke Trials Unit, Division of Clinical NeuroscienceNottinghamUKNG5 1PB
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Meybodi AT, Kim H, Nelson J, Hetts SW, Krings T, terBrugge KG, Faughnan ME, Lawton MT. Surgical Treatment vs Nonsurgical Treatment for Brain Arteriovenous Malformations in Patients with Hereditary Hemorrhagic Telangiectasia: A Retrospective Multicenter Consortium Study. Neurosurgery 2018; 82:35-47. [PMID: 28973426 DOI: 10.1093/neuros/nyx168] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 05/24/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cerebral arteriovenous malformations (AVMs) are common in patients with hereditary hemorrhagic telangiectasia (HHT). However, due to the rarity of HHT and little published evidence of outcomes from management of brain AVMs in this disease, current international HHT guidelines recommend an individualized approach. Specifically, the outcomes for surgical vs nonsurgical management of these lesions have not been reported to date. OBJECTIVE To report long-term outcomes of surgical resection of brain AVMs in HHT patients compared to outcomes in nonsurgically treated patients. METHODS From the database of the Brain Vascular Malformation Consortium HHT project, 19 patients with 20 resected AVMs (group 1) and 22 patients with 33 AVMs who received nonsurgical treatment (group 2) were studied. The groups were retrospectively reviewed for changes in functional status (modified Rankin Scale score) during the follow-up period. RESULTS During the follow-up period, 9% of patients in group 1 suffered from worsening of functional status, whereas this figure was 16% for group 2 (P > .05). Functional outcomes were not statistically different between the 2 groups at the latest follow-up (P > .05). CONCLUSION HHT patients treated surgically for brain AVMs appear to have long-term functional outcomes comparable to nonsurgical (including observational) therapy with fewer unfavorable outcomes. It is therefore reasonable to consider surgical resection as a management option in the multidisciplinary team's individualized treatment strategy for HHT patients with brain AVMs.
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Affiliation(s)
- Ali Tayebi Meybodi
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Helen Kim
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California.,Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California
| | - Jeffrey Nelson
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California.,Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California
| | - Steven W Hetts
- Division of Neurointerventional Radiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California.,Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California
| | - Timo Krings
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Karel G terBrugge
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marie E Faughnan
- Division of Respirology, Keenan Research Centre, and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California.,Center for Cerebrovascular Research, University of California, San Francisco, San Francisco, California
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Sackey FNA, Pinsker NR, Baako BN. Highlights on Cerebral Arteriovenous Malformation Treatment Using Combined Embolization and Stereotactic Radiosurgery: Why Outcomes are Controversial? Cureus 2017; 9:e1266. [PMID: 28652950 PMCID: PMC5481174 DOI: 10.7759/cureus.1266] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 05/22/2017] [Indexed: 11/05/2022] Open
Abstract
Cerebral arteriovenous malformations (AVMs) are abnormal tangling between brain arteries and veins causing an arteriovenous shunt called nidus with an intervening network of vessels from the region of formation and spans through the brain. AVM effect is debilitating to the affected individual due to associated persistent intracerebral hemorrhage, resulting in significant occurrences of seizures and neurological damage. Recent innovative treatments involve a combination of embolization (Embo) procedures followed by stereotactic radiosurgery (SRS), designed to optimize less-invasive practice for the obliteration of the AVMs. Three groups of investigators reported different outcomes based on obliteration rates and adverse events, making the effectiveness of options for therapy, controversial. We have taken the case-oriented-approach to highlight on varying outcomes from various studies and provide insights as to why findings from different operation settings could be so conflicting. We chose 18 articles for systematic analysis based on initial electronic database selection of 40 key papers already identified for inclusion, followed by independent blinding assessment by two co-authors. Our evaluation was based first on our specific inclusion criteria, examining method quality, obliteration rates, serious adverse events (SAEs) and mortality rates. Second, we made a comparison between SRS or embo alone treatments versus combined embo/SRS procedures, relative to AVM sizes, following Spetzler-Martin (SM) method. Third, we considered publications which had concrete statistics with well-defined P-values and clarified outcomes for accurate evaluation. We found that patients with small to medium-sized AVM were susceptible to either embo alone or SRS alone treatments, yielding obliteration rates from 71%-100%. Except for one report, giant sizes AVMs were not amenable to these single treatments, subjecting patients to embo/SRS procedures, which yielded mixed results: One group reported 52%-65% obliteration rates, compared to 23%-28% embo alone treatment. A second group contradicted this apparent beneficial outcome, obtaining obliteration rates of 53% with combined treatment compared to 71% with SRS alone, four-year postoperative. A third group reported there was no difference between single and combined treatments and obtained complete obliteration of 70%-82%, ranging from three-five-years postoperative follow-up. In all the cases analyzed, obliteration rates improved with time. SAEs, such as persistent hemorrhage and permanent neurologic deficits (P-NDs), as well as mortality, were minimal during intraoperative and postoperative follow-ups. The problem of conflicting outcomes in combined treatments of AVM by EMBO/SRS exists. Previous investigators, however, have overlooked to address this issue satisfactorily. Our analysis found that the reported inconsistencies in AVM treatment outcomes are attributable to key factors making therapy unpredictable, which includes: the size of the AVM, nidus localization and accessibility of either Embo or radiation dose applied, certain Embo materials lowering obliteration rates by masking radioactive effect on the nidus during SRS and follow-up timing for obtaining obliteration rates determine the extent of obliteration. We have indicated critical factors which require consideration when planning strategies for treatment of AVM patients and have made suggestions of how to overcome such hurdles.
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Affiliation(s)
- Faustina N A Sackey
- Loeb Health Research Institute at Ottawa Hospital, University of Ottawa, Ontario, Canada
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Thenier-Villa JL, Galárraga-Campoverde RA, Martínez Rolán RM, De La Lama Zaragoza AR, Martínez Cueto P, Muñoz Garzón V, Salgado Fernández M, Conde Alonso C. Linear Accelerator Stereotactic Radiosurgery of Central Nervous System Arteriovenous Malformations: A 15-Year Analysis of Outcome-Related Factors in a Single Tertiary Center. World Neurosurg 2017; 103:291-302. [PMID: 28435119 DOI: 10.1016/j.wneu.2017.04.081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/10/2017] [Accepted: 04/12/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Linear accelerator stereotactic radiosurgery is one of the modalities available for the treatment of central nervous system arteriovenous malformations (AVMs). The aim of this study was to describe our 15-year experience with this technique in a single tertiary center and the analysis of outcome-related factors. METHODS From 1998 to 2013, 195 patients were treated with linear accelerator-based radiosurgery; we conducted a retrospective study collecting patient- and AVM-related variables. Treatment outcomes were obliteration, posttreatment hemorrhage, symptomatic radiation-induced changes, and 3-year neurologic status. We also analyzed prognostic factors of each outcome and predictability analysis of 5 scales: Spetzler-Martin grade, Lawton-Young supplementary and Lawton combined scores, radiosurgery-based AVM score, Virginia Radiosurgery AVM Scale, and Heidelberg score. RESULTS Overall obliteration rate was 81%. Nidus diameter and venous drainage were predictive of obliteration (P < 0.05), ruptured status and previous embolization were not related to rate of obliteration, and low-grade AVMs had higher obliteration rates. Posttreatment hemorrhage incidence was 8.72%; nidus diameter was the only predictor (P = 0.05). Symptomatic radiation-induced changes occurred in 11.79% of patients and were significantly associated with unruptured status (P < 0.05). Treatment success as a composite measure was obtained in 70.77% of patients. Receiver operating characteristic curves were presented for each scoring system and outcome measure; best area under the curve was 0.687 for Lawton combined score in the obliteration outcome. CONCLUSIONS In the long-term, linear accelerator-based radiosurgery is a useful, valid, effective, and safe modality for treatment of brain AVMs.
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Affiliation(s)
- José Luis Thenier-Villa
- Department of Neurosurgery, University Hospital Complex of Vigo-Álvaro Cunqueiro Hospital, Vigo, Pontevedra, Spain.
| | | | - Rosa María Martínez Rolán
- Department of Neurosurgery, University Hospital Complex of Vigo-Álvaro Cunqueiro Hospital, Vigo, Pontevedra, Spain
| | | | - Pedro Martínez Cueto
- Department of Neuroradiology, University Hospital Complex of Vigo-Álvaro Cunqueiro Hospital, Vigo, Pontevedra, Spain
| | - Víctor Muñoz Garzón
- Department of Radiation Oncology, University Hospital Complex of Vigo-Meixoeiro Hospital, Vigo, Pontevedra, Spain
| | - Manuel Salgado Fernández
- Department of Radiophysics, University Hospital Complex of Vigo-Meixoeiro Hospital, Vigo, Pontevedra, Spain
| | - Cesáreo Conde Alonso
- Department of Neurosurgery, University Hospital Complex of Vigo-Álvaro Cunqueiro Hospital, Vigo, Pontevedra, Spain
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Ding D, Starke RM, Sheehan JP. Radiosurgery for the management of cerebral arteriovenous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:69-83. [PMID: 28552160 DOI: 10.1016/b978-0-444-63640-9.00007-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Cerebral arteriovenous malformations (AVMs) are rare, unstable vascular lesions which spontaneously rupture at a rate of approximately 2-4% annually. Stereotactic radiosurgery is a minimally invasive treatment for AVMs, with a favorable risk-to-benefit profile in most patients, with respect to obliteration, hemorrhage, and seizure control. Radiosurgery is ideally suited for small to medium-sized AVMs (diameter <3cm or volume <12cm3) located in deep or eloquent brain regions. Obliteration is ultimately achieved in 70-80% of cases and is directly associated with nidus volume and radiosurgical margin dose. Adverse radiation effects, which appear as T2-weighted hyperintensities on magnetic resonance imaging, develop in 30-40% of patients after AVM radiosurgery, are symptomatic in 10%, and fail to clinically resolve in 2-3%. The risk of AVM hemorrhage may be reduced by radiosurgery, but the hemorrhage risk persists during the latency period between treatment and obliteration. Delayed postradiosurgery cyst formation occurs in 2% of cases and may require surgical treatment. Radiosurgery abolishes or ameliorates seizure activity in the majority of patients with AVM-associated epilepsy and induces de novo seizures in 1-2% of those without preoperative seizures. Strategies for the treatment of large-volume AVMs include neoadjuvant embolization and either dose- or volume-staged radiosurgery.
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Affiliation(s)
- Dale Ding
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
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Oermann EK, Ding D, Yen CP, Starke RM, Bederson JB, Kondziolka D, Sheehan JP. Effect of Prior Embolization on Cerebral Arteriovenous Malformation Radiosurgery Outcomes: A Case-Control Study. Neurosurgery 2016; 77:406-17; discussion 417. [PMID: 25875580 DOI: 10.1227/neu.0000000000000772] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Embolization before stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations (AVM) has been shown to negatively affect obliteration rates, but its impact on the risks of radiosurgery-induced complications and latency period hemorrhage is poorly defined. OBJECTIVE To determine, in a case-control study, the effect of prior embolization on AVM SRS outcomes. METHODS We evaluated a database of AVM patients who underwent SRS. Propensity score analysis was used to match the case (embolized nidi) and control (nonembolized nidi) cohorts. AVM angioarchitectural complexity was defined as the sum of the number of major feeding arteries and draining veins to the nidus. Multivariate Cox proportional hazards regression analyses were performed on the overall study population to determine independent predictors of obliteration and radiation-induced changes. RESULTS The matching process yielded 242 patients in each cohort. The actuarial obliteration rates were significantly lower in the embolized (31%, 49% at 5, 10 years, respectively) compared with the nonembolized (48%, 64% at 5, 10 years, respectively) cohort (P = .003). In the multivariate analysis for obliteration, lower angioarchitectural complexity (P < .001) and radiologically evident radiation-induced changes (P = .016) were independent predictors, but embolization was not significant (P = .744). In the multivariate analysis for radiologic radiation-induced changes, lack of prior embolization (P = .009) and fewer draining veins (P = .011) were independent predictors. CONCLUSION The effect of prior embolization on AVM obliteration after SRS may be significantly confounded by nidus angioarchitectural complexity. Additionally, embolization could reduce the risk of radiation-induced changes. Thus, combined embolization and SRS may be warranted for appropriately selected nidi.
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Affiliation(s)
- Eric K Oermann
- *Mount Sinai Health System, Department of Neurosurgery, New York City, New York; ‡University of Virginia, Department of Neurosurgery, Charlottesville, Virginia; §New York University Langone Medical Center, Department of Neurosurgery, New York City, New York
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Jabbour P, Daou B, Andrews D. Stereotactic radiosurgery for arteriovenous malformations with radiosurgery-based arteriovenous malformation score <1. World Neurosurg 2014; 83:488-9. [PMID: 25219585 DOI: 10.1016/j.wneu.2014.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 09/10/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Pascal Jabbour
- Division of Cerebrovascular Neurosurgery, Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
| | - Badih Daou
- Division of Cerebrovascular Neurosurgery, Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David Andrews
- Division of Neuro-oncology, Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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