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Shaaban A, Tos SM, Mantziaris G, Kotecha R, Fariselli L, Gorgulho A, Levivier M, Ma L, Paddick I, Pollock BE, Regis J, Suh JH, Yomo S, Sahgal A, Sheehan JP. Repeat Single-Session Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations: A Systematic Review, Meta-Analysis, and International Stereotactic Radiosurgery Society Practice Guidelines. Neurosurgery 2024:00006123-990000000-01234. [PMID: 38912814 DOI: 10.1227/neu.0000000000003049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/25/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Repeat stereotactic radiosurgery (SRS) for residual arteriovenous malformations (AVMs) can be considered as a salvage approach after failure of initial SRS. There are no published guidelines regarding patient selection, timing, or SRS parameters to guide clinical practice. This systematic review aimed to review outcomes and complications from the published literature to inform practice recommendations provided on behalf of the International Stereotactic Radiosurgery Society. METHODS We performed a systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of MEDLINE, Scopus, Web of Science, and Embase was conducted. Fourteen studies with 925 patients met the inclusion criteria. Patients were treated between 1985 and 2022. All studies were retrospective, except for one prospective cohort. RESULTS The median patient age at repeat SRS ranged from 32 to 60 years. Four studies (630 patients) reported detailed information on Spetzler-Martin grade at the time of repeat SRS; 12.54% of patients had Spetzler-Martin grade I AVMs (79/630 patients), 46.51% had grade II (293/630), 34.92% had grade III (220/630), 5.08% had grade IV (32/630), and 0.95% had grade V (6/630). The median prescription doses varied between 15 and 25 Gy (mean, 13.06-22.8 Gy). The pooled overall obliteration rate at the last follow-up after repeat SRS was 59% (95% CI 51%-67%) with a median follow-up between 21 and 50 months. The pooled hemorrhage incidence at the last follow-up was 5% (95% CI 4%-7%), and the pooled overall radiation-induced change incidence was 12% (95% CI 7%-20%). CONCLUSION For an incompletely obliterated AVM, repeat radiosurgery after 3 to 5 years of follow-up from the first SRS provides a reasonable benefit to the risk profile. After repeat SRS, obliteration is achieved in the majority of patients. The risk of hemorrhage or radiation-induced change appears low, and International Stereotactic Radiosurgery Society recommendations are presented.
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Affiliation(s)
- Ahmed Shaaban
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Salem M Tos
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Laura Fariselli
- Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alessandra Gorgulho
- Department of Neurosurgery, State University of São Paulo, NeuroSapiens Group, São Paulo, Brazil
- D'Or Institute for Research and Education, São Paulo, Brazil
| | - Marc Levivier
- Department of Neurosurgery and Gamma Knife Center, Lausanne University Hospital, Lausanne, Switzerland
| | - Lijun Ma
- Department of Neurosurgery, State University of São Paulo, NeuroSapiens Group, São Paulo, Brazil
- D'Or Institute for Research and Education, São Paulo, Brazil
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Ian Paddick
- Queen Square Radiosurgery Centre, National Hospital for Neurology and Neurosurgery, London, UK
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jean Regis
- Department of Functional Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix-Marseille University, APHM, CHU Timone, Marseille, France
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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Samaniego EA, Dabus G, Meyers PM, Kan PT, Frösen J, Lanzino G, Welch BG, Volovici V, Gonzalez F, Fifi J, Charbel FT, Hoh BL, Khalessi A, Marks MP, Berenstein A, Pereira VM, Bain M, Colby GP, Narayanan S, Tateshima S, Siddiqui AH, Wakhloo AK, Arthur AS, Lawton MT. Most Promising Approaches to Improve Brain AVM Management: ARISE I Consensus Recommendations. Stroke 2024; 55:1449-1463. [PMID: 38648282 DOI: 10.1161/strokeaha.124.046725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 03/01/2024] [Indexed: 04/25/2024]
Abstract
Brain arteriovenous malformations (bAVMs) are complex, and rare arteriovenous shunts that present with a wide range of signs and symptoms, with intracerebral hemorrhage being the most severe. Despite prior societal position statements, there is no consensus on the management of these lesions. ARISE (Aneurysm/bAVM/cSDH Roundtable Discussion With Industry and Stroke Experts) was convened to discuss evidence-based approaches and enhance our understanding of these complex lesions. ARISE identified the need to develop scales to predict the risk of rupture of bAVMs, and the use of common data elements to perform prospective registries and clinical studies. Additionally, the group underscored the need for comprehensive patient management with specialized centers with expertise in cranial and spinal microsurgery, neurological endovascular surgery, and stereotactic radiosurgery. The collection of prospective multicenter data and gross specimens was deemed essential for improving bAVM characterization, genetic evaluation, and phenotyping. Finally, bAVMs should be managed within a multidisciplinary framework, with clinical studies and research conducted collaboratively across multiple centers, harnessing the collective expertise and centralization of resources.
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Affiliation(s)
- Edgar A Samaniego
- Department of Neurology, Neurosurgery and Radiology, University of Iowa (E.A.S.)
| | - Guilherme Dabus
- Department of Neurosurgery, Baptist Health, Miami, FL (G.D.)
| | - Philip M Meyers
- Department of Radiology and Neurological Surgery, Columbia University, New York (P.M.M.)
| | - Peter T Kan
- Department of Neurological Surgery, University of Texas Medical Branch Galveston (P.T.K.)
| | - Juhana Frösen
- Department of Rehabilitation, Tampere University Hospital, Finland (J.F.)
| | | | - Babu G Welch
- Departments of Neurological Surgery and Radiology; The University of Texas Southwestern, Dallas (B.G.W.)
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands (V.V.)
| | - Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD (F.G.)
| | - Johana Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York (J.F., A.B.)
| | - Fady T Charbel
- Department of Neurosurgery, University of Illinois at Chicago (F.T.C.)
| | - Brian L Hoh
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville (B.L.H.)
| | | | - Michael P Marks
- Interventional Neuroradiology Division, Stanford University Medical Center, Palo Alto, CA (M.P.M.)
| | - Alejandro Berenstein
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York (J.F., A.B.)
| | - Victor M Pereira
- Department of Neurosurgery, St. Michael's Hospital, Toronto, Canada (V.M.P.)
| | - Mark Bain
- Department of Neurological Surgery, Cleveland Clinic, OH (M.B.)
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles (G.P.C.)
| | - Sandra Narayanan
- Neurointerventional Program and Comprehensive Stroke Program, Pacific Neuroscience Institute, Santa Monica, CA (S.N.)
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, Ronald Reagan UCLA Medical Center, Los Angeles (S.T.)
| | - Adnan H Siddiqui
- Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York (A.H.S.)
| | - Ajay K Wakhloo
- Department of Radiology, Tufts University School of Medicine, Boston, MA (A.K.W.)
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis (A.S.A.)
| | - Michael T Lawton
- Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (M.T.L.)
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3
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Han H, Gao D, Ma L, Li R, Li Z, Zhang H, Yuan K, Wang K, Zhang Y, Zhao Y, Jin W, Jin H, Meng X, Yan D, Li R, Lin F, Hao Q, Wang H, Ye X, Kang S, Pu J, Shi Z, Chao X, Lin Z, Lu J, Li Y, Zhao Y, Sun S, Chen Y, Chen X, Wang S. Long-term outcomes of microsurgery and stereotactic radiosurgery as the first-line treatment for arteriovenous malformations: a propensity score-matched analysis using nationwide multicenter prospective registry data. Int J Surg 2023; 109:3983-3992. [PMID: 37720924 PMCID: PMC10720861 DOI: 10.1097/js9.0000000000000751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/25/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND This study aimed to compare the risk and benefit profile of microsurgery (MS) and stereotactic radiosurgery (SRS) as the first-line treatment for unruptured and ruptured arteriovenous malformations (AVMs). MATERIALS AND METHODS The authors included AVMs underwent MS or SRS as the first-line treatment from a nationwide prospective multicenter registry in mainland China. The authors used propensity score-matched methods to balance baseline characteristics between the MS and SRS groups. The primary outcomes were long-term hemorrhagic stroke or death, and the secondary outcomes were long-term obliteration and neurological outcomes. Subgroup analyses and sensitivity analyses with different study designs were performed to confirm the stability of our findings. RESULTS Of the 4286 consecutive AVMs in the registry from August 2011 to December 2021; 1604 patients were eligible. After matching, 244 unruptured and 442 ruptured AVMs remained for the final analysis. The mean follow-up duration was 7.0 years in the unruptured group and 6.1 years in the ruptured group. In the comparison of primary outcomes, SRS was associated with a higher risk of hemorrhagic stroke or death both in the unruptured and ruptured AVMs (unruptured: hazard ratio 4.06, 95% CI: 1.15-14.41; ruptured: hazard ratio 4.19, 95% CI: 1.58-11.15). In terms of the secondary outcomes, SRS was also observed to have a significant disadvantage in long-term obliteration [unruptured: odds ratio (OR) 0.01, 95% CI: 0.00-0.04; ruptured: OR 0.09, 95% CI: 0.05-0.15]. However, it should be noted that SRS may have advantages in preventing neurofunctional decline (unruptured: OR 0.56, 95% CI: 0.27-1.14; ruptured: OR 0.41, 95% CI: 0.23-0.76). The results of subgroup analyses and sensitivity analyses were consistent in trend but with slightly varied powers. CONCLUSIONS This clinical practice-based real-world study comprehensively compared MS and SRS for AVMs with long-term outcomes. MS is more effective in preventing future hemorrhage or death and achieving obliteration, while the risk of neurofunctional decline should not be ignored.
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Affiliation(s)
- Heze Han
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | | | - Li Ma
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | - Ruinan Li
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | - Zhipeng Li
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | - Haibin Zhang
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | - Kexin Yuan
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | - Ke Wang
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | - Yukun Zhang
- Department of Neurosurgery, Peking University International Hospital, Peking University
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Peking University
| | - Weitao Jin
- Department of Neurosurgery, Peking University International Hospital, Peking University
| | - Hengwei Jin
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University
| | - Xiangyu Meng
- Department of Neurosurgery, The First Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang
| | - Debin Yan
- Department of Neurosurgery, Shanxi Provincial People’s Hospital, Shanxi
| | - Runting Li
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | - Fa Lin
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | - Qiang Hao
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | - Hao Wang
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | - Xun Ye
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | - Shuai Kang
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | - Jun Pu
- First Department of Neurosurgery, The Second Affiliated Hospital of Kunming Medical University, Kunming
| | - Zhiyong Shi
- Department of Neurosurgery, Nanjing Drum Tower Hospital, Affiliated to Nanjing University, Nanjing, Jiangsu
| | - Xiaofeng Chao
- Department of Neurosurgery, The Second Affiliated Hospital of Xuzhou Medical University, Jiangsu
| | - Zhengfeng Lin
- Department of Neurosurgery, The First People’s Hospital of Qinzhou, Guangxi
| | - Junlin Lu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University
| | - Yuanli Zhao
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | | | - Yu Chen
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | - Xiaolin Chen
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
| | - Shuo Wang
- Department of Neurosurgery
- China National Clinical Research Center for Neurological Diseases, Beijing
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4
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Ganesh S, Jasper A, Backianathan S, Moorthy RK, Balakrishnan R, Sebastian P, Moses V, Godson HF, Keshava SN, Rajshekhar V. Correlation Between Post-Radiosurgery Perinidal Hyperintensity and AVM Obliteration Following LINAC-Based Stereotactic Radiosurgery. World Neurosurg 2023; 178:e189-e201. [PMID: 37454908 DOI: 10.1016/j.wneu.2023.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE We studied the correlation between new-onset perinidal hyperintensity (PH) on T2-weighted magnetic resonance imaging and obliteration of intracranial arteriovenous malformation (AVM) after stereotactic radiosurgery (SRS). METHODS A retrospective study of 148 patients with an intracranial AVM who underwent SRS between September 2005 and June 2018 and had ≥1 radiological follow-up (early magnetic resonance imaging) 12-18 months after SRS was performed to analyze the correlation between PH (graded from 0 to 2) and AVM obliteration. RESULTS Of the 148 patients, 95 were male. The mean patient age was 27.7 ± 12.4 years. Of the 148 AVMs, 105 (70.9%) were obliterated at a median follow-up of 27 months (interquartile range, 14-48 months). The cumulative 3-, 5-, 10-year obliteration rate was 51.8%, 70.8%, and 91.8%, respectively. New-onset PH was observed in 58 AVMs (39.2%; 50 obliterated and 8 not obliterated). No association was found between the pretreatment variables or dose delivered and the development of PH. Grade 2 PH was associated with the risk of symptoms developing compared with grade 1 PH (37.5% vs. 4%; P = 0.002). Symptomatic PH was more likely to develop in patients with a larger AVM (P = 0.05). On multivariate analysis, the presence of a single draining vein (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.3-6.8), a lower median AVM volume (OR, 0.97; 95% CI, 0.6-0.89), a mean marginal radiation dose (OR, 1.29; 95% CI, 1.02-1.64), and the presence of PH (OR, 3.16; 95% CI, 1.29-7.71) were independent predictors of AVM obliteration. CONCLUSIONS The incidence of PH after SRS for AVM was 39.2%. PH was an independent predictor of AVM obliteration after SRS. Grade 2 PH and a larger AVM volume were associated with symptomatic PH.
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Affiliation(s)
- Swaminathan Ganesh
- Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Anitha Jasper
- Department of Radiodiagnosis, Christian Medical College, Vellore, India
| | | | - Ranjith K Moorthy
- Department of Neurological Sciences, Christian Medical College, Vellore, India.
| | | | - Patricia Sebastian
- Department of Radiation Oncology, Christian Medical College, Vellore, India
| | - Vinu Moses
- Department of Radiodiagnosis, Christian Medical College, Vellore, India
| | | | | | - Vedantam Rajshekhar
- Department of Neurological Sciences, Christian Medical College, Vellore, India
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5
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Alzate JD, Berger A, Bernstein K, Mullen R, Qu T, Silverman JS, Shapiro M, Nelson PK, Raz E, Jafar JJ, Riina HA, Kondziolka D. Preoperative flow analysis of arteriovenous malformations and obliteration response after stereotactic radiosurgery. J Neurosurg 2023; 138:944-954. [PMID: 36057117 DOI: 10.3171/2022.7.jns221008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Morphological and angioarchitectural features of cerebral arteriovenous malformations (AVMs) have been widely described and associated with outcomes; however, few studies have conducted a quantitative analysis of AVM flow. The authors examined brain AVM flow and transit time on angiograms using direct visual analysis and a computer-based method and correlated these factors with the obliteration response after Gamma Knife radiosurgery. METHODS A retrospective analysis was conducted at a single institution using a prospective registry of patients managed from January 2013 to December 2019: 71 patients were analyzed using a visual method of flow determination and 38 were analyzed using a computer-based method. After comparison and validation of the two methods, obliteration response was correlated to flow analysis, demographic, angioarchitectural, and dosimetric data. RESULTS The mean AVM volume was 3.84 cm3 (range 0.64-19.8 cm3), 32 AVMs (45%) were in critical functional locations, and the mean margin radiosurgical dose was 18.8 Gy (range 16-22 Gy). Twenty-seven AVMs (38%) were classified as high flow, 37 (52%) as moderate flow, and 7 (10%) as low flow. Complete obliteration was achieved in 44 patients (62%) at the time of the study; the mean time to obliteration was 28 months for low-flow, 34 months for moderate-flow, and 47 months for high-flow AVMs. Univariate and multivariate analyses of factors predicting obliteration included AVM nidus volume, age, and flow. Adverse radiation effects were identified in 5 patients (7%), and 67 patients (94%) remained free of any functional deterioration during follow-up. CONCLUSIONS AVM flow analysis and categorization in terms of transit time are useful predictors of the probability of and the time to obliteration. The authors believe that a more quantitative understanding of flow can help to guide stereotactic radiosurgery treatment and set accurate outcome expectations.
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Affiliation(s)
| | | | | | | | | | | | - Maksim Shapiro
- 3Interventional Neuroradiology, NYU Langone Health, New York University, New York, New York
| | - Peter K Nelson
- 3Interventional Neuroradiology, NYU Langone Health, New York University, New York, New York
| | - Eytan Raz
- 3Interventional Neuroradiology, NYU Langone Health, New York University, New York, New York
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6
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Naylor RM, Graffeo CS, Nesvick CL, Link MJ, Brown PD, Stafford SL, Laack NN, Pollock BE. Stereotactic radiosurgery for intermediate- and high-grade arteriovenous malformations: outcomes stratified by the supplemented Spetzler-Martin grading system. J Neurosurg 2023; 138:804-809. [PMID: 35901695 DOI: 10.3171/2022.5.jns22761] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The supplemented Spetzler-Martin (Supp-SM) grading system was developed to improve the predictive accuracy of surgical risk for patients with brain arteriovenous malformations (AVMs). The aim of this study was to apply the Supp-SM grading system to patients having stereotactic radiosurgery (SRS) for Spetzler-Martin (SM) intermediate- (grade III) or high-grade (grade IV-V) AVMs to enable comparison with published microsurgical series. METHODS In 219 patients who underwent SRS during the period from 1990 to 2016, the Supp-SM grade was calculated for SM grade III (n = 154) or SM grade IV-V (n = 65) AVMs. The Supp-SM grades in these patients were 4 (n = 14, 6%), 5 (n = 36, 16%), 6 (n = 67, 31%), 7 (n = 76, 35%), and 8-9 (n = 26, 12%). Sixty patients (27%) had deep AVMs (basal ganglia, thalamus, or brainstem). Thirty-nine patients (18%) had volume-staged SRS; 41 patients (19%) underwent repeat SRS. The median follow-up period was 69 months for SM grade III AVMs and 113 months for SM grade IV-V AVMs. RESULTS AVM obliteration was confirmed in 163 patients (74%) at a median of 38 months after initial SRS. The obliteration rates at 4 and 8 years were 59% and 76%, respectively. Thirty-one patients (14%) had post-SRS deficits from hemorrhage (n = 7, 3%) or radiation injury (n = 24, 11%). Six patients (3%) died after SRS (hemorrhage, n = 5; radiation injury, n = 1). The rates of neurological decline or death at 4 and 8 years were 11% and 18%, respectively. Factors predictive of nonobliteration were deep location (HR 0.57, 95% CI 0.39-0.82, p = 0.003) and increasing AVM volume (HR 0.96, 95% CI 0.93-0.99, p = 0.002). Increasing AVM volume was the only factor associated with neurological decline (HR 1.05, 95% CI 1.02-1.08, p = 0.002). The Supp-SM grading score did not correlate with either obliteration (HR 0.94, 95% CI 0.82-1.09, p = 0.43) or neurological decline (HR 1.15, 95% CI 0.84-1.56, p = 0.38). CONCLUSIONS The Supp-SM grading system was not predictive of outcomes after SRS of intermediate- or high-grade AVM. In a cohort that included a high percentage (47%) of "inoperable" AVMs according to Supp-SM grade (≥ 7), most patients had obliteration after SRS, although there was a high risk of neurological decline.
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Affiliation(s)
- Ryan M Naylor
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Christopher S Graffeo
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.,2Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona; and
| | - Cody L Nesvick
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Michael J Link
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Paul D Brown
- 3Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Scott L Stafford
- 3Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Nadia N Laack
- 3Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Bruce E Pollock
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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7
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A Rational Approach to the Management of Cerebral Arteriovenous Malformations. World Neurosurg 2022; 159:338-347. [DOI: 10.1016/j.wneu.2021.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/11/2021] [Accepted: 08/11/2021] [Indexed: 11/21/2022]
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8
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Bergsland N. Editorial on "Quantification of Hemodynamics of Cerebral Arteriovenous Malformations After Stereotactic Radiosurgery Using 4D Flow MRI". J Magn Reson Imaging 2021; 53:1851-1852. [PMID: 33594710 DOI: 10.1002/jmri.27559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/04/2021] [Indexed: 11/07/2022] Open
Affiliation(s)
- Niels Bergsland
- Buffalo Neuroimaging Analysis Center, Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA.,IRCCS, Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
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9
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Chen CJ, Ding D. Is Catheter Angiography Still Necessary to Evaluate Obliteration of Brain Arteriovenous Malformations Treated with Stereotactic Radiosurgery? AJNR Am J Neuroradiol 2021; 42:679-680. [PMID: 33541901 DOI: 10.3174/ajnr.a6954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Ching-Jen Chen
- Department of Neurological SurgeryUniversity of VirginiaCharlottesville, Virginia
| | - Dale Ding
- Department of NeurosurgeryUniversity of LouisvilleLouisville, Kentucky
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10
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Bunevicius A, Joyner DA, Muttikkal TE, Ahn J, Sheehan J. Magnetic Resonance Perfusion Changes of Arteriovenous Malformations Treated with Stereotactic Radiosurgery. World Neurosurg 2020; 146:e1003-e1011. [PMID: 33227527 DOI: 10.1016/j.wneu.2020.11.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The latency period from stereotactic radiosurgery (SRS) to obliteration of arteriovenous malformations (AVM) requires continuous imaging surveillance. Magnetic resonance (MR) perfusion is promising for noninvasive monitoring of AVMs after SRS. We studied longitudinal MR perfusion changes of brain AVMs treated with SRS. METHODS Consecutive patients treated for brain AVMs using SRS who had MR perfusion imaging studies performed before and at least once after SRS were studied. We estimated ipsilateral/contralateral brain hemisphere ratios of MR perfusion indexes, including regional cerebral blood flow (rCBF) and relative cerebral blood volume (rCBV), in the AVM nidus, perinidal region, and remote anterior and posterior brain regions. RESULTS Eleven patients (6 women; median age, 21 years) underwent SRS (median prescription dose, 18 Gy; range, 12-20 Gy) for brain AVMs (median Spetzler-Martin grade 2 and median volume 4.6 mL). Before the SRS, rCBV and rCBF ratios were significantly higher in the AVM nidus compared with other investigated brain regions (P < 0.001). Median time from SRS to the first and last post-SRS MR perfusion studies was 8 and 35 months, respectively. There was a statically significant decrease of rCBV (P = 0.043) and rCBF (P = 0.036) ratios in the AVM nidus, but not other brain regions, during post-SRS follow-up. CONCLUSIONS There is a gradual decrease of rCBV and rCBF in the AVM nidus after SRS. MR perfusion imaging is promising for monitoring of hemodynamic changes of AVMs after SRS. Larger studies investigating clinical value of MR perfusion imaging for AVMs after SRS are warranted.
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Affiliation(s)
- Adomas Bunevicius
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - David A Joyner
- Department of Radiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | | | - Jungeun Ahn
- School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.
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11
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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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12
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Frager MJ, Glazener EM, Rahimian J, Zhi M, Lodin K, Feng L, Chen JC, Girvigian MR. A comparative outcomes analysis of patients treated for arteriovenous malformation with LINAC-based stereotactic radiosurgery by a standard frame-based technique or a frameless technique utilizing 3-dimensional rotational angiography. J Clin Neurosci 2020; 77:185-190. [DOI: 10.1016/j.jocn.2020.04.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/16/2020] [Indexed: 11/26/2022]
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13
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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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14
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Graffeo CS, Link MJ, Stafford SL, Garces YI, Foote RL, Pollock BE. More II It than Meets the Eye: Outcomes After Single-Fraction Stereotactic Radiosurgery in a Case Series of Low-Grade Arteriovenous Malformations. Oper Neurosurg (Hagerstown) 2020; 18:136-144. [PMID: 31250901 DOI: 10.1093/ons/opz153] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/21/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Surgical resection is typically cited as the optimal treatment of patients with Spetzler-Martin Grade I-II arteriovenous malformation (AVM). OBJECTIVE To report our experience with single-fraction stereotactic radiosurgery (SRS) for Spetzler-Martin Grade I-II AVM. METHODS A prospectively maintained registry was reviewed for patients with nonsyndromic Spetzler-Martin Grade I-II AVM having SRS from 1990 to 2011. Patients with <24 mo of follow-up or prior radiotherapy/SRS were excluded, resulting in a study population of 173 patients. Actuarial analysis was performed using the Kaplan-Meier method, and Cox proportional hazards modeling was performed with excellent outcomes (obliteration without new deficits) as the dependent variable. RESULTS Median post-SRS follow-up was 68 mo (range, 24-275). AVM obliteration was achieved in 132 (76%) after initial SRS. Eleven additional patients achieved obliteration after repeat SRS for an overall obliteration rate of 83%. The rate of obliteration was 60% at 4 yr and 78% at 8 yr. Post-SRS hemorrhage occurred in 7 patients (4%), resulting in 3 minor deficits (2%) and 1 death (<1%). Radiation-induced complications occurred in 5 patients (3%), resulting in minor deficits only. One hundred and thirty-seven patients (79%) had excellent outcomes at last follow-up. CONCLUSION SRS is a safe and effective treatment for patients with Spetzler-Martin Grade I-II AVM. Selection bias is likely a contributing factor to explain the superior outcomes generally noted in reported series of microsurgery for patients with low grade AVM.
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Affiliation(s)
- Christopher S Graffeo
- Department of Neurological Surgery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Michael J Link
- Department of Neurological Surgery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.,Department of Otorhinolaryngology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Scott L Stafford
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Yolanda I Garces
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.,Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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15
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Chen CJ, Ding D, Wang TR, Buell TJ, Ilyas A, Ironside N, Lee CC, Kalani MY, Park MS, Liu KC, Sheehan JP. Microsurgery Versus Stereotactic Radiosurgery for Brain Arteriovenous Malformations: A Matched Cohort Study. Neurosurgery 2020; 84:696-708. [PMID: 29762746 DOI: 10.1093/neuros/nyy174] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 04/05/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Microsurgery (MS) and stereotactic radiosurgery (SRS) remain the preferred interventions for the curative treatment of brain arteriovenous malformations (AVM), but their relative efficacy remains incompletely defined. OBJECTIVE To compare the outcomes of MS to SRS for AVMs through a retrospective, matched cohort study. METHODS We evaluated institutional databases of AVM patients who underwent MS and SRS. MS-treated patients were matched, in a 1:1 ratio based on patient and AVM characteristics, to SRS-treated patients. Statistical analyses were performed to compare outcomes data between the 2 cohorts. The primary outcome was defined as AVM obliteration without a new permanent neurological deficit. RESULTS The matched MS and SRS cohorts were each comprised of 59 patients. Both radiological (85 vs 11 mo; P < .001) and clinical (92 vs 12 mo; P < .001) follow-up were significantly longer for the SRS cohort. The primary outcome was achieved in 69% of each cohort. The MS cohort had a significantly higher obliteration rate (98% vs 72%; P = .001), but also had a significantly higher rate of new permanent deficit (31% vs 10%; P = .011). The posttreatment hemorrhage rate was significantly higher for the SRS cohort (10% for SRS vs 0% for MS; P = .027). In subgroup analyses of ruptured and unruptured AVMs, no significant differences between the primary outcomes were observed. CONCLUSION For patients with comparable AVMs, MS and SRS afford similar rates of deficit-free obliteration. Nidal obliteration is more frequently achieved with MS, but this intervention also incurs a greater risk of new permanent neurological deficit.
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Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Tony R Wang
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Natasha Ironside
- Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - M Yashar Kalani
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Min S Park
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kenneth C Liu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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16
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Chen CJ, Kearns KN, Ding D, Kano H, Mathieu D, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Grills IS, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for arteriovenous malformations of the basal ganglia and thalamus: an international multicenter study. J Neurosurg 2020; 132:122-131. [PMID: 30641831 DOI: 10.3171/2018.8.jns182106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 08/31/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Arteriovenous malformations (AVMs) of the basal ganglia (BG) and thalamus are associated with elevated risks of both hemorrhage if left untreated and neurological morbidity after resection. Therefore, stereotactic radiosurgery (SRS) has become a mainstay in the management of these lesions, although its safety and efficacy remain incompletely understood. The aim of this retrospective multicenter cohort study was to evaluate the outcomes of SRS for BG and thalamic AVMs and determine predictors of successful endpoints and adverse radiation effects. METHODS The authors retrospectively reviewed data on patients with BG or thalamic AVMs who had undergone SRS at eight institutions participating in the International Gamma Knife Research Foundation (IGKRF) from 1987 to 2014. Favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RICs). Multivariable models were developed to identify independent predictors of outcome. RESULTS The study cohort comprised 363 patients with BG or thalamic AVMs. The mean AVM volume and SRS margin dose were 3.8 cm3 and 20.7 Gy, respectively. The mean follow-up duration was 86.5 months. Favorable outcome was achieved in 58.5% of patients, including obliteration in 64.8%, with rates of post-SRS hemorrhage and permanent RIC in 11.3% and 5.6% of patients, respectively. Independent predictors of favorable outcome were no prior AVM embolization (p = 0.011), a higher margin dose (p = 0.008), and fewer isocenters (p = 0.044). CONCLUSIONS SRS is the preferred intervention for the majority of BG and thalamic AVMs. Patients with morphologically compact AVMs that have not been previously embolized are more likely to have a favorable outcome, which may be related to the use of a higher margin dose.
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Affiliation(s)
- Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kathryn N Kearns
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- 2Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - Hideyuki Kano
- 3Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - David Mathieu
- 4Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Quebec, Canada
| | - Douglas Kondziolka
- 5Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Caleb Feliciano
- 6Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Inga S Grills
- 7Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan; and
| | - Gene H Barnett
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - L Dade Lunsford
- 3Department 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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17
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Patibandla MR, Ding D, Kano H, Starke RM, Lee JYK, Mathieu D, Whitesell J, Pierce JT, Huang PP, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP. Effect of treatment period on outcomes after stereotactic radiosurgery for brain arteriovenous malformations: an international multicenter study. J Neurosurg 2018; 130:579-588. [PMID: 29393755 DOI: 10.3171/2017.8.jns171336] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/01/2017] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The role of and technique for stereotactic radiosurgery (SRS) in the management of arteriovenous malformations (AVMs) have evolved over the past four decades. The aim of this multicenter, retrospective cohort study was to compare the SRS outcomes of AVMs treated during different time periods. METHODS The authors selected patients with AVMs who underwent single-session SRS at 8 different centers from 1988 to 2014 with follow-up ≥ 6 months. The SRS eras were categorized as early (1988-2000) or modern (2001-2014). Statistical analyses were performed to compare the baseline characteristics and outcomes of the early versus modern SRS eras. Favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RICs). RESULTS The study cohort comprised 2248 patients with AVMs, including 1584 in the early and 664 in the modern SRS eras. AVMs in the early SRS era were significantly smaller (p < 0.001 for maximum diameter and volume), and they were treated with a significantly higher radiosurgical margin dose (p < 0.001). The obliteration rate was significantly higher in the early SRS era (65% vs 51%, p < 0.001), and earlier SRS treatment period was an independent predictor of obliteration in the multivariate analysis (p < 0.001). The rates of post-SRS hemorrhage and radiological, symptomatic, and permanent RICs were not significantly different between the two groups. Favorable outcome was achieved in a significantly higher proportion of patients in the early SRS era (61% vs 45%, p < 0.001), but the earlier SRS era was not statistically significant in the multivariate analysis (p = 0.470) with favorable outcome. CONCLUSIONS Despite considerable advances in SRS technology, refinement of AVM selection, and contemporary multimodality AVM treatment, the study failed to observe substantial improvements in SRS favorable outcomes or obliteration for patients with AVMs over time. Differences in baseline AVM characteristics and SRS treatment parameters may partially account for the significantly lower obliteration rates in the modern SRS era. However, improvements in patient selection and dose planning are necessary to optimize the utility of SRS in the contemporary management of AVMs.
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Affiliation(s)
| | - Dale Ding
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Hideyuki Kano
- 2Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Robert M Starke
- 3Department of Neurological Surgery, University of Miami, Florida
| | - John Y K Lee
- 4Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Mathieu
- 5Department of Neurosurgery, University of Sherbrooke, Quebec, Canada
| | - Jamie Whitesell
- 4Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John T Pierce
- 4Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul P Huang
- 6Gamma Knife Center, New York University, New York, New York
| | | | - Caleb Feliciano
- 7Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Luis Almodovar
- 8Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Inga S Grills
- 8Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Danilo Silva
- 9Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mahmoud Abbassy
- 9Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Symeon Missios
- 9Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gene H Barnett
- 9Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - L Dade Lunsford
- 2Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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18
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Li CQ, Hsiao A, Hattangadi-Gluth J, Handwerker J, Farid N. Early Hemodynamic Response Assessment of Stereotactic Radiosurgery for a Cerebral Arteriovenous Malformation Using 4D Flow MRI. AJNR Am J Neuroradiol 2018; 39:678-681. [PMID: 29371257 DOI: 10.3174/ajnr.a5535] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 11/13/2017] [Indexed: 11/07/2022]
Abstract
Brain AVMs treated with stereotactic radiosurgery typically demonstrate a minimum latency period of 1-3 years between treatment and nidus obliteration. Assessment of treatment response is usually limited to evaluation of AVM nidus structural changes using conventional MR imaging and MRA techniques. This report describes the use of 4D Flow MRI to also measure radiation-induced hemodynamic changes in a Spetzler-Martin grade III AVM, which were detectable as early as 6 months after treatment.
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Affiliation(s)
- C Q Li
- From the Department of Radiology (C.Q.L., A.H., J.H., N.F.), University of California, San Diego, San Diego, California
| | - A Hsiao
- From the Department of Radiology (C.Q.L., A.H., J.H., N.F.), University of California, San Diego, San Diego, California
| | - J Hattangadi-Gluth
- Department of Radiation Medicine and Applied Sciences (J.H.-G.), University of California, San Diego, La Jolla, California
| | - J Handwerker
- From the Department of Radiology (C.Q.L., A.H., J.H., N.F.), University of California, San Diego, San Diego, California
| | - N Farid
- From the Department of Radiology (C.Q.L., A.H., J.H., N.F.), University of California, San Diego, San Diego, California
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19
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Ding D, Starke RM, Kano H, Lee JYK, Mathieu D, Pierce J, Huang P, Missios S, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Kondziolka D, Barnett GH, Lunsford LD, Sheehan JP. Radiosurgery for Unruptured Brain Arteriovenous Malformations: An International Multicenter Retrospective Cohort Study. Neurosurgery 2018; 80:888-898. [PMID: 28431024 DOI: 10.1093/neuros/nyx181] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 04/10/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The role of intervention in the management of unruptured brain arteriovenous malformations (AVM) is controversial. OBJECTIVE To analyze in a multicenter, retrospective cohort study, the outcomes following radiosurgery for unruptured AVMs and determine predictive factors. METHODS We evaluated and pooled AVM radiosurgery data from 8 institutions participating in the International Gamma Knife Research Foundation. Patients with unruptured AVMs and ≥12 mo of follow-up were included in the study cohort. Favorable outcome was defined as AVM obliteration, no postradiosurgical hemorrhage, and no permanently symptomatic radiation-induced changes. RESULTS The unruptured AVM cohort comprised 938 patients with a median age of 35 yr. The median nidus volume was 2.4 cm 3 , 71% of AVMs were located in eloquent brain areas, and the Spetzler-Martin grade was III or higher in 57%. The median radiosurgical margin dose was 21 Gy and follow-up was 71 mo. AVM obliteration was achieved in 65%. The annual postradiosurgery hemorrhage rate was 1.4%. Symptomatic and permanent radiation-induced changes occurred in 9% and 3%, respectively. Favorable outcome was achieved in 61%. In the multivariate logistic regression analysis, smaller AVM maximum diameter ( P = .001), the absence of AVM-associated arterial aneurysms ( P = .001), and higher margin dose ( P = .002) were found to be independent predictors of a favorable outcome. A margin dose ≥ 20 Gy yielded a significantly higher rate of favorable outcome (70% vs 36%; P < .001). CONCLUSION Radiosurgery affords an acceptable risk to benefit profile for patients harboring unruptured AVMs. These findings justify further prospective studies comparing radiosurgical intervention to conservative management for unruptured AVMs.
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Affiliation(s)
- Dale Ding
- Department of Neurosurgery, Uni-versity of Virginia, Charlottesville, Virginia
| | - Robert M Starke
- Department of Neurosurgery, Uni-versity of Virginia, Charlottesville, Virginia
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pensylvania
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Mathieu
- Division of Neurosurgery, University of Sher-brooke, Centre de recherché du CHUS, Sherbrooke, Quebec, Canada
| | - John Pierce
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul Huang
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Symeon Missios
- Department of Neurosurgery, Cleveland Clinic Foun-dation, Cleveland, Ohio
| | - Caleb Feliciano
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Luis Almodovar
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Danilo Silva
- Department of Neurosurgery, Cleveland Clinic Foun-dation, Cleveland, Ohio
| | - Mahmoud Abbassy
- Department of Neurosurgery, Cleveland Clinic Foun-dation, Cleveland, Ohio
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic Foun-dation, Cleveland, Ohio
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pensylvania
| | - Jason P Sheehan
- Department of Neurosurgery, Uni-versity of Virginia, Charlottesville, Virginia
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Pollock BE, Link MJ, Stafford SL, Lanzino G, Garces YI, Foote RL. Volume-Staged Stereotactic Radiosurgery for Intracranial Arteriovenous Malformations: Outcomes Based on an 18-Year Experience. Neurosurgery 2017; 80:543-550. [PMID: 28362923 DOI: 10.1093/neuros/nyw107] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 06/27/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Radiation-based treatment options of large intracranial arteriovenous malformations (AVM) must balance the likelihood of obliteration with the risk of adverse radiation effects (ARE). OBJECTIVE To analyze the efficacy and risks of volume-staged stereotactic radiosurgery (VS-SRS) for AVM. METHODS Retrospective study of 34 AVM patients having VS-SRS between 1997 and 2012. A median of 2 stages (range, 2-4) was used to treat a median AVM volume of 22.2 cm 3 (range, 7.4-56.7). The median AVM margin dose was 16 Gy (range, 14-18); the median radiosurgery-based AVM score was 2.81 (range, 1.54-6.45). The median follow-up after VS-SRS was 8.2 years (range, 3-13.3). RESULTS Nidus obliteration was noted in 18 patients (53%) after VS-SRS. The rate of obliteration was 14% at 3 years, 54% at 5 years, and 75% at 7 years. Six patients (18%) had 11 bleeds after VS-SRS. Two patients (6%) remained neurologically stable, 2 (6%) patients had significant deficits, and 2 patients (6%) died. The actuarial risk of a first bleed after VS-SRS was 6% at 1 year, 12% at 3 years, and 19% at 7 years. Six patients (18%) underwent repeat SRS; all achieved nidus obliteration for an overall cure rate of 71%. Two patients (6%) had a permanent ARE after VS-SRS or repeat SRS. CONCLUSION VS-SRS permitted large volume intracranial AVM to be treated with a low rate of ARE. Further study is needed on dose escalation and decreasing the treatment volume per stage to determine if this will increase the rate of obliteration with this technique.
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Affiliation(s)
- Bruce E Pollock
- Department of Neurological Surgery.,Department of Radiation Oncology
| | - Michael J Link
- Department of Neurological Surgery.,Department of Otorhinolaryngology
| | | | - Giuseppe Lanzino
- Department of Neurological Surgery.,Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota
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Patibandla MR, Ding D, Kano H, Xu Z, Lee JYK, Mathieu D, Whitesell J, Pierce JT, Huang PP, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for Spetzler-Martin Grade IV and V arteriovenous malformations: an international multicenter study. J Neurosurg 2017; 129:498-507. [PMID: 28885118 DOI: 10.3171/2017.3.jns162635] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Due to the complexity of Spetzler-Martin (SM) Grade IV-V arteriovenous malformations (AVMs), the management of these lesions remains controversial. The aims of this multicenter, retrospective cohort study were to evaluate the outcomes after single-session stereotactic radiosurgery (SRS) for SM Grade IV-V AVMs and determine predictive factors. METHODS The authors retrospectively pooled data from 233 patients (mean age 33 years) with SM Grade IV (94.4%) or V AVMs (5.6%) treated with single-session SRS at 8 participating centers in the International Gamma Knife Research Foundation. Pre-SRS embolization was performed in 71 AVMs (30.5%). The mean nidus volume, SRS margin dose, and follow-up duration were 9.7 cm3, 17.3 Gy, and 84.5 months, respectively. Statistical analyses were performed to identify factors associated with post-SRS outcomes. RESULTS At a mean follow-up interval of 84.5 months, favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RIC) and was achieved in 26.2% of patients. The actuarial obliteration rates at 3, 7, 10, and 12 years were 15%, 34%, 37%, and 42%, respectively. The annual post-SRS hemorrhage rate was 3.0%. Symptomatic and permanent RIC occurred in 10.7% and 4% of the patients, respectively. Only larger AVM diameter (p = 0.04) was found to be an independent predictor of unfavorable outcome in the multivariate logistic regression analysis. The rate of favorable outcome was significantly lower for unruptured SM Grade IV-V AVMs compared with ruptured ones (p = 0.042). Prior embolization was a negative independent predictor of AVM obliteration (p = 0.024) and radiologically evident RIC (p = 0.05) in the respective multivariate analyses. CONCLUSIONS In this multi-institutional study, single-session SRS had limited efficacy in the management of SM Grade IV-V AVMs. Favorable outcome was only achieved in a minority of unruptured SM Grade IV-V AVMs, which supports less frequent utilization of SRS for the management of these lesions. A volume-staged SRS approach for large AVMs represents an alternative approach for high-grade AVMs, but it requires further investigation.
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Affiliation(s)
| | - Dale Ding
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Hideyuki Kano
- 2Department of Neurosurgery, University of Pittsburgh
| | - Zhiyuan Xu
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - John Y K Lee
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Mathieu
- 4Department of Neurosurgery, University of Sherbrooke, Quebec, Canada
| | - Jamie Whitesell
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John T Pierce
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul P Huang
- 5Gamma Knife Center, New York University, New York, New York
| | | | - Caleb Feliciano
- 6Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Luis Almodovar
- 7Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Inga S Grills
- 7Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Danilo Silva
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mahmoud Abbassy
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Symeon Missios
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gene H Barnett
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Jason P Sheehan
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Peres CMA, Souza ECD, Teixeira MJ, Figueiredo EG, Caldas JGM. Impact of Associated Nidal Lesions in Outcome of Brain Arteriovenous Malformations After Radiosurgery with or without Embolization. World Neurosurg 2017. [DOI: 10.1016/j.wneu.2017.06.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Kodera T, Arai Y, Arishima H, Higashino Y, Isozaki M, Tsunetoshi K, Matsuda K, Kitai R, Shimizu K, Kosaka N, Yamamoto T, Shioura H, Kimura H, Kikuta KI. Evaluation of obliteration of arteriovenous malformations after stereotactic radiosurgery with arterial spin labeling MR imaging. Br J Neurosurg 2017; 31:641-647. [PMID: 28830253 DOI: 10.1080/02688697.2017.1365818] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Complete obliteration of treated arteriovenous malformations (AVMs) can be diagnosed only by confirming the disappearance of arterio-venous (A-V) shunts with invasive catheter angiography. The authors evaluated whether non-invasive arterial spin labeling (ASL) magnetic resonance (MR) imaging can be used to diagnose the obliteration of AVMs facilitate the diagnosis of AVM obliteration after treatment with stereotactic radiosurgery (SRS). MATERIAL AND METHODS Seven patients with a cerebral AVM treated by SRS were followed up with ASL images taken with a 3T-MR unit, and received digital subtraction angiography (DSA) after the AVM had disappeared on ASL images. Three patients among the seven received DSA also after the postradiosurgical AVM had disappeared on conventional MR images but A-V shunt was residual on ASL images. Four patients among the seven received contrast-enhanced (CE) MR imaging around the same period as DSA. RESULTS ASL images could visualize postradiosurgical residual A-V shunts clearly. In all seven patients, DSA after the disappearance of A-V shunts on ASL images demonstrated no evidence of A-V shunts. In all three patients, DSA after the AVM had disappeared on conventional MR images but not on ASL images demonstrated residual A-V shunt. CE MR findings of AVMs treated by SRS did not correspond with DSA findings in three out of four patients. CONCLUSIONS Findings of radiosurgically treated AVMs on ASL images corresponded with those on DSA. The results of this study suggest that ASL imaging can be utilized to follow up AVMs after SRS and to decide their obliteration facilitate to decide the precise timing of catheter angiography for the final diagnosis of AVM obliteration after SRS.
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Affiliation(s)
- Toshiaki Kodera
- a Department of Neurosurgery , Faculty of Medical Sciences, University of Fukui , Eiheiji , Fukui , Japan
| | - Yoshikazu Arai
- b Department of Neurosurgery , Municipal Tsuruga Hospital , Tsuruga , Fukui, Japan
| | - Hidetaka Arishima
- a Department of Neurosurgery , Faculty of Medical Sciences, University of Fukui , Eiheiji , Fukui , Japan
| | - Yoshifumi Higashino
- a Department of Neurosurgery , Faculty of Medical Sciences, University of Fukui , Eiheiji , Fukui , Japan
| | - Makoto Isozaki
- a Department of Neurosurgery , Faculty of Medical Sciences, University of Fukui , Eiheiji , Fukui , Japan
| | - Kenzo Tsunetoshi
- a Department of Neurosurgery , Faculty of Medical Sciences, University of Fukui , Eiheiji , Fukui , Japan
| | - Ken Matsuda
- a Department of Neurosurgery , Faculty of Medical Sciences, University of Fukui , Eiheiji , Fukui , Japan
| | - Ryuhei Kitai
- a Department of Neurosurgery , Faculty of Medical Sciences, University of Fukui , Eiheiji , Fukui , Japan
| | - Kazuhiro Shimizu
- c Department of Radiology, Faculty of Medical Sciences , University of Fukui , Eiheiji , Fukui , Japan
| | - Nobuyuki Kosaka
- c Department of Radiology, Faculty of Medical Sciences , University of Fukui , Eiheiji , Fukui , Japan
| | - Tatsuya Yamamoto
- c Department of Radiology, Faculty of Medical Sciences , University of Fukui , Eiheiji , Fukui , Japan
| | - Hiroki Shioura
- c Department of Radiology, Faculty of Medical Sciences , University of Fukui , Eiheiji , Fukui , Japan
| | - Hirohiko Kimura
- c Department of Radiology, Faculty of Medical Sciences , University of Fukui , Eiheiji , Fukui , Japan
| | - Ken-Ichiro Kikuta
- a Department of Neurosurgery , Faculty of Medical Sciences, University of Fukui , Eiheiji , Fukui , Japan
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24
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Derdeyn CP, Zipfel GJ, Albuquerque FC, Cooke DL, Feldmann E, Sheehan JP, Torner JC. Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2017. [DOI: 10.1161/str.0000000000000134] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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25
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Cohen-Inbar O, Starke RM, Lee CC, Kano H, Huang P, Kondziolka D, Grills IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic Radiosurgery for Brainstem Arteriovenous Malformations: A Multicenter Study. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx189] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
The management of brainstem arteriovenous malformations (bAVMs) is a formidable challenge. bAVMs harbor higher morbidity and mortality compared to other locations.
OBJECTIVE
To review the outcomes following stereotactic radiosurgery (SRS) of bAVMs in a multicenter study.
METHODS
Six medical centers contributed data from 205 patients through the International Gamma Knife Research Foundation. Median age was 32 yr (6-81). Median nidus volume was 1.4 mL (0.1-69 mL). Favorable outcome (FO) was defined as AVM obliteration and no post-treatment hemorrhage or permanent symptomatic radiation-induced complications.
RESULTS
Overall obliteration was reported in 65.4% (n = 134) at a mean follow-up of 69 mo. Obliteration was angiographically proven in 53.2% (n = 109) and on MRA in 12.2% (n = 25). Actuarial rate of obliteration at 2, 3, 5, 7, and 10 yr after SRS was 24.5%, 43.3%, 62.3%, 73%, and 81.8% respectively. Patients treated with a margin dose >20 Gy were more likely to achieve obliteration (P = .001). Obliteration occurred earlier in patients who received a higher prescribed margin dose (P = .05) and maximum dose (P = .041). Post-SRS hemorrhage occurred in 8.8% (n = 18). Annual postgamma knife latency period hemorrhage was 1.5%. Radiation-induced complications were radiologically evident in 35.6% (n = 73), symptomatic in 14.6% (n = 30), and permanent in 14.6% (n = 30, which included long-tract signs and new cranial nerve deficits). FO was achieved in 64.4% (n = 132). Predictors of an FO were a higher Virginia radiosurgery AVM scale score (P = .003), prior hemorrhage (P = .045), and a lower prescribed maximum dose (P = .006).
CONCLUSION
SRS for bAVMs results in obliteration and avoids permanent complications in the majority of patients.
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Affiliation(s)
- Or Cohen-Inbar
- Department of Neurosurgery and Gam-ma-Knife center, University of Virginia, Charlottesville, Virginia
- Department of Neurosurgery, Rambam Health Care Center Haifa Israel, Technion Israel Institute of Technology, Haifa, Israel
| | - Robert M Starke
- Department of Neurosurgery and Gam-ma-Knife center, University of Virginia, Charlottesville, Virginia
| | - Cheng-Chia Lee
- Department of Neurological Surgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Hideyuki Kano
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Paul Huang
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Danilo Silva
- Rose-Ella Burkhardt Brain Tumor and Neuro-oncology center, Cleveland Clinic, Cleveland, Ohio
| | - Mohmoud Abbassy
- Rose-Ella Burkhardt Brain Tumor and Neuro-oncology center, Cleveland Clinic, Cleveland, Ohio
| | - Symeon Missios
- Rose-Ella Burkhardt Brain Tumor and Neuro-oncology center, Cleveland Clinic, Cleveland, Ohio
| | - Gene H Barnett
- Rose-Ella Burkhardt Brain Tumor and Neuro-oncology center, Cleveland Clinic, Cleveland, Ohio
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- Department of Neurosurgery and Gam-ma-Knife center, University of Virginia, Charlottesville, Virginia
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26
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Ding D, Starke RM, Kano H, Mathieu D, Huang PP, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic Radiosurgery for ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations)–Eligible Spetzler-Martin Grade I and II Arteriovenous Malformations: A Multicenter Study. World Neurosurg 2017; 102:507-517. [DOI: 10.1016/j.wneu.2017.03.061] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/12/2017] [Accepted: 03/14/2017] [Indexed: 11/12/2022]
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27
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Marks MP, Marcellus ML, Santarelli J, Dodd RL, Do HM, Chang SD, Adler JR, Mlynash M, Steinberg GK. Embolization Followed by Radiosurgery for the Treatment of Brain Arteriovenous Malformations (AVMs). World Neurosurg 2017; 99:471-476. [PMID: 28017742 DOI: 10.1016/j.wneu.2016.12.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/10/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Michael P Marks
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA.
| | - Mary L Marcellus
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Justin Santarelli
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Robert L Dodd
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Huy M Do
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - John R Adler
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Michael Mlynash
- Department of Neurology, Stanford University Medical Center, Stanford, California, USA
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA; Department of Neurology, Stanford University Medical Center, Stanford, California, USA
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28
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Starke RM, Ding D, Kano H, Mathieu D, Huang PP, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Kondziolka D, Barnett GH, Dade Lunsford L, Sheehan JP. International multicenter cohort study of pediatric brain arteriovenous malformations. Part 2: Outcomes after stereotactic radiosurgery. J Neurosurg Pediatr 2017; 19:136-148. [PMID: 27911249 DOI: 10.3171/2016.9.peds16284] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Pediatric patients (age < 18 years) harboring brain arteriovenous malformations (AVMs) are burdened with a considerably higher cumulative lifetime risk of hemorrhage than adults. Additionally, the pediatric population was excluded from recent prospective comparisons of intervention versus conservative management for unruptured AVMs. The aims of this multicenter, retrospective cohort study are to analyze the outcomes after stereotactic radiosurgery for unruptured and ruptured pediatric AVMs. METHODS We analyzed and pooled AVM radiosurgery data from 7 participating in the International Gamma Knife Research Foundation. Patients younger than 18 years of age who had at least 12 months of follow-up were included in the study cohort. Favorable outcome was defined as AVM obliteration, no post-radiosurgical hemorrhage, and no permanently symptomatic radiation-induced changes (RIC). The post-radiosurgery outcomes of unruptured versus ruptured pediatric AVMs were compared, and statistical analyses were performed to identify predictive factors. RESULTS The overall pediatric AVM cohort comprised 357 patients with a mean age of 12.6 years (range 2.8-17.9 years). AVMs were previously treated with embolization, resection, and fractionated external beam radiation therapy in 22%, 6%, and 13% of patients, respectively. The mean nidus volume was 3.5 cm3, 77% of AVMs were located in eloquent brain areas, and the Spetzler-Martin grade was III or higher in 59%. The mean radiosurgical margin dose was 21 Gy (range 5-35 Gy), and the mean follow-up was 92 months (range 12-266 months). AVM obliteration was achieved in 63%. During a cumulative latency period of 2748 years, the annual post-radiosurgery hemorrhage rate was 1.4%. Symptomatic and permanent radiation-induced changes occurred in 8% and 3%, respectively. Favorable outcome was achieved in 59%. In the multivariate logistic regression analysis, the absence of prior AVM embolization (p = 0.001) and higher margin dose (p < 0.001) were found to be independent predictors of a favorable outcome. The rates of favorable outcome for patients treated with a margin dose ≥ 22 Gy vs < 22 Gy were 78% (110/141 patients) and 47% (101/216 patients), respectively. A margin dose ≥ 22 Gy yielded a significantly higher probability of a favorable outcome (p < 0.001). The unruptured and ruptured pediatric AVM cohorts included 112 and 245 patients, respectively. Ruptured AVMs had significantly higher rates of obliteration (68% vs 53%, p = 0.005) and favorable outcome (63% vs 51%, p = 0.033), with a trend toward a higher incidence of post-radiosurgery hemorrhage (10% vs 4%, p = 0.07). The annual post-radiosurgery hemorrhage rates were 0.8% for unruptured and 1.6% for ruptured AVMs. CONCLUSIONS Radiosurgery is a reasonable treatment option for pediatric AVMs. Obliteration and favorable outcomes are achieved in the majority of patients. The annual rate of latency period hemorrhage after radiosurgery for both ruptured and unruptured pediatric AVM patients conveys a significant risk until the nidus is obliterated.
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Affiliation(s)
- Robert M Starke
- University of Miami, Department of Neurological Surgery, Miami, Florida
| | - Dale Ding
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
| | - Hideyuki Kano
- University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania
| | - David Mathieu
- University of Sherbrooke, Division of Neurosurgery, Sherbrooke, Quebec, Canada; and
| | - Paul P Huang
- New York University Langone Medical Center, Department of Neurosurgery, New York, New York
| | - Caleb Feliciano
- University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico
| | | | - Luis Almodovar
- University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico
| | - Inga S Grills
- Beaumont Health System, Department of Radiation Oncology, Royal Oak, Michigan
| | - Danilo Silva
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Mahmoud Abbassy
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Symeon Missios
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Douglas Kondziolka
- New York University Langone Medical Center, Department of Neurosurgery, New York, New York
| | - Gene H Barnett
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - L Dade Lunsford
- University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
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29
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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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30
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Starke RM, Kano H, Ding D, Lee JYK, Mathieu D, Whitesell J, Pierce JT, Huang PP, Kondziolka D, Yen CP, Feliciano C, Rodgriguez-Mercado R, Almodovar L, Pieper DR, Grills IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for cerebral arteriovenous malformations: evaluation of long-term outcomes in a multicenter cohort. J Neurosurg 2017; 126:36-44. [DOI: 10.3171/2015.9.jns151311] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE
In this multicenter study, the authors reviewed the results following Gamma Knife radiosurgery (GKRS) of cerebral arteriovenous malformations (AVMs), determined predictors of outcome, and assessed predictive value of commonly used grading scales based upon this large cohort with long-term follow-up.
METHODS
Data from a cohort of 2236 patients undergoing GKRS for cerebral AVMs were compiled from the International Gamma Knife Research Foundation. Favorable outcome was defined as AVM obliteration and no posttreatment hemorrhage or permanent symptomatic radiation-induced complications. Patient and AVM characteristics were assessed to determine predictors of outcome, and commonly used grading scales were assessed.
RESULTS
The mean maximum AVM diameter was 2.3 cm, with a mean volume of 4.3 cm3. A mean margin dose of 20.5 Gy was delivered. Mean follow-up was 7 years (range 1–20 years). Overall obliteration was 64.7%. Post-GRKS hemorrhage occurred in 165 patients (annual risk 1.1%). Radiation-induced imaging changes occurred in 29.2%; 9.7% were symptomatic, and 2.7% had permanent deficits. Favorable outcome was achieved in 60.3% of patients. Patients with prior nidal embolization (OR 2.1, p < 0.001), prior AVM hemorrhage (OR 1.3, p = 0.007), eloquent location (OR 1.3, p = 0.029), higher volume (OR 1.01, p < 0.001), lower margin dose (OR 0.9, p < 0.001), and more isocenters (OR 1.1, p = 0.011) were more likely to have unfavorable outcomes in multivariate analysis. The Spetzler-Martin grade and radiosurgery-based AVM score predicted outcome, but the Virginia Radiosurgery AVM Scale provided the best assessment.
CONCLUSIONS
GKRS for cerebral AVMs achieves obliteration and avoids permanent complications in the majority of patients. Patient, AVM, and treatment parameters can be used to predict long-term outcomes following radiosurgery.
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Affiliation(s)
- Robert M. Starke
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Hideyuki Kano
- 2Department of Neurosurgery, University of Pittsburgh
| | - Dale Ding
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - John Y. K. Lee
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Mathieu
- 4Department of Neurosurgery, University of Sherbrooke, Quebec, Canada
| | - Jamie Whitesell
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John T. Pierce
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul P. Huang
- 5Gamma Knife Center, New York University, New York, New York
| | | | - Chun-Po Yen
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Caleb Feliciano
- 6Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Luis Almodovar
- 6Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | - Daniel R. Pieper
- 7Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Inga S. Grills
- 7Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Danilo Silva
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mahmoud Abbassy
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Symeon Missios
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gene H. Barnett
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Jason P. Sheehan
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Ding D, Xu Z, Shih HH, Starke RM, Yen CP, Cohen-Inbar O, Sheehan JP. Worse Outcomes After Repeat vs Initial Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations. Neurosurgery 2016; 79:690-700. [DOI: 10.1227/neu.0000000000001409] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND:
Incompletely obliterated cerebral arteriovenous malformations (AVMs) after initial treatment with stereotactic radiosurgery (SRS) can be treated with a repeat session of SRS. However, the relative efficacy of repeat vs initial SRS is not well specified.
OBJECTIVE:
To retrospectively compare in matched cohorts the outcomes of repeat vs initial SRS for the treatment of matched cohorts with angioarchitecturally similar AVMs.
METHODS:
We studied a data set of patients with AVM treated with radiosurgery during the period spanning 1989 to 2013. Patients with AVM who underwent repeat SRS with radiologic follow-up of ≥2 years or nidus obliteration were identified for the study and matched, in a 1:1 fashion that was blinded to outcome, to patients with previously untreated AVMs who underwent initial SRS. Statistical analyses were performed to compare the outcomes after repeat vs initial SRS.
RESULTS:
The matching approach resulted in 84 patients for the repeat and the initial SRS cohort (mean margin doses, 20.7 and 20.9 Gy, respectively; P =.74). In the repeat SRS cohort, obliteration was achieved in 67%; the radiologic, symptomatic, and permanent radiation-induced change rates were 35%, 10%, and 4%, respectively; and the post-SRS hemorrhage rate was 3.1%/y. Compared with the initial SRS cohort, the repeat SRS cohort had significantly lower obliteration rates (P =.04) and higher post-SRS hemorrhage rates (P =.04). The radiation-induced change rates of the 2 cohorts were not significantly different.
CONCLUSION:
Repeat SRS yields considerably poorer outcomes than initial SRS for angioarchitecturally comparable AVMs. Further studies in AVM radiobiology and vascular structure are necessary to elucidate this potentially differential response.
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Affiliation(s)
- Dale Ding
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Han-Hsun Shih
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert M. Starke
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Chun-Po Yen
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Or Cohen-Inbar
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Ding D, Starke RM, Kano H, Lee JYK, Mathieu D, Pierce J, Huang PP, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Kondziolka D, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for Spetzler-Martin Grade III arteriovenous malformations: an international multicenter study. J Neurosurg 2016; 126:859-871. [PMID: 27081906 DOI: 10.3171/2016.1.jns152564] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Because of the angioarchitectural diversity of Spetzler-Martin (SM) Grade III arteriovenous malformations (AVMs), the management of these lesions is incompletely defined. The aims of this multicenter, retrospective cohort study were to evaluate the outcomes after stereotactic radiosurgery (SRS) for SM Grade III AVMs and to determine the factors predicting these outcomes. METHODS The authors analyzed and pooled data from patients with SM Grade III AVMs treated with SRS at 8 institutions participating in the International Gamma Knife Research Foundation. Patients with these AVMs and a minimum follow-up length of 12 months were included in the study cohort. An optimal outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RICs). Data were analyzed by univariate and multivariate regression analyses. RESULTS The SM Grade III AVM cohort comprised 891 patients with a mean age of 34 years at the time of SRS. The mean nidus volume, radiosurgical margin dose, and follow-up length were 4.5 cm3, 20 Gy, and 89 months, respectively. The actuarial obliteration rates at 5 and 10 years were 63% and 78%, respectively. The annual postradiosurgery hemorrhage rate was 1.2%. Symptomatic and permanent RICs were observed in 11% and 4% of the patients, respectively. Optimal outcome was achieved in 56% of the patients and was significantly more frequent in cases of unruptured AVMs (OR 2.3, p < 0.001). The lack of a previous hemorrhage (p = 0.037), absence of previous AVM embolization (p = 0.002), smaller nidus volume (p = 0.014), absence of AVM-associated arterial aneurysms (p = 0.023), and higher margin dose (p < 0.001) were statistically significant independent predictors of optimal outcome in a multivariate analysis. CONCLUSIONS Stereotactic radiosurgery provided better outcomes for patients with small, unruptured SM Grade III AVMs than for large or ruptured SM Grade III nidi. A prospective trial or registry that facilitates a comparison of SRS with conservative AVM management might further clarify the authors' observations for these often high-risk AVMs.
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Affiliation(s)
- Dale Ding
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert M Starke
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, and
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Mathieu
- Division of Neurosurgery, University of Sherbrooke, Centre de recherché du CHUS, Sherbrooke, Quebec, Canada
| | - John Pierce
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul P Huang
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Caleb Feliciano
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Luis Almodovar
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Danilo Silva
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mahmoud Abbassy
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Symeon Missios
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Douglas Kondziolka
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, and
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Pollock BE, Storlie CB, Link MJ, Stafford SL, Garces YI, Foote RL. Comparative analysis of arteriovenous malformation grading scales in predicting outcomes after stereotactic radiosurgery. J Neurosurg 2016; 126:852-858. [PMID: 27058199 DOI: 10.3171/2015.11.jns151300] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Successful stereotactic radiosurgery (SRS) for the treatment of arteriovenous malformations (AVMs) results in nidus obliteration without new neurological deficits related to either intracranial hemorrhage (ICH) or radiation-induced complications (RICs). In this study the authors compared 5 AVM grading scales (Spetzler-Martin grading scale, radiosurgery-based AVM score [RBAS], Heidelberg score, Virginia Radiosurgery AVM Scale [VRAS], and proton radiosurgery AVM scale [PRAS]) at predicting outcomes after SRS. METHODS The study group consisted of 381 patients with sporadic AVMs who underwent Gamma Knife SRS between January 1990 and December 2009; none of the patients underwent prior radiation therapy. The primary end point was AVM obliteration without a decline in modified Rankin Scale (mRS) score (excellent outcome). Comparison of the area under the receiver operating characteristic curve (AUC) and accuracy was performed between the AVM grading scales and the best linear regression model (generalized linear model, elastic net [GLMnet]). RESULTS The median radiological follow-up after initial SRS was 77 months; the median clinical follow-up was 93 months. AVM obliteration was documented in 297 patients (78.0%). Obliteration was 59% at 4 years and 85% at 8 years. Fifty-five patients (14.4%) had a decline in mRS score secondary to RICs (n = 29, 7.6%) or ICH (n = 26, 6.8%). The mRS score declined by 10% at 4 years and 15% at 8 years. Overall, 274 patients (71.9%) had excellent outcomes. There was no difference between the AUC for the GLMnet (0.69 [95% CI 0.64-0.75]), RBAS (0.68 [95% CI 0.62-0.74]), or PRAS (0.69 [95% CI 0.62-0.74]). Pairwise comparison for accuracy showed no difference between the GLMnet and the RBAS (p = 0.08) or PRAS (p = 0.16), but it did show a significant difference between the GLMnet and the Spetzler-Martin grading system (p < 0.001), Heidelberg score (p < 0.001), and the VRAS (p < 0.001). The RBAS and the PRAS were more accurate when compared with the Spetzler-Martin grading scale (p = 0.03 and p = 0.01), Heidelberg score (p = 0.02 and p = 0.02), and VRAS (p = 0.03 and p = 0.02). CONCLUSIONS SRS provides AVM obliteration without functional decline in the majority of treated patients. AVM grading scales having continuous scores (RBAS and PRAS) outperformed integer-based grading systems in the prediction of AVM obliteration without mRS score decline after SRS.
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Affiliation(s)
| | | | - Michael J Link
- Departments of 1 Neurological Surgery.,Otorhinolaryngology, Mayo Clinic College of Medicine, Rochester, Minnesota
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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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Ding D, Xu Z, Starke RM, Yen CP, Shih HH, Buell TJ, Sheehan JP. Radiosurgery for Cerebral Arteriovenous Malformations with Associated Arterial Aneurysms. World Neurosurg 2016; 87:77-90. [DOI: 10.1016/j.wneu.2015.11.080] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/25/2015] [Accepted: 11/26/2015] [Indexed: 01/08/2023]
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Stereotactic Radiosurgery for Partially Resected Cerebral Arteriovenous Malformations. World Neurosurg 2016; 85:263-72. [DOI: 10.1016/j.wneu.2015.10.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 09/29/2015] [Accepted: 10/01/2015] [Indexed: 11/20/2022]
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Ding D, Starke RM, Kano H, Mathieu D, Huang P, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP. Radiosurgery for Cerebral Arteriovenous Malformations in A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA)-Eligible Patients: A Multicenter Study. Stroke 2015; 47:342-9. [PMID: 26658441 DOI: 10.1161/strokeaha.115.011400] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 11/05/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The benefit of intervention for patients with unruptured cerebral arteriovenous malformations (AVMs) was challenged by results demonstrating superior clinical outcomes with conservative management from A Randomized Trial of Unruptured Brain AVMs (ARUBA). The aim of this multicenter, retrospective cohort study is to analyze the outcomes of stereotactic radiosurgery for ARUBA-eligible patients. METHODS We combined AVM radiosurgery outcome data from 7 institutions participating in the International Gamma Knife Research Foundation. Patients with ≥12 months of follow-up were screened for ARUBA eligibility criteria. Favorable outcome was defined as AVM obliteration, no postradiosurgery hemorrhage, and no permanently symptomatic radiation-induced changes. Adverse neurological outcome was defined as any new or worsening neurological symptoms or death. RESULTS The ARUBA-eligible cohort comprised 509 patients (mean age, 40 years). The Spetzler-Martin grade was I to II in 46% and III to IV in 54%. The mean radiosurgical margin dose was 22 Gy and follow-up was 86 months. AVM obliteration was achieved in 75%. The postradiosurgery hemorrhage rate during the latency period was 0.9% per year. Symptomatic and permanent radiation-induced changes occurred in 11% and 3%, respectively. The rates of favorable outcome, adverse neurological outcome, permanent neurological morbidity, and mortality were 70%, 13%, 5%, and 4%, respectively. CONCLUSIONS Radiosurgery may provide durable clinical benefit in some ARUBA-eligible patients. On the basis of the natural history of untreated, unruptured AVMs in the medical arm of ARUBA, we estimate that a follow-up duration of 15 to 20 years is necessary to realize a potential benefit of radiosurgical intervention for conservative management in unruptured patients with AVM.
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Affiliation(s)
- Dale Ding
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Robert M Starke
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Hideyuki Kano
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - David Mathieu
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Paul Huang
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Douglas Kondziolka
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Caleb Feliciano
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Rafael Rodriguez-Mercado
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Luis Almodovar
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Inga S Grills
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Danilo Silva
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Mahmoud Abbassy
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Symeon Missios
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Gene H Barnett
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - L Dade Lunsford
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
| | - Jason P Sheehan
- From the Department of Neurosurgery, University of Virginia, Charlottesville (D.D., R.M.S., J.P.S.); Department of Neurological Surgery, University of Pittsburgh, PA (H.K., L.D.L.); Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada (D.M.); Department of Neurosurgery, New York University Langone Medical Center (P.H., D.K.); Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico (C.F., R.R.-M., L.A.); Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI (I.S.G.); and Department of Neurosurgery, Cleveland Clinic Foundation, OH (D.S., M.A., S.M., G.H.B.)
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Pollock BE, Link MJ, Stafford SL, Garces YI, Foote RL. Stereotactic Radiosurgery for Arteriovenous Malformations. Neurosurgery 2015; 78:499-509. [DOI: 10.1227/neu.0000000000001085] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Stereotactic radiosurgery (SRS) has been performed on patients with cerebral arteriovenous malformations (AVMs) for over 40 years.
OBJECTIVE:
To evaluate the impact of treatment period on obliteration, intracranial hemorrhage (ICH), and radiation-induced complications (RICs).
METHODS:
Retrospective comparison of 381 AVM patients having SRS during a 20-year period (group 1, January 1990 through March 1997, n = 160; group 2, April 1997 through December 2009, n = 221). The median radiological and clinical follow-up after initial SRS was 77 months and 93 months, respectively.
RESULTS:
Obliteration was 59.1% at 4 years and 85.1% at 8 years. Obliteration was more common in patients with hemispheric or cerebellar AVMs (P = .001), smaller prescription isodose volume (PIV) (P < .001), and group 1 patients (P < .001). The ICH rate was 7.7% at 4 years and 10.6% at 8 years. ICH was more common in older patients (P = .02), patients with deep AVM (P = .01), and larger PIV (P < .001). There was no difference in the ICH rate between the treatment groups (P = .18). The rate of permanent RICs was 4.4% at 4 years and 8.6% at 8 years. RICs were more common with larger PIVs (P < .001) and group 1 patients (P = .02). There was no difference in the number of patients having obliteration without new deficits between the 2 treatment periods (68.8% vs 73.3%, P = .33).
CONCLUSION:
Advances in SRS procedures over the past 20 years have resulted in a lower risk of RIC, but fewer patients had AVM obliteration. Increasing the prescription dose for patients with medium- and large-volume AVMs by using current conformal dose-planning techniques may improve the obliteration rate while maintaining a low risk of RICs.
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Affiliation(s)
- Bruce E. Pollock
- Department of Neurological Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
- Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Michael J. Link
- Department of Neurological Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
- Department of Otorhinolaryngology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Scott L. Stafford
- Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Yolanda I. Garces
- Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Robert L. Foote
- Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota
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Ding D, Quigg M, Starke RM, Xu Z, Yen CP, Przybylowski CJ, Dodson BK, Sheehan JP. Radiosurgery for temporal lobe arteriovenous malformations: effect of temporal location on seizure outcomes. J Neurosurg 2015; 123:924-34. [DOI: 10.3171/2014.10.jns141807] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The temporal lobe is particularly susceptible to epileptogenesis. However, the routine use of anticonvulsant therapy is not implemented in temporal lobe AVM patients without seizures at presentation. The goals of this case-control study were to determine the radiosurgical outcomes for temporal lobe AVMs and to define the effect of temporal lobe location on postradiosurgery AVM seizure outcomes.
METHODS
From a database of approximately 1400 patients, the authors generated a case cohort from patients with temporal lobe AVMs with at least 2 years follow-up or obliteration. A control cohort with similar baseline AVM characteristics was generated, blinded to outcome, from patients with non-temporal, cortical AVMs. They evaluated the rates and predictors of seizure freedom or decreased seizure frequency in patients with seizures or de novo seizures in those without seizures.
RESULTS
A total of 175 temporal lobe AVMs were identified based on the inclusion criteria. Seizure was the presenting symptom in 38% of patients. The median AVM volume was 3.3 cm3, and the Spetzler-Martin grade was III or higher in 39% of cases. The median radiosurgical prescription dose was 22 Gy. At a median clinical follow-up of 73 months, the rates of seizure control and de novo seizures were 62% and 2%, respectively. Prior embolization (p = 0.023) and lower radiosurgical dose (p = 0.027) were significant predictors of seizure control. Neither temporal lobe location (p = 0.187) nor obliteration (p = 0.522) affected seizure outcomes. The cumulative obliteration rate was 63%, which was significantly higher in patients without seizures at presentation (p = 0.046). The rates of symptomatic and permanent radiation-induced changes were 3% and 1%, respectively. The annual risk of postradiosurgery hemorrhage was 1.3%.
CONCLUSIONS
Radiosurgery is an effective treatment for temporal lobe AVMs. Furthermore, radiosurgery is protective against seizure progression in patients with temporal lobe AVM–associated seizures. Temporal lobe location does not affect radiosurgery-induced seizure control. The low risk of new-onset seizures in patients with temporal or extratemporal AVMs does not seem to warrant prophylactic use of anticonvulsants.
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Affiliation(s)
- Dale Ding
- Departments of 1Neurological Surgery and
| | - Mark Quigg
- 2Neurology, University of Virginia, Charlottesville, Virginia
| | | | - Zhiyuan Xu
- Departments of 1Neurological Surgery and
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40
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Cerebral Arteriovenous Malformations and Epilepsy, Part 2: Predictors of Seizure Outcomes Following Radiosurgery. World Neurosurg 2015; 84:653-62. [DOI: 10.1016/j.wneu.2015.04.064] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/23/2015] [Accepted: 04/23/2015] [Indexed: 11/23/2022]
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Radiosurgery for Cerebral Arteriovenous Malformations in Elderly Patients: Effect of Advanced Age on Outcomes After Intervention. World Neurosurg 2015; 84:795-804. [DOI: 10.1016/j.wneu.2015.05.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 05/11/2015] [Accepted: 05/13/2015] [Indexed: 11/21/2022]
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Chen CJ, Lee CC, Ding D, Starke RM, Chivukula S, Yen CP, Moosa S, Xu Z, Pan DHC, Sheehan JP. Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: a systematic review. J Neurosurg 2015; 122:353-62. [DOI: 10.3171/2014.10.jns14871] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The goal of this study was to evaluate the obliteration rate of intracranial dural arteriovenous fistulas (DAVFs) in patients treated with stereotactic radiosurgery (SRS), and to compare obliteration rates between cavernous sinus (CS) and noncavernous sinus (NCS) DAVFs, and between DAVFs with and without cortical venous drainage (CVD).
METHODS
A systematic literature review was performed using PubMed. The CS DAVFs and the NCS DAVFs were categorized using the Barrow and Borden classification systems, respectively. The DAVFs were also categorized by location and by the presence of CVD. Statistical analyses of pooled data were conducted to assess complete obliteration rates in CS and NCS DAVFs, and in DAVFs with and without CVD.
RESULTS
Nineteen studies were included, comprising 729 patients harboring 743 DAVFs treated with SRS. The mean obliteration rate was 63% (95% CI 52.4%–73.6%). Complete obliteration for CS and NCS DAVFs was achieved in 73% and 58% of patients, respectively. No significant difference in obliteration rates between CS and NCS DAVFs was found (OR 1.72, 95% CI 0.66–4.46; p = 0.27). Complete obliteration in DAVFs with and without CVD was observed in 56% and 75% of patients, respectively. A significantly higher obliteration rate was observed in DAVFs without CVD compared with DAVFs with CVD (OR 2.37, 95% CI 1.07–5.28; p = 0.03).
CONCLUSIONS
Treatment with SRS offers favorable rates of DAVF obliteration with low complication rates. Patients harboring DAVFs that are refractory or not amenable to endovascular or surgical therapy may be safely and effectively treated using SRS.
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Affiliation(s)
| | - Cheng-Chia Lee
- Departments of 1Neurological Surgery and
- 2Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Dale Ding
- Departments of 1Neurological Surgery and
| | | | - Srinivas Chivukula
- 3Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Zhiyuan Xu
- Departments of 1Neurological Surgery and
| | - David Hung-Chi Pan
- 2Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Jason P. Sheehan
- Departments of 1Neurological Surgery and
- 4Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
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Radiosurgery for unruptured cerebral arteriovenous malformations in pediatric patients. Acta Neurochir (Wien) 2015; 157:281-91. [PMID: 25514868 DOI: 10.1007/s00701-014-2305-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 12/03/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Unruptured cerebral arteriovenous malformations (AVMs) in pediatric patients (age <18 years) were excluded from A Randomized Trial of Unruptured AVMs (ARUBA). Therefore, the efficacy of radiosurgery for unruptured pediatric AVMs is poorly understood. The goal of this study is to determine the outcomes and define the predictors of obliteration following radiosurgery for unruptured AVMs in pediatric patients. METHODS We evaluated a prospective database, from 1989 to 2013, of AVM patients treated with radiosurgery at our institution. Patients with age less than 18 years at the time of radiosurgery, unruptured nidi, and at least 2 years of radiologic follow-up or AVM obliteration were selected for analysis. Statistical analyses were performed to determine actuarial obliteration rates and identify factors associated with obliteration. RESULTS In the 51 unruptured pediatric AVM patients included for analysis, the median age was 13 years, and the most common presentation was seizure in 53 %. The median nidus volume and radiosurgical margin dose were 3.2 cm(3) and 21.5 Gy, respectively. The median radiologic follow-up was 45 months. The actuarial AVM obliteration rates at 3, 5, and 10 years were 29 %, 54 %, and 72 %, respectively. In the multivariate Cox proportional hazards regression analysis, higher margin dose (P = 0.002), fewer draining veins (P = 0.038), and lower Virginia Radiosurgery AVM Scale (P = 0.003) were independent predictors of obliteration. Obliteration rates were significantly higher with a margin dose of at least 22 Gy (P = 0.003) and for nidi with 2 or fewer draining veins (P = 0.001). The incidences of radiologically evident, symptomatic, and permanent radiation-induced changes were 55 %, 16 %, and 2 %, respectively. The annual post-radiosurgery hemorrhage rate was 1.3 %, and the incidence of post-radiosurgery cyst formation was 2 %. CONCLUSION Radiosurgery affords a favorable risk to benefit profile for unruptured pediatric AVMs. Pediatric patients with unruptured AVMs merit further study to define an optimal management approach.
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Przybylowski CJ, Ding D, Starke RM, Yen CP, Quigg M, Dodson B, Ball BZ, Sheehan JP. Seizure and anticonvulsant outcomes following stereotactic radiosurgery for intracranial arteriovenous malformations. J Neurosurg 2015; 122:1299-305. [PMID: 25614948 DOI: 10.3171/2014.11.jns141388] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Epilepsy associated with arteriovenous malformations (AVMs) has an unclear course after stereotactic radiosurgery (SRS). Neither the risks of persistent seizures nor the requirement for postoperative antiepileptic drugs (AEDs) are well defined. METHODS The authors performed a retrospective review of all patients with AVMs who underwent SRS at the University of Virginia Health System from 1989 to 2012. Seizure status was categorized according to a modified Engel classification. The effects of demographic, AVM-related, and SRS treatment factors on seizure outcomes were evaluated with logistic regression analysis. Changes in AED status were evaluated using McNemar's test. RESULTS Of the AVM patients with pre- or post-SRS seizures, 73 with pre-SRS epilepsy had evaluable data for subsequent analysis. The median patient age was 37 years (range 5-69 years), and the median follow-up period was 65.6 months (range 12-221 months). Sixty-five patients (89%) achieved seizure remission (Engel Class IA or IB outcome). Patients presenting with simple partial or secondarily generalized seizures were more likely to achieve Engel Class I outcome (p = 0.045). Twenty-one (33%) of 63 patients tapered off of pre-SRS AEDs. The incidence of freedom from AED therapy increased significantly after SRS (p < 0.001, McNemar's test). Of the Engel Class IA patients who continued AED therapy, 54% had patent AVM nidi, whereas only 19% continued AED therapy with complete AVM obliteration (p = 0.05). CONCLUSIONS Stereotactic radiosurgery is an effective treatment for long-term AVM-related epilepsy. Seizure-free patients on continued AED therapy were more likely to have residual AVM nidi. Simple partial or secondarily generalized seizure type were associated with better seizure outcomes following SRS.
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Affiliation(s)
| | - Dale Ding
- Departments of 1Neurological Surgery
| | | | | | | | | | | | - Jason P Sheehan
- Departments of 1Neurological Surgery.,3Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
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Ding D, Yen CP, Starke RM, Xu Z, Sheehan JP. Effect of Prior Hemorrhage on Intracranial Arteriovenous Malformation Radiosurgery Outcomes. Cerebrovasc Dis 2014; 39:53-62. [DOI: 10.1159/000369959] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 11/17/2014] [Indexed: 11/19/2022] Open
Abstract
Background: Intracerebral hemorrhage is simultaneously the most frequent and most debilitating manifestation of intracranial arteriovenous malformations (AVM), but its impact on success and complications of radiosurgery has not been rigorously assessed. In this case-control study, we define the effect of prior hemorrhage on AVM radiosurgery outcomes. Methods: From a prospective, institutional database of 1,400 AVM patients treated with Gamma Knife radiosurgery, unruptured and ruptured AVMs were matched in a 1:1 fashion, blinded to outcome, based on patient demographics, prior embolization (26.6% of each cohort), AVM size (mean volume of unruptured AVMs 3.7 cm3 versus ruptured AVMs 3.5 cm3, p = 0.195), Spetzler-Martin grade (Grade I 17.0%, Grade II 37.8%, Grade III 34.8%, Grade IV 10.4% for each cohort), and radiosurgical treatment parameters (mean prescription dose for unruptured AVMs 20.9 Gy versus ruptured AVMs 21.0 Gy, p = 0.837). There were 270 patients in each cohort. Matched statistical analyses were used to compare the baseline characteristics, obliteration rates, post-radiosurgery latency period hemorrhage risks, and incidences of radiation-induced changes (RIC) between the two cohorts. Results: The actuarial obliteration rates of the two cohorts were similar (unruptured AVMs: 38, 58, and 76% at 3, 5, 10 years, respectively; ruptured AVMs: 40, 60, and 73% at 3, 5, 10 years, respectively; p = 0.592). However, for embolized AVMs, complete obliteration was more likely to be achieved in unruptured lesions (unruptured AVMs: 25, 32, and 54% at 3, 5, 10 years, respectively; ruptured AVMs: 18, 27, and 42% at 3, 5, 10 years, respectively; p = 0.038). Prior AVM rupture resulted in a higher annual risk of post-radiosurgery latency period hemorrhage (ruptured AVMs 2.3% versus unruptured AVMs 1.1%, p = 0.025) but a lower rate of cumulative and symptomatic RIC (cumulative RIC: ruptured AVMs 30.4% versus unruptured AVMs 48.9%, p < 0.0001; symptomatic RIC: ruptured AVMs 7.0% versus unruptured AVMs 12.2%, p = 0.041, respectively). The rates of permanent RIC were similar between the unruptured (2.2%) and ruptured (1.9%) AVM cohorts (p = 0.761). The mean time interval to onset of RIC (unruptured AVMs 13.3 months versus ruptured AVMs 12.1 months, p = 0.783), and the mean duration of RIC (unruptured AVMs 22.0 months versus ruptured AVMs 21.7 months, p = 0.599) were not significantly different between the two cohorts. Conclusions: Prior AVM rupture significantly alters the risk of latency period hemorrhage and RIC following radiosurgery. These effects should be taken into consideration with the multidisciplinary management of AVM patients. Radiosurgery does not significantly alter the natural history of the hemorrhage risks of unruptured and ruptured AVMs unless obliteration is achieved.
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Walcott BP, Hattangadi-Gluth JA, Stapleton CJ, Ogilvy CS, Chapman PH, Loeffler JS. Proton beam stereotactic radiosurgery for pediatric cerebral arteriovenous malformations. Neurosurgery 2014; 74:367-73; discussion 374. [PMID: 24448188 DOI: 10.1227/neu.0000000000000294] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND For cerebral arteriovenous malformations (AVMs) determined to be high risk for surgery or endovascular embolization, stereotactic radiosurgery (SRS) is considered the mainstay of treatment. OBJECTIVE To determine the outcomes of pediatric patients with AVMs treated with proton SRS. METHODS We reviewed the records of 44 consecutively treated pediatric patients (younger than 18 years of age) who underwent proton SRS at our institution from 1998 to 2010. The median target volume was 4.5 ± 5.9 mL (range, 0.3-29.0 mL) and the median maximal diameter was 3.6 ± 1.5 cm (range, 1-6 cm). Radiation was administered with a median prescription dose of 15.50 ± 1.87 CGE to the 90% isodose. RESULTS At a median follow-up of 52 ± 25 months, 2 patients (4.5%) had no response, 24 patients (59.1%) had a partial response, and 18 patients (40.9%) experienced obliteration of their AVM. The median time to obliteration was 49 ± 26 months, including 17 patients who underwent repeat proton radiosurgery. Four patients (9%) experienced hemorrhage after treatment at a median time of 45 ± 15 months. Univariate analysis identified modified AVM scale score (P = .045), single fraction treatment (0.04), larger prescription dose (0.01), larger maximum dose (<0.001), and larger minimum dose (0.01) to be associated with AVM obliteration. CONCLUSION High-risk AVMs can be safely treated with proton radiosurgery in the pediatric population. Because protons deposit energy more selectively than photons, there is the potential benefit of protons to lower the probability of damage to healthy tissue in the developing brain.
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Affiliation(s)
- Brian P Walcott
- Departments of *Neurosurgery and ‡Radiation Oncology, §Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; ¶Department of Radiation Oncology, University of California San Diego, San Diego, California; ‖Department of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Burrow AM, Link MJ, Pollock BE. Is stereotactic radiosurgery the best treatment option for patients with a radiosurgery-based arteriovenous malformation score ≤ 1? World Neurosurg 2014; 82:1144-7. [PMID: 25014752 DOI: 10.1016/j.wneu.2014.07.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 04/08/2014] [Accepted: 07/08/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The best management of patients with brain arteriovenous malformations (BAVM) is controversial. The radiosurgery-based arteriovenous malformation (AVM) score (RBAS) was developed to predict outcomes for patients with BAVM having stereotactic radiosurgery (SRS). METHODS The RBAS is calculated for patients with BAVM having SRS at our center as part of our prospectively maintained SRS database (RBAS = [0.1] [AVM volume; cm(3)] + [0.02] [patient age; years] + [0.5] [AVM location; 0 = cerebral/cerebellar hemispheres/corpus callosum, 1 = basal ganglia/thalamus/brainstem]). Review of the SRS database from 1990 to 2009 identified 80 patients with a RBAS ≤1 and at least 1 year of follow-up. The primary end point of the study was a decline in modified Rankin Score. The mean follow-up after SRS was 68 months (range, 12-133). RESULTS The mean patient age was 25.2 years (range, 7-44). Seventy-six patients (95%) had superficially located BAVMs; the mean BAVM volume was 2.3 cm(3) (range, 0.1-8.0). The mean RBAS was 0.76 (range, 0.21-1.00). The patients' MRS before SRS was 0 (n = 52, 65%), 1 (n = 24, 30%), 2 (n = 3, 4%), and 3 (n = 1, 1%). BAVM obliteration was confirmed in 92% of patients with follow-up beyond 3 years (70/76; 95% confidence interval 84%-97%). No patient had a hemorrhage or a radiation-related complication after SRS. The observed rate of modified Rankin Score decrease after SRS was 0% (0/80; 95% confidence interval 0%-6%). CONCLUSIONS SRS provided a high rate of obliteration at very low risk for patients with BVAM with a RBAS ≤1. Patient outcomes after SRS are likely equivalent to resection for younger patients with small-volume BAVM who do not require a craniotomy for clot removal.
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Affiliation(s)
- Anthony M Burrow
- Department of Neurological Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Michael J Link
- Department of Neurological Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA; Department of Otorhinolaryngology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA; Department of Radiation Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
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48
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Zipfel GJ, Heros RC. Gamma Knife radiosurgery and arteriovenous malformations. J Neurosurg 2014; 120:955-7. [PMID: 24460493 DOI: 10.3171/2013.10.jns131763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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