1
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Essibayi MA, Tos SM, Vadset T, Behbahani M, Lasala PA, Altschul DJ, Sheehan JP. Stereotactic Radiosurgery Outcomes in Arteriovenous Malformations: A Pediatric-Adult Comparative Meta-Analysis. World Neurosurg 2024:S1878-8750(24)01405-0. [PMID: 39151696 DOI: 10.1016/j.wneu.2024.08.045] [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: 07/09/2024] [Revised: 08/05/2024] [Accepted: 08/06/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is an established treatment for brain arteriovenous malformations (AVMs), but outcomes between pediatric and adult populations are not well compared. We conducted a systematic review and meta-analysis comparing SRS outcomes for pediatric versus adult AVMs. METHODS PubMed was searched for studies reporting SRS outcomes for pediatric or adult AVMs up to January 2024. Primary outcome was obliteration rate, with secondary outcomes including post-SRS hemorrhage, symptomatic radiation-induced changes (RICs), and permanent RICs. Pooled estimates were calculated using random effects models. RESULTS Analysis included 22 studies with 3469 patients (1316 pediatric, 2153 adult). Pooled obliteration rate was 63% (95% confidence interval: 56%-70%) overall, with no significant difference between pediatric (61%) and adult (67%) cohorts (P = 0.38). Post-SRS hemorrhage rates were similar (5% pediatric, 6% adult, P = 0.60). Symptomatic RICs occurred in 9% (95% confidence interval: 6%-13%) overall, with 10% in both cohorts (P = 0.91). Permanent RIC rates were 4% in pediatric and 3% in adult cohorts (P = 0.43). Cyst formation (0.6%) and radiation-induced tumors (0.2%) were rare. All-cause mortality was significantly lower in the pediatric cohort (2.6% vs. 9.8%, P = 0.003). Hemorrhagic AVM presentation was inversely correlated with symptomatic RICs across both groups. CONCLUSIONS SRS is a reasonable treatment option for appropriately selected AVM patients in both pediatric and adult populations, offering comparable obliteration rates and adverse event profiles. The lower mortality in pediatric patients underscores the importance of early intervention in this population given their high cumulative lifetime rupture risks.
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Affiliation(s)
- Muhammed Amir Essibayi
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Salem M Tos
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Taylor Vadset
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Mandana Behbahani
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Patrick A Lasala
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - David J Altschul
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
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2
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Flores-Milan G, Rainone GJ, Peto I, Vakharia KV, Guerrero WR, Mokin M, Hartnett SM, Agazzi S. Timing of Embolization, Radiosurgery, and Resection of Arteriovenous Malformations in Pediatric Patients: A Retrospective, Descriptive Study. World Neurosurg 2024:S1878-8750(24)01301-9. [PMID: 39074586 DOI: 10.1016/j.wneu.2024.07.161] [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: 02/11/2024] [Revised: 07/21/2024] [Accepted: 07/22/2024] [Indexed: 07/31/2024]
Abstract
OBJECTIVE Cerebral arteriovenous malformations (AVMs) are a challenging pathology in pediatric patients, carrying a high risk of morbidity and mortality. Treatment modalities include resection, endovascular embolization, and stereotactic radiosurgery. There is currently no consensus favoring one modality over another. Timing of multimodal therapy with embolization/stereotactic radiosurgery and resection is not well explored in the literature. We present a series of pediatric patients with AVMs, with special attention directed to the timing of treatment. METHODS Electronic medical records of all pediatric patients (<18 years old at treatment) with AVMs treated at our institution were retrospectively reviewed after institutional review board approval. Demographic information, AVM characteristics, treatment variables, and outcomes were recorded. RESULTS In our cohort of 27 patients, 21 (77.8%) presented with a ruptured AVM. Of these patients, 6 (28.6%) had a Glasgow Coma Scale score of 3-10 and underwent treatment within 24 hours of presentation, and 10 (47.6%) with a Glasgow Coma Scale score of 12-15 were treated between 24 and 120 hours after presentation. The remaining 5 patients (23.8%) were treated 3 weeks to 14 months after AVM rupture. Regardless of rupture status, 96% of our cohort had a modified Rankin Scale score of 1-2 at most recent follow-up. CONCLUSIONS We present our institution's experience with pediatric AVMs, focusing on the timing of treatment. Based on our experience, early treatment of AVMs seems to be safe and effective regardless of rupture status.
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Affiliation(s)
- Gabriel Flores-Milan
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Gersham J Rainone
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA.
| | - Ivo Peto
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Kunal V Vakharia
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA; Neurosciences Group, Tampa General Hospital, Tampa, Florida, USA
| | - Waldo R Guerrero
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA; Neurosciences Group, Tampa General Hospital, Tampa, Florida, USA
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA; Neurosciences Group, Tampa General Hospital, Tampa, Florida, USA
| | - Sara M Hartnett
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
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3
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Becerril-Gaitan A, Ironside N, Chen CJ, Ding D. Commentary: Risk for Hemorrhage the First 2 Years After Gamma Knife Surgery for Arteriovenous Malformations: An Update. Neurosurgery 2022; 91:e153-e154. [PMID: 36250710 DOI: 10.1227/neu.0000000000002179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 08/19/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
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4
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Mooney J, Salehani A, Erickson N, Thomas E, Ilyas A, Rahm S, Eustace N, Maleknia P, Yousuf O, Bredel M, Fiveash J, Dobelbower C, Fisher W. Stereotactic radiosurgery for ruptured versus unruptured intracranial arteriovenous malformations. Surg Neurol Int 2022; 13:194. [PMID: 35673645 PMCID: PMC9168326 DOI: 10.25259/sni_86_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/22/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
There are a limited data examining the effects of prior hemorrhage on outcomes after stereotactic radiosurgery (SRS). The goal of this study was to identify risk factors for arteriovenous malformation (AVM) rupture and compare outcomes, including post-SRS hemorrhage, between patients presenting with ruptured and unruptured AVMs.
Methods:
A retrospective review of consecutive patients undergoing SRS for intracranial AVMs between 2009 and 2019 at our institution was conducted. Chi-square and multivariable logistic regression analyses were utilized to identify patient and AVM factors associated with AVM rupture at presentation and outcomes after SRS including the development of recurrent hemorrhage in both ruptured and unruptured groups.
Results:
Of 210 consecutive patients with intracranial AVMs treated with SRS, 73 patients (34.8%) presented with AVM rupture. Factors associated with AVM rupture included smaller AVM diameter, deep venous drainage, cerebellar location, and the presence of intranidal aneurysms (P < 0.05). In 188 patients with adequate follow-up time (mean 42.7 months), the overall post-SRS hemorrhage rate was 8.5% and was not significantly different between ruptured and unruptured groups (10.3 vs. 7.5%, P = 0.51). There were no significant differences in obliteration rate, time to obliteration, or adverse effects requiring surgery or steroids between unruptured and ruptured groups.
Conclusion:
Smaller AVM size, deep venous drainage, and associated intranidal aneurysms were associated with rupture at presentation. AVM rupture at presentation was not associated with an increased risk of recurrent hemorrhage or other complication after SRS when compared to unruptured AVM presentation. Obliteration rates were similar between ruptured and unruptured groups.
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Affiliation(s)
- James Mooney
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Arsalaan Salehani
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Nicholas Erickson
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Evan Thomas
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Sage Rahm
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Nicholas Eustace
- Department of School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Pedram Maleknia
- Department of School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Omer Yousuf
- Department of School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States,
| | - Markus Bredel
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - John Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Chris Dobelbower
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Winfield Fisher
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, United States,
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5
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Hasegawa T, Kato T, Naito T, Tanei T, Okada K, Ito R, Koketsu Y, Hirayama K. Long-Term Risks of Hemorrhage and Adverse Radiation Effects of Stereotactic Radiosurgery for Brain Arteriovenous Malformations. Neurosurgery 2022; 90:784-792. [PMID: 35315812 DOI: 10.1227/neu.0000000000001913] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/16/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The information about long-term risks of hemorrhage and late adverse radiation effects (AREs) after stereotactic radiosurgery for brain arteriovenous malformations (AVMs) is lacking. OBJECTIVE To evaluate the long-term risks of hemorrhage and late ARE rates in patients with AVM treated with Gamma Knife surgery (GKS). METHODS We examined 1249 patients with AVM treated with GKS. The Spetzler-Martin grade was I in 313 patients (25%), II in 394 (32%), III in 458 (37%), and IV/V in 84 (7%). The median treatment volume was 2.5 cm3, and the median marginal dose was 20 Gy. RESULTS The median follow-up period was 61 months. The 5- and 10-year nidus obliteration rates were 63% and 82%, respectively. The 5- and 10-year cumulative hemorrhage rates were 7% and 10%, respectively. The annual hemorrhage rate was 1.5% for the first 5 years post-GKS, which decreased to 0.5% thereafter. During the follow-up period, 42 symptomatic cyst formations/chronic encapsulated hematomas ([CFs/CEHs], 3%) and 3 radiation-induced tumors (0.2%) were observed. The 10- and 15-year cumulative CF/CEH rates were 3.7% and 9.4%, respectively. CONCLUSION GKS is associated with reduced hemorrhage risk and high nidus obliteration rates in patients with AVM. The incidence of late AREs tended to increase over time. The most common ARE was CF/CEH, which can be safely removed; however, careful attention should be paid to the long-term development of fatal radiation-induced tumors.
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Affiliation(s)
- Toshinori Hasegawa
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
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6
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Sporns PB, Fullerton HJ, Lee S, Kim H, Lo WD, Mackay MT, Wildgruber M. Childhood stroke. Nat Rev Dis Primers 2022; 8:12. [PMID: 35210461 DOI: 10.1038/s41572-022-00337-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 01/09/2023]
Abstract
Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, Benioff Children's Hospital, University of California at San Francisco, San Francisco, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Helen Kim
- Departments of Anesthesia and Perioperative Care, and Epidemiology and Biostatistics, Center for Cerebrovascular Research, University of California at San Francisco, San Francisco, CA, USA
| | - Warren D Lo
- Departments of Pediatrics and Neurology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Mark T Mackay
- Department of Neurology, Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Munich, LMU Munich, Munich, Germany.
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7
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Yan D, Chen Y, Li Z, Zhang H, Li R, Yuan K, Han H, Meng X, Jin H, Gao D, Li Y, Sun S, Liu A, Chen X, Zhao Y. Stereotactic Radiosurgery With vs. Without Prior Embolization for Brain Arteriovenous Malformations: A Propensity Score Matching Analysis. Front Neurol 2021; 12:752164. [PMID: 34712200 PMCID: PMC8545857 DOI: 10.3389/fneur.2021.752164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/08/2021] [Indexed: 11/24/2022] Open
Abstract
Objective: Whether partial embolization could facilitate the post-stereotactic radiosurgery (SRS) obliteration for brain arteriovenous malformations (bAVMs) remains controversial. We performed this study to compare the outcomes of SRS with and without prior embolization for bAVMs. Methods: We retrospectively reviewed the Beijing Tiantan AVMs prospective registration research database from September 2011 to October 2014. Patients were categorized into two groups, combined upfront embolization and SRS (Em+SRS group) and SRS alone (SRS group), and we performed a propensity score matching analysis based on pre-embolization baseline characteristics; the matched groups each comprised 76 patients. Results: The obliteration rate was similar between SRS and Em+SRS (44.7 vs. 31.6%; OR, 1.754; 95% CI, 0.905–3.401; p = 0.096). However, the SRS group was superior to the Em+SRS group in terms of cumulative obliteration rate at a follow-up of 5 years (HR,1.778; 95% CI, 1.017–3.110; p = 0.033). The secondary outcomes, including functional state, post-SRS hemorrhage, all-cause mortality, and edema or cyst formation were similar between the matched cohorts. In the ruptured subgroup, the SRS group could achieve higher obliteration rate than Em+SRS group (56.5 vs. 31.9%; OR, 2.773; 95% CI, 1.190–6.464; p = 0.018). The cumulative obliteration rate at 5 years was also higher in the SRS group (64.5 vs. 41.3%; HR, 2.012; 95% CI, 1.037–3.903; p = 0.038), and the secondary outcomes were also similar between the matched cohorts. Conclusion: Although there was no significant difference in the overall obliteration rate between the two strategies, this study suggested that pre-SRS embolization may have a negative effect on post-SRS obliteration. Furthermore, the obliteration rates of the SRS only strategy was significantly higher than that of the Em+SRS strategy in the ruptured cohort, while no such phenomenon was found in the unruptured cohort.
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Affiliation(s)
- Debin Yan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiangyu Meng
- Stroke Center, Beijing Institute for Brain Disorders, Beijing, China
| | - Hengwei Jin
- Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translation Medicine for Cerebrovascular Disease, Beijing, China
| | - Dezhi Gao
- Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Youxiang Li
- Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translation Medicine for Cerebrovascular Disease, Beijing, China
| | - Shibin Sun
- Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Ali Liu
- Beijing Translational Engineering Enter for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Gamma-Knife Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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8
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Chen CJ, Ding D, Lee CC, Kearns KN, Pomeraniec IJ, Cifarelli CP, Arsanious DE, Liscak R, Hanuska J, Williams BJ, Yusuf MB, Woo SY, Ironside N, Burke RM, Warnick RE, Trifiletti DM, Mathieu D, Mureb M, Benjamin C, Kondziolka D, Feliciano CE, Rodriguez-Mercado R, Cockroft KM, Simon S, Mackley HB, Zammar SG, Patel NT, Padmanaban V, Beatson N, Saylany A, Lee JYK, Sheehan JP. Stereotactic radiosurgery with versus without prior Onyx embolization for brain arteriovenous malformations. J Neurosurg 2021; 135:742-750. [PMID: 33307527 PMCID: PMC8192588 DOI: 10.3171/2020.7.jns201731] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Investigations of the combined effects of neoadjuvant Onyx embolization and stereotactic radiosurgery (SRS) on brain arteriovenous malformations (AVMs) have not accounted for initial angioarchitectural features prior to neuroendovascular intervention. The aim of this retrospective, multicenter matched cohort study is to compare the outcomes of SRS with versus without upfront Onyx embolization for AVMs using de novo characteristics of the preembolized nidus. METHODS The International Radiosurgery Research Foundation AVM databases from 1987 to 2018 were retrospectively reviewed. Patients were categorized based on AVM treatment approach into Onyx embolization (OE) and SRS (OE+SRS) or SRS alone (SRS-only) cohorts and then propensity score matched in a 1:1 ratio. The primary outcome was AVM obliteration. Secondary outcomes were post-SRS hemorrhage, all-cause mortality, radiological and symptomatic radiation-induced changes (RICs), and cyst formation. Comparisons were analyzed using crude rates and cumulative probabilities adjusted for competing risk of death. RESULTS The matched OE+SRS and SRS-only cohorts each comprised 53 patients. Crude rates (37.7% vs 47.2% for the OE+SRS vs SRS-only cohorts, respectively; OR 0.679, p = 0.327) and cumulative probabilities at 3, 4, 5, and 6 years (33.7%, 44.1%, 57.5%, and 65.7% for the OE+SRS cohort vs 34.8%, 45.5%, 59.0%, and 67.1% for the SRS-only cohort, respectively; subhazard ratio 0.961, p = 0.896) of AVM obliteration were similar between the matched cohorts. The secondary outcomes of the matched cohorts were also similar. Asymptomatic and symptomatic embolization-related complication rates in the matched OE+SRS cohort were 18.9% and 9.4%, respectively. CONCLUSIONS Pre-SRS AVM embolization with Onyx does not appear to negatively influence outcomes after SRS. These analyses, based on de novo nidal characteristics, thereby refute previous studies that found detrimental effects of Onyx embolization on SRS-induced AVM obliteration. However, given the risks incurred by nidal embolization using Onyx, this neoadjuvant intervention should be used judiciously in multimodal treatment strategies involving SRS for appropriately selected large-volume or angioarchitecturally high-risk AVMs.
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Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Kentucky
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kathryn N. Kearns
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | | | - David E. Arsanious
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
| | - Roman Liscak
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir Hanuska
- Department of Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | | | - Mehran B. Yusuf
- Department of Radiation Oncology, University of Louisville, Kentucky
| | - Shiao Y. Woo
- Department of Radiation Oncology, University of Louisville, Kentucky
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Rebecca M. Burke
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | | | | | - David Mathieu
- Department of Neurosurgery, University of Sherbrooke, Canada
| | - Monica Mureb
- Department of Neurosurgery, New York University, New York, New York
| | | | | | - Caleb E. Feliciano
- Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Kevin M. Cockroft
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Scott Simon
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Heath B. Mackley
- Department of Radiation Oncology, Pennsylvania State University, Hershey, Pennsylvania
| | - Samer G. Zammar
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Neel T. Patel
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Varun Padmanaban
- Department of Neurosurgery, Pennsylvania State University, Hershey, Pennsylvania
| | - Nathan Beatson
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anissa Saylany
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Y. K. Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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9
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Burke RM, Chen CJ, Ding D, Buell TJ, Sokolowski J, Sheehan KA, Lee CC, Sheehan DE, Kano H, Kearns KN, Tzeng SW, Yang HC, Huang PP, Kondziolka D, Ironside N, Mathieu D, Iorio-Morin C, Grills IS, Feliciano C, Barnett G, Starke RM, Lunsford LD, Sheehan JP. Effect of Prior Embolization on Outcomes After Stereotactic Radiosurgery for Pediatric Brain Arteriovenous Malformations: An International Multicenter Study. Neurosurgery 2021; 89:672-679. [PMID: 34333653 DOI: 10.1093/neuros/nyab245] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 05/08/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pediatric brain arteriovenous malformations (AVMs) are a significant cause of morbidity but the role of multimodal therapy in the treatment of these lesions is not well understood. OBJECTIVE To compare the outcomes of stereotactic radiosurgery (SRS) with and without prior embolization for pediatric AVMs. METHODS We retrospectively evaluated the International Radiosurgery Research Foundation pediatric AVM database. AVMs were categorized, based on use of pre-embolization (E + SRS) or lack thereof (SRS-only). Outcomes were compared in unadjusted and inverse probability weight (IPW)-adjusted models. Favorable outcome was defined as obliteration without post-SRS hemorrhage or permanent radiation-induced changes (RIC). RESULTS The E + SRS and SRS-only cohorts comprised 91 and 448 patients, respectively. In unadjusted models, the SRS-only cohort had higher rates of obliteration (68.5% vs 43.3%, < .001) and favorable outcome (61.2% vs 36.3%, P < .001) but a lower rate of symptomatic RIC (9.0% vs 16.7%, P = .031). The IPW-adjusted rates of every outcome were similar between the 2 cohorts. However, cumulative obliteration rates at 3, 5, 8, and 10 yr remained higher in the absence of prior embolization (46.3%, 64.6%, 72.6%, and 77.4% for SRS-only vs 24.4%, 37.2%, 44.1%, and 48.7% for E + SRS cohorts, respectively; SHR = 0.449 [0.238-0.846], P = .013). CONCLUSION Embolization appears to decrease cumulative obliteration rates after SRS for pediatric AVMs without affecting the risk of post-treatment hemorrhage or adverse radiation effects arguing against the routine use of pre-SRS embolization. While endovascular therapy can be considered for occlusion of high-risk angioarchitectural features prior to SRS, future studies are necessary to clarify its role.
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Affiliation(s)
- Rebecca M Burke
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jennifer Sokolowski
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Kimball A Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Darrah E Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kathryn N Kearns
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Shih-Wei Tzeng
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Paul P Huang
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
| | - Natasha Ironside
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - David Mathieu
- Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Christian Iorio-Morin
- Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan, USA
| | - Caleb Feliciano
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | - Gene Barnett
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami, Florida, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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10
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Burke RM, Chen CJ, Ding D, Buell TJ, Sokolowski JD, Lee CC, Kano H, Kearns KN, Tzeng SW, Yang HC, Huang PP, Kondziolka D, Ironside N, Mathieu D, Iorio-Morin C, Grills IS, Feliciano C, Barnett GH, Starke RM, Lunsford LD, Sheehan JP. Early obliteration of pediatric brain arteriovenous malformations after stereotactic radiosurgery: an international multicenter study. J Neurosurg Pediatr 2020; 26:398-405. [PMID: 32590353 DOI: 10.3171/2020.4.peds19738] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 04/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is a treatment option for pediatric brain arteriovenous malformations (AVMs), and early obliteration could encourage SRS utilization for a subset of particularly radiosensitive lesions. The objective of this study was to determine predictors of early obliteration after SRS for pediatric AVMs. METHODS The authors performed a retrospective review of the International Radiosurgery Research Foundation AVM database. Obliterated pediatric AVMs were sorted into early (obliteration ≤ 24 months after SRS) and late (obliteration > 24 months after SRS) responders. Predictors of early obliteration were identified, and the outcomes of each group were compared. RESULTS The overall study cohort was composed of 345 pediatric patients with obliterated AVMs. The early and late obliteration cohorts were made up of 95 (28%) and 250 (72%) patients, respectively. Independent predictors of early obliteration were female sex, a single SRS treatment, a higher margin dose, a higher isodose line, a deep AVM location, and a smaller AVM volume. The crude rate of post-SRS hemorrhage was 50% lower in the early (3.2%) than in the late (6.4%) obliteration cohorts, but this difference was not statistically significant (p = 0.248). The other outcomes of the early versus late obliteration cohorts were similar, with respect to symptomatic radiation-induced changes (RICs), cyst formation, and tumor formation. CONCLUSIONS Approximately one-quarter of pediatric AVMs that become obliterated after SRS will achieve this radiological endpoint within 24 months of initial SRS. The authors identified multiple factors associated with early obliteration, which may aid in prognostication and management. The overall risks of delayed hemorrhage, RICs, cyst formation, and tumor formation were not statistically different in patients with early versus late obliteration.
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Affiliation(s)
- Rebecca M Burke
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- 5Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Thomas J Buell
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jennifer D Sokolowski
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- 2Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hideyuki Kano
- 4Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Kathryn N Kearns
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Shih-Wei Tzeng
- 2Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
| | - Huai-Che Yang
- 2Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
| | - Paul P Huang
- 7Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Douglas Kondziolka
- 7Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Natasha Ironside
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - David Mathieu
- 8Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Quebec, Canada
| | - Christian Iorio-Morin
- 8Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Quebec, Canada
| | - Inga S Grills
- 9Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Caleb Feliciano
- 10Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico; and
| | - Gene H Barnett
- 6Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - L Dade Lunsford
- 4Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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11
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Daou BJ, Palmateer G, Thompson BG, Maher CO, Hayman JA, Lam KL, Wahl DR, Kim M, Pandey AS. Stereotactic Radiosurgery for Brain Arteriovenous Malformations: Evaluation of Obliteration and Review of Associated Predictors. J Stroke Cerebrovasc Dis 2020; 29:104863. [PMID: 32689634 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104863] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/11/2020] [Accepted: 04/02/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND High arteriovenous malformation (AVM) obliteration rates have been reported with stereotactic radiosurgery (SRS), and multiple factors have been found to be associated with AVM obliteration. These predictors have been inconsistent throughout studies. We aimed to analyze our experience with linear accelerator (LINAC)-based SRS for brain AVMs, evaluate outcomes, assess factors associated with AVM obliteration and review the various reported predictors of AVM obliteration. METHODS Electronic medical records were retrospectively reviewed to identify consecutive patients with brain AVMs treated with SRS over a 27-year period with at least 2 years of follow-up. Logistic regression analysis was performed to identify factors associated with AVM obliteration. RESULTS One hundred twenty-eight patients with 142 brain AVMs treated with SRS were included. Mean age was 34.4 years. Fifty-two percent of AVMs were associated with a hemorrhage before SRS, and 14.8% were previously embolized. Mean clinical and angiographic follow-up times were 67.8 months and 58.6 months, respectively. The median Spetzler-Martin grade was 3. Mean maximal AVM diameter was 2.8 cm and mean AVM target volume was 7.4 cm3 with a median radiation dose of 16 Gy. Complete AVM obliteration was achieved in 80.3%. Radiation-related signs and symptoms were encountered in 32.4%, only 4.9% of which consisted of a permanent deficit. Post-SRS AVM-related hemorrhage occurred in 6.3% of cases. In multivariate analysis, factors associated with AVM obliteration included younger patient age (P = .019), male gender (P = .008), smaller AVM diameter (P = .04), smaller AVM target volume (P = .009), smaller isodose surface volume (P = .005), a higher delivered radiation dose (P = .013), and having only one major draining vein (P = .04). CONCLUSIONS AVM obliteration with LINAC-based radiosurgery was safe and effective and achieved complete AVM obliteration in about 80% of cases. The most prominent predictors of AVM success included AVM size, AVM volume, radiation dose, number of draining veins and patient age.
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Affiliation(s)
- Badih J Daou
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - Gregory Palmateer
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - B Gregory Thompson
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - Cormac O Maher
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - James A Hayman
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Kwok L Lam
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Daniel R Wahl
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Michelle Kim
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Aditya S Pandey
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
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12
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Chen CJ, Lee CC, Kano H, Kearns KN, Ding D, Tzeng SW, Atik A, Joshi K, Barnett GH, Huang PP, Kondziolka D, Mathieu D, Iorio-Morin C, Grills IS, Quinn TJ, Siddiqui ZA, Marvin K, Feliciano C, Faramand A, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for pediatric brain arteriovenous malformations: long-term outcomes. J Neurosurg Pediatr 2020; 25:497-505. [PMID: 32032957 DOI: 10.3171/2019.12.peds19595] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Contrary to the better described obliteration- and hemorrhage-related data after stereotactic radiosurgery (SRS) of brain arteriovenous malformations (AVMs) in pediatric patients, estimates of the rarer complications, including cyst and tumor formation, are limited in the literature. The aim of the present study was to assess the long-term outcomes and risks of SRS for AVMs in pediatric patients (age < 18 years). METHODS The authors retrospectively analyzed the International Radiosurgery Research Foundation pediatric AVM database for the years 1987 to 2018. AVM obliteration, post-SRS hemorrhage, cyst formation, and tumor formation were assessed. Cumulative probabilities, adjusted for the competing risk of death, were calculated. RESULTS The study cohort comprised 539 pediatric AVM patients (mean follow-up 85.8 months). AVM obliteration was observed in 64.3% of patients, with cumulative probabilities of 63.6% (95% CI 58.8%-68.0%), 77.1% (95% CI 72.1%-81.3%), and 88.1% (95% CI 82.5%-92.0%) over 5, 10, and 15 years, respectively. Post-SRS hemorrhage was observed in 8.4% of patients, with cumulative probabilities of 4.9% (95% CI 3.1%-7.2%), 9.7% (95% CI 6.4%-13.7%), and 14.5% (95% CI 9.5%-20.5%) over 5, 10, and 15 years, respectively. Cyst formation was observed in 2.1% of patients, with cumulative probabilities of 5.5% (95% CI 2.3%-10.7%) and 6.9% (95% CI 3.1%-12.9%) over 10 and 15 years, respectively. Meningiomas were observed in 2 patients (0.4%) at 10 and 12 years after SRS, with a cumulative probability of 3.1% (95% CI 0.6%-9.7%) over 15 years. CONCLUSIONS AVM obliteration can be expected after SRS in the majority of the pediatric population, with a relatively low risk of hemorrhage during the latency period. Cyst and benign tumor formation after SRS can be observed in 7% and 3% of patients over 15 years, respectively. Longitudinal surveillance for delayed neoplasia is prudent despite its low incidence.
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Affiliation(s)
- Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- 2Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hideyuki Kano
- 4Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kathryn N Kearns
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- 5Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Shih-Wei Tzeng
- 2Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital
| | - Ahmet Atik
- 6Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Krishna Joshi
- 6Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gene H Barnett
- 6Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Paul P Huang
- 7Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Douglas Kondziolka
- 7Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - David Mathieu
- 8Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Christian Iorio-Morin
- 8Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Inga S Grills
- 9Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan; and
| | - Thomas J Quinn
- 9Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan; and
| | - Zaid A Siddiqui
- 9Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan; and
| | - Kim Marvin
- 9Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan; and
| | - Caleb Feliciano
- 10Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | - Andrew Faramand
- 4Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- 4Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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