1
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He Z, Ho MKJ, Lee WYV, Law HY, Wong YWV, Leung TW, Mui WH, Wong ST, Wong CSF, Yam KY. Frameless versus frame-based stereotactic radiosurgery for intracranial arteriovenous malformations: A propensity-matched analysis. Clin Transl Radiat Oncol 2023; 41:100642. [PMID: 37304170 PMCID: PMC10248791 DOI: 10.1016/j.ctro.2023.100642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/13/2023] Open
Abstract
Objective The frameless linear accelerator (LINAC) based stereotactic radiosurgery (SRS) has been evolving with a reduction in patient discomfort. However, there was limited evidence comparing frame-based and frameless SRS for intracranial arteriovenous malformations (AVM). We aimed to compare the treatment outcomes between frame-based and frameless LINAC SRS. Materials and Methods This retrospective cohort compared the outcomes of frame-based LINAC SRS (1998-2009) with frameless LINAC SRS (2010-2020). The primary outcome was the obliteration rate. The other outcomes included the neurological, radiological, and functional outcomes after SRS. A matched cohort was identified by propensity scores for further comparisons. Results A total of 65 patients were included with a mean follow-up time of 13.2 years (158.5 months). There were 40 patients in the frame-based group and 25 patients in the frameless group. The overall obliteration rate was comparable (Frame-based 82.5% vs Frameless 80.0%, p = 0.310) and not significantly different over time (log-rank p = 0.536). The crude post-SRS hemorrhage rate was 1.5% and the incidence was 0.3 per 100 person-years. There were 67.7% of patients with AVM obliteration without new persistent neurological deficits at the last visit and 56.9% of patients with AVM obliteration without any deficits (transient or persistent) during the entire follow-up period. Four patients (8.0%) developed late onset persistent adverse radiation effects (more than 96 months after SRS) among 50 patients with more than 8-year surveillance. In the propensity-matched cohort of 42 patients, there was no significant difference in AVM obliteration (Frame-based vs Frameless, log-rank p = 0.984). Conclusion Frameless and frame-based LINAC SRS have comparable efficacy in intracranial AVM obliteration. A longer follow-up duration may further characterize the rate of late adverse radiation effects in frameless SRS.
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Affiliation(s)
- Zhexi He
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Man Kit Jason Ho
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Wan Yan Venus Lee
- Department of Clinical Oncology, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Hing Yuen Law
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Yee Wa Victy Wong
- Department of Clinical Oncology, Tuen Mun Hospital, N.T., Hong Kong, China
| | - To-wai Leung
- Department of Clinical Oncology, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Wing Ho Mui
- Department of Clinical Oncology, Tuen Mun Hospital, N.T., Hong Kong, China
| | - Sui-To Wong
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
| | | | - Kwong Yui Yam
- Department of Neurosurgery, Tuen Mun Hospital, N.T., Hong Kong, China
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2
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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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3
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Yahia-Cherif M, Fenton C, Bonnet T, De Witte O, Simon S, De Maertelaer V, Mine B, Lefranc F, Lubicz B. Embolization before Gamma Knife radiosurgery for cerebral arteriovenous malformations does not negatively impact its obliteration rate: a series of 190 patients. Neuroradiology 2023; 65:391-399. [PMID: 36271057 DOI: 10.1007/s00234-022-03066-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/09/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Embolization of arteriovenous malformations (AVMs) before radiosurgery has been reported to negatively impact the obliteration rate. This study aims to assess treatment outcomes in a series of 190 patients treated by Gamma Knife radiosurgery (GKRS) for previously embolized AVMs. METHODS The institutional database of AVMs was retrospectively reviewed between January 2004 and March 2018. The clinical and radiological data of patients treated with GKRS for previously embolized AVMs were analyzed. Predicting factors of obliteration and hemorrhage following GKRS were assessed with univariate and multivariate regression analyses. RESULTS The mean AVM size was significantly reduced after embolization (p < 0.001). The obliteration rate was 78.4%. Multivariate analyses showed that a lower Spetzler-Martin grade (p = 0.035) and a higher marginal dose (p = 0.007) were associated with obliteration. Post-GKRS hemorrhages occurred in 14 patients (7.4%). A longer time between diagnosis and GKRS was the only factor associated with post-GKRS hemorrhages in multivariate analysis (p = 0.022). Complications related to the combined treatment were responsible for a new permanent neurological disability in 20 patients (10.5%), and a case of death (0.5%). CONCLUSIONS This study shows that the embolization of AVMs does not have a negative impact on the obliteration rate after radiosurgery. Embolization reduces the AVM size to a treatable volume by GKRS. However, the combined treatment results in an increased complication rate related to the addition of the risks of each treatment modality.
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Affiliation(s)
- Mehdi Yahia-Cherif
- Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Brussels, Belgium.
| | - Chifra Fenton
- Department of Interventional Neuroradiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Thomas Bonnet
- Department of Interventional Neuroradiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Olivier De Witte
- Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Brussels, Belgium
| | - Stéphane Simon
- Department of Medical Physics, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Viviane De Maertelaer
- Department of Biostatistics, IRIBHM, Université Libre de Bruxelles, Brussels, Belgium
| | - Benjamin Mine
- Department of Interventional Neuroradiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Florence Lefranc
- Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, 808 route de Lennik, 1070, Brussels, Belgium
| | - Boris Lubicz
- Department of Interventional Neuroradiology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Shinya Y, Hasegawa H, Kawashima M, Koizumi S, Katano A, Umekawa M, Saito N. Prognosis of Rotational Angiography-Based Stereotactic Radiosurgery for Dural Arteriovenous Fistulas: A Retrospective Analysis. Neurosurgery 2023; 92:167-178. [PMID: 36255184 DOI: 10.1227/neu.0000000000002168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/26/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Cerebral dural arteriovenous fistulas (DAVFs) are intracranial vascular malformations with fine, abnormal vascular architecture. High-resolution vascular imaging is vital for their visualization. Currently, rotational angiography (RA) provides the finest 3-dimensional visualization of the arteriovenous shunt with high spatial resolution; however, the efficacies of the integration of RA have never been studied in stereotactic radiosurgery (SRS) for DAVFs until now. Since 2015, our institution has integrated RA into SRS (RA-SRS) to provide more conformal planning, thereby decreasing overtreatment and undertreatment. OBJECTIVE To analyze the outcomes of RA-SRS for DAVFs. METHODS We retrospectively analyzed the outcomes of 51 patients with DAVFs and compared those of 20 DAVFs treated with RA-SRS with those of 31 DAVFs treated with conventional SRS (c-SRS). RESULTS The time to obliteration was shorter in the RA-SRS group (median, 15 months vs 26 months [cumulative rate, 77% vs 33% at 2 years, 77% vs 64% at 4 years]; P = .015). Multivariate Cox proportional hazards analysis demonstrated that RA-SRS (hazard ratio 2.39, 95% CI 1.13-5.05; P = .022) and the absence of cortical venous reflux (hazard ratio 2.12, 95% CI 1.06-4.25; P = .034) were significantly associated with obliteration. The cumulative 5-year post-SRS stroke-free survival rates were 95% and 97% in the RA-SRS and c-SRS groups, respectively ( P = .615). Neurological improvement tended to occur earlier in the RA-SRS group than in the c-SRS group (median time to improvement, 5 months vs 20 months, log-rank test; P = .077). CONCLUSION RA-based SRS may facilitate earlier fistula obliteration and may contribute to early neurological improvement.
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Affiliation(s)
- Yuki Shinya
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Atsuto Katano
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Motoyuki Umekawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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5
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Huang PW, Peng SJ, Pan DHC, Yang HC, Tsai JT, Shiau CY, Su IC, Chen CJ, Wu HM, Lin CJ, Chung WY, Guo WY, Lo WL, Lai SW, Lee CC. Compactness index: a radiosurgery outcome predictor for patients with unruptured brain arteriovenous malformations. J Neurosurg 2023; 138:241-250. [PMID: 35594883 DOI: 10.3171/2022.4.jns212369] [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: 10/09/2021] [Accepted: 04/07/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The goal of the study was to define and quantify brain arteriovenous malformation (bAVM) compactness and to assess its effect on outcomes after Gamma Knife radiosurgery (GKRS) for unruptured bAVMs. METHODS Unsupervised machine learning with fuzzy c-means clustering was used to differentiate the tissue constituents of bAVMs on T2-weighted MR images. The percentages of vessel, brain, and CSF were quantified. The proposed compactness index, defined as the ratio of vasculature tissue to brain tissue, categorized bAVM morphology into compact, intermediate, and diffuse types according to the tertiles of this index. The outcomes of interest were complete obliteration and radiation-induced changes (RICs). RESULTS A total of 209 unruptured bAVMs treated with GKRS were retrospectively included. The median imaging and clinical follow-up periods were 49.2 and 72.3 months, respectively. One hundred seventy-three bAVMs (82.8%) achieved complete obliteration after a median latency period of 43.3 months. The rates of RIC and permanent RIC were 76.1% and 3.8%, respectively. Post-GKRS hemorrhage occurred in 14 patients (6.7%), resulting in an annual bleeding risk of 1.0%. Compact bAVM, smaller bAVM volume, and exclusively superficial venous drainage were independent predictors of complete obliteration. Diffuse bAVM morphology, larger bAVM volume, and higher margin dose were independently associated with RICs. CONCLUSIONS The compactness index quantitatively describes the compactness of unruptured bAVMs. Moreover, compact bAVMs may have a higher obliteration rate and a smaller risk of RICs than diffuse bAVMs. This finding could help guide decision-making regarding GKRS treatment for patients with unruptured bAVMs.
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Affiliation(s)
- Po-Wei Huang
- 1Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City
| | - Syu-Jyun Peng
- 2Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei
| | - David Hung-Chi Pan
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei.,4Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,14Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; and
| | - Huai-Che Yang
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Jo-Ting Tsai
- 1Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,11Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei.,13Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei
| | - Cheng-Ying Shiau
- 8Cancer Center, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - I-Chang Su
- 4Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,12Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei.,14Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; and
| | - Ching-Jen Chen
- 6Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Hsiu-Mei Wu
- 7Department of Radiology, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Chung-Jung Lin
- 7Department of Radiology, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Wen-Yuh Chung
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei.,5Department of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Wan-Yuo Guo
- 7Department of Radiology, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Wei-Lun Lo
- 4Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City.,12Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei.,14Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan; and
| | - Shao-Wen Lai
- 15Product and Engineering, Zippin, San Carlos, California
| | - Cheng-Chia Lee
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei.,9School of Medicine, National Yang Ming Chiao Tung University, Taipei.,10Brain Research Center, National Yang Ming Chiao Tung University, Taipei
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6
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Ung TH, Belanger K, Hashmi A, Sekar V, Meola A, Chang SD. Microenvironment changes in arteriovenous malformations after stereotactic radiation. Front Hum Neurosci 2022; 16:982190. [PMID: 36590065 PMCID: PMC9797682 DOI: 10.3389/fnhum.2022.982190] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/23/2022] [Indexed: 12/23/2022] Open
Abstract
Cerebral arteriovenous malformations are dysplastic vascular tangles with aberrant vascular dynamics and can result significant morbidity and mortality. A myriad of challenges are encountered when treating these lesions and are largely based on nidal size, location, and prior hemorrhage. Currently, stereotactic radiosurgery is an accepted form of treatment for small to medium sized lesions and is especially useful in the treatment of lesions in non-surgically assessable eloquent areas of the brain. Despite overall high rates of nidal obliteration, there is relatively limited understand on the mechanisms that drive the inflammatory and obliterative pathways observed after treatment with stereotactic radiosurgery. This review provides an overview of arteriovenous malformations with respect to stereotactic radiosurgery and the current understanding of the mechanisms that lead to nidal obliteration.
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Affiliation(s)
- Timothy H. Ung
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States,Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States,*Correspondence: Timothy H. Ung
| | - Katherine Belanger
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Ayesha Hashmi
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States
| | - Vashisht Sekar
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States
| | - Antonio Meola
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States
| | - Steven D. Chang
- Department of Neurosurgery, Stanford University, Palo Alto, CA, United States
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7
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Loebel F, Pontoriero A, Kluge A, Iatì G, Acker G, Kufeld M, Cacciola A, Pergolizzi S, Vinci S, Lillo S, Xu R, Stromberger C, Budach V, Vajkoczy P, Senger C, Conti A. Image-guided robotic radiosurgery for the treatment of arteriovenous malformations. PLoS One 2022; 17:e0266744. [PMID: 36137082 PMCID: PMC9499208 DOI: 10.1371/journal.pone.0266744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 03/26/2022] [Indexed: 11/26/2022] Open
Abstract
Background Cerebral arteriovenous malformations (AVMs) are challenging lesions, often requiring multimodal interventions; however, data on the efficacy of stereotactic radiosurgery for cerebral AVMs are limited. This study aimed to evaluate the clinical and radiographic results following robotic radiosurgery, alone or in combination with endovascular treatment, and to investigate factors associated with obliteration and complications in patients with AVM. Methods We retrospectively analyzed the clinical and imaging characteristics of 123 patients with AVMs of all Spetzler-Martin grades treated at two institutions by robotic radiosurgery in single-fraction doses (CyberKnife). Embolization was performed before radiosurgery in a subset of patients to attempt to downgrade the lesions. Factors associated with AVM obliteration and complications (toxicity) were identified via univariate and multivariate analyses. Results The median follow-up time was 48.1 months (range, 3.6–123 months). Five patients were lost to follow-up. The obliteration rate in the 59 patients with a follow-up period exceeding four years was 72.8%. Complete obliteration and partial remission were achieved in 67 (56.8%) and 31 (26.3%) cases, respectively, whereas no change was observed in 20 cases (17.8%). Embolization was performed in 54/123 cases (43.9%). Complete and partial obliteration were achieved in 29 (55.7%) and 14 (26.9%) embolized patients, respectively. In the multivariate analysis, the factors associated with obliteration were age (p = .018) and the Spetzler-Martin grade (p = .041). Treatment-induced toxicity (radiation necrosis and/or edema) was observed in 15 cases (12.7%), rebleeding occurred in three cases (2.5%), and the rate of mortality associated with rebleeding was 1.7%. Conclusions CyberKnife radiosurgery is a valid approach for treating AVMs of all Spetzler-Martin-grades, with satisfactory obliteration rates, low toxicity, and a relatively rare incidence of rebleeding.
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Affiliation(s)
- Franziska Loebel
- Department of Neurosurgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
- Department of Radiation Oncology, Charité Universitaetsmedizin Berlin, Berlin, Germany
- * E-mail:
| | | | - Anne Kluge
- Department of Radiation Oncology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Giuseppe Iatì
- Department of Radiation Oncology, University of Messina, Messina, Italy
| | - Gueliz Acker
- Department of Neurosurgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
- Department of Radiation Oncology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Markus Kufeld
- Department of Radiation Oncology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Alberto Cacciola
- Department of Radiation Oncology, University of Messina, Messina, Italy
| | | | - Sergio Vinci
- Department of Neuroradiology, University of Messina, Messina, Italy
| | - Sara Lillo
- Department of Radiation Oncology, University of Messina, Messina, Italy
| | - Ran Xu
- Department of Neurosurgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Carmen Stromberger
- Department of Radiation Oncology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Volker Budach
- Department of Radiation Oncology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Carolin Senger
- Department of Radiation Oncology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Alfredo Conti
- Department of Neurosurgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
- Department of Neurosurgery, Alma Mater Studiorum University of Bologna, Bologna, Italy
- IRCCS ISNB-Istituto delle Scienze Neurologiche Bologna, Bologna, Italy
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8
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Nguyen BT, Huynh CT, Nguyen TM, Nguyen VT, Karras CL, Huynh-Le P, Tran HM. Gamma Knife radiosurgery for brain arteriovenous malformations: a 15-year single-center experience in Southern Vietnam. World Neurosurg 2022; 163:71-79. [DOI: 10.1016/j.wneu.2022.04.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 11/28/2022]
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9
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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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10
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Gamma Knife radiosurgery for cerebral arteriovenous malformations: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:1987-2004. [PMID: 35178626 PMCID: PMC9160151 DOI: 10.1007/s10143-022-01751-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/16/2022]
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11
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Abstract
The treatment of arteriovenous malformations (AVMs) has evolved over the last 10 years. It is now possible to see that obliteration continues for up to 10 years and that the final obliteration rate may be between 85% and 90%. Improved imaging has made the treatment more efficient and has reduced the complications. It is possible to treat larger AVMs in a single session than was previously thought possible without increases in the complication rates. In addition, treatments of larger lesions can be staged. The use of 3D rotating angiography produces remarkable images which can be imported into GammaPlan. On the other hand efforts are ongoing to avoid the need for digital subtraction angiography, which would make the treatment a lot more comfortable.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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12
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Li W, Wang Y, Lu L, Zhang Y. The factors associated with obliteration following stereotactic radiosurgery in patients with brain arteriovenous malformations: a meta-analysis. ANZ J Surg 2021; 92:970-979. [PMID: 34676665 DOI: 10.1111/ans.17299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/26/2021] [Accepted: 10/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Various factors have been reported to affect the obliteration of brain arteriovenous malformations (AVM) following stereotactic radiosurgery (SRS). This meta-analysis was conducted to identify the factors potentially associated with AVM obliteration after SRS. METHODS We comprehensively searched databases and included studies that evaluated predictors of AVM obliteration after SRS using Cox proportional hazard regression analysis. Hazard ratios (HRs) with 95% confidence intervals (CIs) were utilized as effect estimates. RESULTS Twelve studies, involving 4415 AVM cases, were included. According to combined estimates on univariate (UV) and multivariate (MV) analysis, age, gender and prior haemorrhage did not affect the closure probability. The following factors showed a significant and independent association with increased AVM obliteration: smaller AVMs maximal diameter (MV, HR: 1.32), smaller AVM volume (MV, HR: 1.05), AVM volume <10-15 cc (MV, HR: 1.55), higher margin dose (MV, HR: 1.05), margin dose ≥17-18 Gy (MV, HR: 3.71) and early treatment period (MV, HR: 1.78). Previous embolization and deep-seated AVM were independently negative predictors of obliteration whereas deep venous drainage was a positive predictor. Prior surgery, compactness of nidus, lower grading scores and higher SRS maximum dose were associated factors subject to confounding factors. CONCLUSION Multiple factors associated with obliteration should be taken into consideration for selection of candidates with AVMs for SRS. AVM volume and radiation dose are the most prominent factor in assessing obliteration after SRS. Age, gender and prior haemorrhage may not affect the consideration of SRS treatment. Cautious use of SRS is needed for previously embolized AVM patients.
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Affiliation(s)
- Weiyan Li
- Department of General Surgery, Tianjin Fifth Central Hospital, Tianjin, 300450, China
| | - Yuqiang Wang
- Department of General Surgery, Tianjin Fifth Central Hospital, Tianjin, 300450, China
| | - Lantao Lu
- Department of General Surgery, Tianjin Fifth Central Hospital, Tianjin, 300450, China
| | - Yi Zhang
- Department of General Surgery, Tianjin Fifth Central Hospital, Tianjin, 300450, China
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13
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Shimizu A, Yamaguchi K, Okada Y, Funatsu T, Ishikawa T, Hayashi M, Tamura N, Horiba A, Kawamata T. Results of surgical treatment after Gamma Knife radiosurgery for cerebral arteriovenous malformations: patient series. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE21181. [PMID: 35855079 PMCID: PMC9245776 DOI: 10.3171/case21181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 04/01/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Gamma Knife radiosurgery (GKRS) is a safe and effective treatment, but it has a risk of bleeding. Herein, the authors describe their experience with some patients who required surgical removal of cerebral arteriovenous malformations (AVMs) located mainly in eloquent areas of the brain after GKRS, and they consider the advantages of surgical removal after GKRS. OBSERVATIONS Twelve patients who had undergone surgical removal of AVMs after GKRS at Tokyo Women’s Medical University between April 2013 and July 2019 were selected for analysis. All participants underwent GKRS as first-line therapy for AVMs located in an eloquent region or if requested by the patient. Complete obliteration was achieved in 7 patients, and the size of the nidus decreased in 3 patients during the follow-up period. The Spetzler-Martin grade decreased in 11 patients. Three patients experienced symptomatic intracerebral hemorrhage before and after confirmation of complete obliteration of the nidus via GKRS, and 7 patients experienced some neurological deficits because of an encapsulated expanding hematoma. All patients underwent resection of the nidus without complications. The preoperative neurological deficits improved in 6 patients and remained unchanged in 6 patients. LESSONS This report indicates that performing GKRS before surgery may be useful for future multimodal therapy.
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Affiliation(s)
- Atsushi Shimizu
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Koji Yamaguchi
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yoshikazu Okada
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Takayuki Funatsu
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Tatsuya Ishikawa
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Motohiro Hayashi
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Noriko Tamura
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Ayako Horiba
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan
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14
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Nesvick CL, Graffeo CS, Brown PD, Link MJ, Stafford SL, Foote RL, Laack NN, Pollock BE. The Role of Biological Effective Dose in Predicting Obliteration After Stereotactic Radiosurgery of Cerebral Arteriovenous Malformations. Mayo Clin Proc 2021; 96:1157-1164. [PMID: 33958052 DOI: 10.1016/j.mayocp.2020.09.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 09/14/2020] [Accepted: 09/23/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether biological effective dose (BED) was predictive of obliteration after stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations (AVMs). PATIENTS AND METHODS We studied patients undergoing single-session AVM SRS between January 1, 1990, and December 31, 2014, with at least 2 years of imaging follow-up. Excluded were patients with syndromic AVM, previous SRS or embolization, and patients treated with volume-staged SRS. Biological effective dose was calculated using a mono-exponential model described by Jones and Hopewell. The primary outcome was likelihood of total obliteration defined by digital subtraction angiography or magnetic resonance imaging (MRI). Variables were analyzed as continuous and dichotomous variables based on the maximum value of (sensitivity-[1-specificity]). RESULTS This study included 352 patients (360 AVM, median follow-up, 5.9 years). The median margin dose prescribed was 18.75 Gy (interquartile range [IQR]: 18 to 20 Gy). Two hundred fifty-nine patients (71.9%) had obliteration shown by angiography (n=176) or MRI (n=83) at a median of 36 months after SRS (IQR: 26 to 44 months). Higher BED was associated with increased likelihood of obliteration in univariate Cox regression analyses, when treated as either a dichotomous (≥133 Gy; hazard ratio [HR],1.52; 95% confidence interval [CI], 1.19 to 1.95; P<.001) or continuous variable (HR, 1.00, 95% CI, 1.0002 to 1.005; P=.04). In multivariable analyses including dichotomized BED and location, BED remained associated with obliteration (P=.001). CONCLUSION Biological effective dose ≥133 Gy was predictive of AVM obliteration after single-session SRS within the prescribed margin dose range 15 to 25 Gy. Further study is warranted to determine whether BED optimization should be considered as well as treatment dose for AVM SRS planning.
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Affiliation(s)
- Cody L Nesvick
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| | | | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Michael J Link
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| | | | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Nadia N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN; Department of Radiation Oncology, Mayo Clinic, Rochester, MN.
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15
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Long-term Outcomes of Gamma Knife Radiosurgery for Treating Vestibular Schwannoma With a Lower Prescription Dose of 12 Gy Compared With Higher Dose Treatment. Otol Neurotol 2021; 41:e1314-e1320. [PMID: 33492807 DOI: 10.1097/mao.0000000000002885] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Gamma knife radiosurgery (GKRS) is commonly used to treat vestibular schwannomas (VSs). The risk of complications from GKRS decreases at lower doses, but it is unknown if long-term tumor control is negatively affected by dose reduction. STUDY DESIGN This was a retrospective case review and analysis of patient data. SETTING Tertiary referral center. PATIENTS Patients with VSs who underwent GKRS between 1990 and 2007 at the authors' institution. INTERVENTION(S) The subjects were divided into two cohorts based on the prescribed doses of radiation received: a 12 Gy cohort (96 patients) with a follow-up period of 124 months and a >12 Gy cohort (118 patients) with a follow-up period of 143 months. MAIN OUTCOME MEASURES Tumor control rates at 10 to 15 years, frequency of facial and trigeminal nerve complications, and hearing function. RESULTS The 10 to 15-year tumor control rates were 95% in the 12 Gy cohort and 88% in the > 12 Gy cohort, but the differences were not significant. Compared with the >12 Gy cohort, facial and trigeminal nerve deficits occurred significantly less frequently in the 12 Gy cohort, with the 10-year cumulative, permanent deficit-free rates being 2% and 0%, respectively. Multivariate analyses revealed that treatment doses exceeding 12 Gy were associated with a significantly higher risk for cranial nerve deficits. The percentage of subjects retaining pure-tone average ≤ 50 dB at the final follow-up did not significantly differ between the cohorts (12 Gy cohort, 30% and >12 Gy cohort, 33%; p = 0.823). CONCLUSIONS Dose reduction to 12 Gy for GKRS to treat VSs decreased facial and trigeminal nerve complications without worsening tumor control rates.
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16
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Shinya Y, Hasegawa H, Shin M, Kawashima M, Sugiyama T, Ishikawa O, Koizumi S, Suzuki Y, Nakatomi H, Saito N. Rotational Angiography-Based Gamma Knife Radiosurgery for Brain Arteriovenous Malformations: Preliminary Therapeutic Outcomes of the Novel Method. Neurosurgery 2021; 89:60-69. [PMID: 33770182 DOI: 10.1093/neuros/nyab066] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 01/04/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND High-definition vascular imaging is desirable for treatment planning in Gamma Knife radiosurgery (GKRS; Elekta AB) for brain arteriovenous malformations (BAVMs). Currently, rotational angiography (RA) provides the clearest 3-dimensional visualization of niduses with high spatial resolution; however, its efficacy for GKRS has not been clarified. At our institution, RA has been integrated into GKRS (RA-GKRS) for better treatment planning and outcomes since 2015. OBJECTIVE To evaluate RA-GKRS outcomes of BAVMs and compare them with conventional GKRS (c-GKRS) outcomes. METHODS We retrospectively analyzed the radiosurgical outcomes of 50 BAVMs treated with RA-GKRS compared with the 306 BAVMs treated with c-GKRS. Considering possible differences in the baseline characteristics, we also created propensity score-matched cohorts and compared the radiosurgical outcomes between them to ensure comparability. RESULTS The obliteration time was shorter in the RA-GKRS group (cumulative rate, 88% vs 65% at 4 yr [P = .001]). Multivariate Cox proportional hazards analysis demonstrated that the RA-GKRS group (hazard ratio 2.38, 95% CI 1.58-3.60; P = .001) had a better obliteration rate. The cumulative 4-yr post-GKRS hemorrhage rates were 4.0% and 2.6% in the RA-GKRS and c-GKRS groups, respectively (P = .558). There was a trend toward early post-GKRS signal change in the RA-GKRS group compared with the c-GKRS group (cumulative rate, 38% vs 29% at 2 yr; P = .118). Those results were also confirmed in the matched cohort analyses. CONCLUSION The integration of RA into GKRS is promising and may provide earlier nidus obliteration.
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Affiliation(s)
- Yuki Shinya
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan.,Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Osamu Ishikawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yuichi Suzuki
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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17
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Zhu S, Brodin NP, Garg MK, LaSala PA, Tomé WA. Systematic Review and Meta-Analysis of the Dose-Response and Risk Factors for Obliteration of Arteriovenous Malformations Following Radiosurgery: An Update Based on the Last 20 Years of Published Clinical Evidence. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okab004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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18
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Graffeo CS, Sahgal A, De Salles A, Fariselli L, Levivier M, Ma L, Paddick I, Regis JM, Sheehan J, Suh J, Yomo S, Pollock BE. Stereotactic Radiosurgery for Spetzler-Martin Grade I and II Arteriovenous Malformations: International Society of Stereotactic Radiosurgery (ISRS) Practice Guideline. Neurosurgery 2020; 87:442-452. [PMID: 32065836 PMCID: PMC7426190 DOI: 10.1093/neuros/nyaa004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 11/30/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND No guidelines have been published regarding stereotactic radiosurgery (SRS) in the management of Spetzler-Martin grade I and II arteriovenous malformations (AVMs). OBJECTIVE To establish SRS practice guidelines for grade I-II AVMs on the basis of a systematic literature review. METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant search of Medline, Embase, and Scopus, 1986-2018, for publications reporting post-SRS outcomes in ≥10 grade I-II AVMs with a follow-up of ≥24 mo. Primary endpoints were obliteration and hemorrhage; secondary outcomes included Spetzler-Martin parameters, dosimetric variables, and “excellent” outcomes (defined as total obliteration without new post-SRS deficit). RESULTS Of 447 abstracts screened, 8 were included (n = 1, level 2 evidence; n = 7, level 4 evidence), representing 1102 AVMs, of which 836 (76%) were grade II. Obliteration was achieved in 884 (80%) at a median of 37 mo; 66 hemorrhages (6%) occurred during a median follow-up of 68 mo. Total obliteration without hemorrhage was achieved in 78%. Of 836 grade II AVMs, Spetzler-Martin parameters were reported in 680: 377 were eloquent brain and 178 had deep venous drainage, totaling 555/680 (82%) high-risk SRS-treated grade II AVMs. CONCLUSION The literature regarding SRS for grade I-II AVM is low quality, limiting interpretation. Cautiously, we observed that SRS appears to be a safe, effective treatment for grade I-II AVM and may be considered a front-line treatment, particularly for lesions in deep or eloquent locations. Preceding publications may be influenced by selection bias, with favorable AVMs undergoing resection, whereas those at increased risk of complications and nonobliteration are disproportionately referred for SRS.
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Affiliation(s)
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Canada
| | - Antonio De Salles
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California
| | - Laura Fariselli
- Fondazione IRCCS Istituto Neurologico Carlo Besta Milano, Unità di Radioterapia, Milan, Italy
| | - Marc Levivier
- Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Ian Paddick
- National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Jean Marie Regis
- Department of Functional Neurosurgery, Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - John Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota.,Department Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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19
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Kelly R, Conte A, Nair MN, Voyadzis JM, Anaizi A, Collins S, Kalhorn C, Stemer A, Mai J, Armonda R, Lischalk J, Berkowitz F, Nayar V, McGrail K, Collins BT. Arteriovenous Malformations Treated With Frameless Robotic Radiosurgery Using Non-Invasive Angiography: Long-Term Outcomes of a Single Center Pilot Study. Front Oncol 2020; 10:570782. [PMID: 33330045 PMCID: PMC7734323 DOI: 10.3389/fonc.2020.570782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/22/2020] [Indexed: 12/31/2022] Open
Abstract
Objective CT-guided, frameless robotic radiosurgery is a novel radiotherapy technique for the treatment of intracranial arteriovenous malformations (AVMs) that serves as an alternative to traditional catheter-angiography targeted, frame-based methods. Methods Patients diagnosed with AVMs who completed single fraction frameless robotic radiosurgery at Medstar Georgetown University Hospital between July 20, 2006 – March 11, 2013 were included in the present study. All patients received pre-treatment planning with CT angiogram (CTA) and MRI, and were treated using the CyberKnife radiosurgery platform. Patients were followed for at least four years or until radiographic obliteration of the AVM was observed. Results Twenty patients were included in the present study. The majority of patients were diagnosed with Spetzler Martin Grade II (35%) or III (35%) AVMs. The AVM median nidus diameter and nidal volume was 1.8 cm and 4.38 cc, respectively. Median stereotactic radiosurgery dose was 1,800 cGy. After a median follow-up of 42 months, the majority of patients (81.3%) had complete obliteration of their AVM. All patients who were treated to a total dose of 1800 cGy demonstrated complete obliteration. One patient treated at a dose of 2,200 cGy developed temporary treatment-related toxicity, and one patient developed post-treatment hemorrhage. Conclusions Frameless robotic radiosurgery with non-invasive CTA and MRI radiography appears to be a safe and effective radiation modality and serves as a novel alternative to traditional invasive catheter-angiography, frame-based methods for the treatment of intracranial AVMs. Adequate obliteration can be achieved utilizing 1,800 cGy in a single fraction, and minimizes treatment-related side effects.
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Affiliation(s)
- Ryan Kelly
- Georgetown University School of Medicine, Washington, DC, United States
| | - Anthony Conte
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - M Nathan Nair
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Amjad Anaizi
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Sean Collins
- Department of Radiation Medicine, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Christopher Kalhorn
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Andrew Stemer
- Department of Neurology, Medstar Georgetown University Hospital, Washington, DC, United States.,Department of Radiology, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Jeffery Mai
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, United States
| | - Rocco Armonda
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, United States
| | - Jonathan Lischalk
- Department of Radiation Medicine, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Frank Berkowitz
- Department of Radiology, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Vikram Nayar
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Kevin McGrail
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, United States
| | - Brian Timothy Collins
- Department of Radiation Medicine, Medstar Georgetown University Hospital, Washington, DC, United States
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20
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Yang HC, Peng SJ, Lee CC, Wu HM, Chen YW, Lin CJ, Shiau CY, Guo WY, Pan DHC, Liu KD, Chung WY, Lin YY. Does the Diffuseness of the Nidus Affect the Outcome of Stereotactic Radiosurgery in Patients with Unruptured Cerebral Arteriovenous Malformations? Stereotact Funct Neurosurg 2020; 99:113-122. [PMID: 33264796 DOI: 10.1159/000510683] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/31/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND We proposed an algorithm to automate the components within the identification of components within the nidus of cerebral arteriovenous malformations (AVMs) which may be used to analyze the relationship between its diffuseness and treatment outcomes following stereotactic radiosurgery (SRS). OBJECTIVES to determine the impact of the diffuseness of the AVM nidus on SRS outcomes. METHODS This study conducted regular follow-ups of 209 patients with unruptured AVMs who underwent SRS. The diffuseness of the AVM nidus was estimated by quantifying the proportions of vascular nidal component, brain parenchyma, and cerebrospinal fluid in T2-weighted MRIs. We used Cox regression analysis to characterize the association between nidal diffuseness and treatment outcomes in terms of obliteration rate and radiation-induced change (RICs) rate following SRS. RESULTS The median AVM volume was 20.7 cm3. The median duration of imaging follow-up was 51 months after SRS. The overall AVM obliteration rate was 68.4%. RICs were identified in 156 of the 209 patients (74.6%). The median proportions of the nidus of AVM and brain parenchyma components within the prescription isodose range were 30.2 and 52.2%, respectively. Cox regression multivariate analysis revealed that the only factor associated with AVM obliteration rate after SRS was AVM volume. However, a larger AVM volume (>20 mL) and a larger proportion of brain parenchyma (>50%) within the prescription isodose range were both correlated with a higher RIC rate following SRS. CONCLUSIONS The diffuseness of the nidus indeed appears to affect the RIC rate following SRS in patients with unruptured AVMs.
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Affiliation(s)
- Huai-Che Yang
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Syu-Jyun Peng
- Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chia Lee
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Wei Chen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Ying Shiau
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - David Hung-Chi Pan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Kang-Du Liu
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yung-Yang Lin
- Institute of Brain Science, National Yang-Ming University, Taipei, Taiwan, .,School of Medicine, National Yang-Ming University, Taipei, Taiwan, .,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, .,Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan,
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21
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Lefevre E, Robert T, Escalard S, Fahed R, Smajda S, Ciccio G, Desilles JP, Mazighi M, Blanc R, Piotin M. Presence of direct vertebrobasilar perforator feeders in posterior fossa arteriovenous malformations and association with poor outcomes after endovascular treatment. J Neurosurg 2020; 133:1802-1810. [PMID: 31703199 DOI: 10.3171/2019.8.jns191971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 08/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Treatment of posterior fossa arteriovenous malformations (PFAVMs) remains controversial as it is always challenging and may lead to major complications. Nonetheless, these lesions are more likely to bleed and generate poorer outcomes than other brain AVMs. The aim of this study was to evaluate the effect of endovascular treatment on long-term outcomes and identify the patient subgroups that might benefit from endovascular treatment. METHODS The authors performed a retrospective analysis of all consecutive cases of PFAVM managed at the Fondation Rothschild Hospital between 1995 and 2018. Clinical, imaging, and treatment data were prospectively gathered; these data were analyzed with respect to long-term outcomes. RESULTS Among the 1311 patients with brain AVMs, 114 (8.7%) had a PFAVM, and 88 (77.2%) of these patients had a history of bleeding. Of the 114 PFAVMs, 101 (88.6%) were treated (83 ruptured and 18 unruptured). The mean duration of follow-up was 47.6 months (range 0-240 months). Good neurological outcome at last follow-up was achieved in 79 cases (78.2%). Follow-up angiography showed obliteration of the PFAVM in 68.3% of treated cases. The presence of direct vertebrobasilar perforator feeders was associated with neurological deterioration (OR 5.63, 95% CI 11.15-30.76) and a lower obliteration rate (OR 15.69, 95% CI 2.52-304.03) after endovascular treatment. Other predictors of neurological deterioration and obliteration rate were consistent with the Spetzler-Martin grading system. CONCLUSIONS Advances in endovascular techniques have enabled higher obliteration rates in the treatment of PFAVMs, but complication rates are still high. Subgroups of patients who might benefit from treatment must be carefully selected and the presence of direct vertebrobasilar perforator feeders must call into question the indication for endovascular treatment.
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Affiliation(s)
- Etienne Lefevre
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Thomas Robert
- 2Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Ticino, Switzerland
| | - Simon Escalard
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Robert Fahed
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Stanislas Smajda
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Gabriele Ciccio
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Jean-Philippe Desilles
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Mikael Mazighi
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Raphaël Blanc
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
| | - Michel Piotin
- 1Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France; and
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22
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Chen CJ, Ding D, Derdeyn CP, Lanzino G, Friedlander RM, Southerland AM, Lawton MT, Sheehan JP. Brain arteriovenous malformations: A review of natural history, pathobiology, and interventions. Neurology 2020; 95:917-927. [PMID: 33004601 DOI: 10.1212/wnl.0000000000010968] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/08/2020] [Indexed: 11/15/2022] Open
Abstract
Brain arteriovenous malformations (AVMs) are anomalous direct shunts between cerebral arteries and veins that convalesce into a vascular nidus. The treatment strategies for AVMs are challenging and variable. Intracranial hemorrhage and seizures comprise the most common presentations of AVMs. However, incidental AVMs are being diagnosed with increasing frequency due to widespread use of noninvasive neuroimaging. The balance between the estimated cumulative lifetime hemorrhage risk vs the risk of intervention is often the major determinant for treatment. Current management options include surgical resection, embolization, stereotactic radiosurgery (SRS), and observation. Complete nidal obliteration is the goal of AVM intervention. The risks and benefits of interventions vary and can be used in a combinatorial fashion. Resection of the AVM nidus affords high rates of immediate obliteration, but it is invasive and carries a moderate risk of neurologic morbidity. AVM embolization is minimally invasive, but cure can only be achieved in a minority of lesions. SRS is also minimally invasive and has little immediate morbidity, but AVM obliteration occurs in a delayed fashion, so the patient remains at risk of hemorrhage during the latency period. Whether obliteration can be achieved in unruptured AVMs with a lower risk of stroke or death compared with the natural history of AVMs remains controversial. Over the past 5 years, multicenter prospective and retrospective studies describing AVM natural history and treatment outcomes have been published. This review provides a contemporary and comprehensive discussion of the natural history, pathobiology, and interventions for brain AVMs.
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Affiliation(s)
- Ching-Jen Chen
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Dale Ding
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Colin P Derdeyn
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Giuseppe Lanzino
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Robert M Friedlander
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Andrew M Southerland
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Michael T Lawton
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ
| | - Jason P Sheehan
- From the Department of Neurological Surgery (C.-J.C., J.P.S.), University of Virginia School of Medicine, Charlottesville, VA; Department of Neurosurgery (D.D.), University of Louisville School of Medicine, Louisville, KY; Department of Radiology (C.P.D.), University of Iowa Carver School of Medicine, Iowa City, IA; Deparment of Neurosurgery (G.L.), Mayo Clinic, Rochester, MN; Department of Neurological Surgery (R.M.F.), University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Neurology (A.M.S.), University of Virginia School of Medicine, Charlottesville, VA; and Department of Neurosurgery (M.T.L.), Barrow Neurological Institute, Phoenix, AZ.
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23
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Graffeo CS, Donegan D, Erickson D, Brown PD, Perry A, Link MJ, Young WF, Pollock BE. The Impact of Insulin-Like Growth Factor Index and Biologically Effective Dose on Outcomes After Stereotactic Radiosurgery for Acromegaly: Cohort Study. Neurosurgery 2020; 87:538-546. [PMID: 32267504 PMCID: PMC7426191 DOI: 10.1093/neuros/nyaa054] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 01/30/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is a safe and effective treatment for acromegaly. OBJECTIVE To improve understanding of clinical and dosimetric factors predicting biochemical remission. METHODS A single-institution cohort study of nonsyndromic, radiation-naïve patients with growth hormone-producing pituitary adenomas (GHA) having single-fraction SRS between 1990 and 2017. Exclusions were treatment with pituitary suppressive medications at the time of SRS, or <24 mo of follow-up. The primary outcome was biochemical remission-defined as normalization of insulin-like growth factor-1 index (IGF-1i) off suppression. Biochemical remission was assessed using Cox proportional hazards. Prior studies reporting IGF-1i were assessed via systematic literature review and meta-analysis using random-effect modeling. RESULTS A total of 102 patients met study criteria. Of these, 46 patients (45%) were female. The median age was 49 yr (interquartile range [IQR] = 37-59), and the median follow-up was 63 mo (IQR = 29-100). The median pre-SRS IGF-1i was 1.66 (IQR = 1.37-3.22). The median margin dose was 25 Gy (IQR = 21-25); the median estimated biologically effective dose (BED) was 169.49 Gy (IQR = 124.95-196.00). Biochemical remission was achieved in 58 patients (57%), whereas 22 patients (22%) had medication-controlled disease. Pre-SRS IGF-1i ≥ 2.25 was the strongest predictor of treatment failure, with an unadjusted hazard ratio (HR) of 0.51 (95% CI = 0.26-0.91, P = .02). Number of isocenters, margin dose, and BED predicted remission on univariate analysis, but after adjusting for sex and baseline IGF-1i, only BED remained significant-and was independently associated with outcome in continuous (HR = 1.01, 95% CI = 1.00-1.01, P = .02) and binary models (HR = 2.27, 95% CI = 1.39-5.22, P = .002). A total of 24 patients (29%) developed new post-SRS hypopituitarism. Pooled HR for biochemical remission given subthreshold IGF-1i was 2.25 (95% CI = 1.33-3.16, P < .0001). CONCLUSION IGF-1i is a reliable predictor of biochemical remission after SRS. BED appears to predict biochemical outcome more reliably than radiation dose, but confirmatory study is needed.
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Affiliation(s)
| | - Diane Donegan
- Division of Endocrinology, Indiana University, Indianapolis, Indiana
| | - Dana Erickson
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Avital Perry
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael J Link
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - William F Young
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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24
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Karlsson B, Jokura H, Yang HC, Yamamoto M, Martinez R, Kawagishi J, Guo WY, Beute G, Chung WY, Söderman M, Yeo TT. Clinical outcome following cerebral AVM hemorrhage. Acta Neurochir (Wien) 2020; 162:1759-1766. [PMID: 32385636 DOI: 10.1007/s00701-020-04380-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/29/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND A significant difference exists between the published results reporting the clinical outcome following brain arteriovenous malformation (AVM) ruptures. Information about the outcome following hemorrhage in an AVM population treated with radiosurgery could provide additional information to assess the risk of mortality and morbidity following an AVM hemorrhage. METHODS Clinical outcome was studied in 383 patients, the largest patient population yet studied, who suffered from a symptomatic hemorrhage after Gamma Knife® surgery (GKS) but before confirmed AVM obliteration. The impact of different patient, AVM, and treatment parameters on the clinical outcome was analyzed. The aim was to generate outcome predictions by comparing our data to and combining them with earlier published results. RESULTS No relation was found between clinical outcome and treatment parameters, indicating that the results are applicable also on untreated AVMs. Twenty-one percent of the patients died, 45% developed or experienced worsening of neurological sequelae, and 35% recovered completely after the hemorrhage. Old age was a predictor of poor outcome. Sex, AVM location, AVM volume, and history of prior hemorrhage did not influence the outcome. The mortality rate was comparable to earlier published prospective data, but higher than that found in retrospective studies. CONCLUSIONS The mortality rates in earlier published retrospective series as well as in studies focusing on clinical outcome following AVM hemorrhage significantly underestimate the risk for a mortal outcome following an AVM hemorrhage. Based on our findings, an AVM rupture has around 20% likelihood to result in mortality, 45% likelihood to result in a minor or major deficit, and 35% likelihood of complete recovery. The findings are probably applicable also for AVM ruptures in general. The cumulative mortality and morbidity rates 25 years after diagnosis were estimated to be around 40% in a patient with a patent AVM.
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Affiliation(s)
- Bengt Karlsson
- Department of Surgery, Div. of Neurosurgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore.
| | - Hidefumi Jokura
- Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Furukawa, Osaki, Japan
| | - Huai-Che Yang
- Department of Neurosurgery, Veterans General Hospital, Taipei, Taiwan
- Yang-Ming University, Taipei, Taiwan
| | | | | | - Jun Kawagishi
- Jiro Suzuki Memorial Gamma House, Furukawa Seiryo Hospital, Furukawa, Osaki, Japan
| | - Wan-Yuo Guo
- Department of Radiology, Veterans General Hospital, Taipei, Taiwan
| | - Guus Beute
- St Elizabeth Ziekenhuis, Tilburg, the Netherlands
| | - Wen-Yuh Chung
- Department of Neurosurgery, Veterans General Hospital, Taipei, Taiwan
| | | | - Tseng Tsai Yeo
- Department of Surgery, Div. of Neurosurgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
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25
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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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26
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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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27
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Kato Y, Dong VH, Chaddad F, Takizawa K, Izumo T, Fukuda H, Hara T, Kikuta K, Nakai Y, Endo T, Kurita H, Xu B, Beneš V, Christian R, Pavesi G, Hodaie M, Sharma RK, Agarwal H, Mohan K, Liew BS. Expert Consensus on the Management of Brain Arteriovenous Malformations. Asian J Neurosurg 2019; 14:1074-1081. [PMID: 31903343 PMCID: PMC6896626 DOI: 10.4103/ajns.ajns_234_19] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Brain arteriovenous malformations (bAVMs) are complex, heterogeneous, and uncommon intracranial lesions. They can be treated by one or a combination of the following treatment modalities, namely embolization, radiosurgery, or microsurgical resection. In Spetzler-Martin Grade 4 and 5 arteriovenous malformations (AVMs), conservative management may be the best option. A group of experts in the management of AVMs of different disciplines gathered in January 2019 in Hanoi to compile the “Expert Consensus on the Management of Brain Arteriovenous Malformations”.
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Affiliation(s)
- Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Van He Dong
- Department of Neurosurgery, VietDuc University Hospital, Hoan Kiem, Hanoi, Vietnam
| | - Feres Chaddad
- Department of Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Katsumi Takizawa
- Department of Neurosurgery, Japanese Red Cross Asahikawa Hospital, Asahikawa, Japan
| | - Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto, Nagasaki, Japan
| | - Hitoshi Fukuda
- Department of Neurosurgery, Kochi University Hospital, Nankoku, Kochi, Japan
| | - Takayuki Hara
- Department of Neurosurgery, Toranomon Hospital, MinatoKu, Tokyo, Japan
| | | | - Yasunobu Nakai
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | - Toshiki Endo
- Department of Neurosurgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryo Aoba, Sendai, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Bin Xu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Vladimír Beneš
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University, Military University Hospital, Prague, Czech Republic
| | - Raftopoulos Christian
- Department of Neurosurgery, Cliniques Universitaires SaintLuc Bruxelles, Brussels, Belgium
| | - Giacomo Pavesi
- Department of Neurosurgery, Sant'Agostino Estense Hospital, Modena, Italy
| | - Mojgan Hodaie
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rajan Kumar Sharma
- Department of Neurosurgery, Bir Hospital, National Academy of Medical Sciences, Kathmandu, Nepal
| | | | - Krishna Mohan
- Department of Neurosurgery, SVIMS, Tirupathi, Andhra Pradesh, India
| | - Boon Seng Liew
- Department of Neurosurgery, Hospital Sungai Buloh, Selangor, Malaysia
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28
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Hirschmann D, Goebl P, Witte FH, Gatterbauer B, Wang WT, Dodier P, Bavinzski G, Ertl A, Marik W, Mallouhi A, Roetzer T, Dorfer C, Eisner W, Gruber A, Kitz K, Frischer JM. Evaluation of the radiosurgical treatment of cerebral arteriovenous malformations: a retrospective single-center analysis of three decades. J Neurointerv Surg 2019; 12:401-406. [PMID: 31558656 DOI: 10.1136/neurintsurg-2019-015332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/13/2019] [Accepted: 09/16/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Gamma Knife radiosurgery (GKRS) in the treatment of arteriovenous malformations (AVMs) is still controversially discussed. OBJECTIVE To present long-term follow-up data on patients after Gamma Knife radiosurgery for cerebral AVMs. METHODS Overall, 516 patients received radiosurgery for cerebral AVMs between 1992 and 2018 at our department, of whom 265 received radiosurgery alone and 207 were treated with a combined endovascular-radiosurgical approach. Moreover, 45 patients were treated with a volume-staged approach. Two eras were analyzed, the pre-modern era between 1992 and 2002 and the modern era thereafter. RESULTS In GKRS-only treated patients, median time to nidus occlusion was 3.8 years. Spetzler-Ponce (SP) class was a significant predictor for time to obliteration in the whole sample. Median time to obliteration for the combined treatment group was 6.5 years. Patients in the pre-modern era had a significantly higher obliteration rate than those treated in the modern era. Overall, the calculated yearly hemorrhage risk in the observation period after first GKRS was 1.3%. Permanent post-radiosurgical complications occurred in 4.9% of cases but did not differ between the treatment groups or treatment eras. The obliteration rate was significantly lower and the hemorrhage rate was higher in volume-staged treated patients than in conventionally treated patients. CONCLUSION GKRS is an effective treatment option for SP class A and B cerebral AVMs. After combined endovascular-radiosurgical treatment, the outcome of selected SP class C AVMs aligns with that of SP class B lesions. Both the combined therapy and radiosurgery alone constitute sound methods for treatment of cerebral AVMs.
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Affiliation(s)
- Dorian Hirschmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Goebl
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Frederic H Witte
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | | | - Wei-Te Wang
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Adolf Ertl
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Marik
- Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Ammar Mallouhi
- Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Thomas Roetzer
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
| | - Christian Dorfer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Wilhelm Eisner
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Johannes Kepler Universitat Linz, Linz, Austria
| | - Klaus Kitz
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Josa M Frischer
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
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29
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Hasegawa H, Hanakita S, Shin M, Sugiyama T, Kawashima M, Takahashi W, Ishikawa O, Nakatomi H, Saito N. Re-Evaluation of the Size Limitation in Single-Session Stereotactic Radiosurgery for Brain Arteriovenous Malformations: Detailed Analyses on the Outcomes with Focusing on Radiosurgical Doses. Neurosurgery 2019; 86:685-696. [DOI: 10.1093/neuros/nyz280] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 04/16/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Single-session stereotactic radiosurgery (SRS) for large arteriovenous malformations (AVMs) ≥10 mL remains controversial, which is considered as the current size limitation.
OBJECTIVE
To reconsider the size limitation of SRS for AVMs by profoundly analyzing dose-volume relationship.
METHODS
Data on 610 consecutive patients with AVM treated with SRS using regular (18-22 Gy) or low (<18 Gy) prescription doses were retrospectively analyzed. AVMs were classified into 4 groups: small (<5 mL), medium (≥5 and <10 mL), medium-large (≥10 and <15 mL), and large (≥15 mL). The maximum volumes were 22.5 mL (regular-dose group) and 23.5 mL (low-dose group).
RESULTS
When treated with regular doses, the cumulative 6-yr obliteration rates for each of the 4 AVM groups were 86%, 80%, 87%, and 79%, respectively; the cumulative 10-yr significant neurological event (SNE) rates were 2.6%, 3.9%, 6.8%, and 5.3%, respectively. Regarding large AVMs, regular-dose SRS resulted in marginally better obliteration rate (6-yr cumulative rate, 79% vs 48%, P = .111) and significantly lower SNE (5-yr cumulative rate, 5% vs 31%, P = .038) and post-SRS hemorrhage rate (8-yr cumulative rate, 0% vs 54%, P = .002) compared to low-dose SRS. Multivariate analyses revealed that regular-dose SRS significantly contributed to increase in the obliteration rate and decrease in SNEs and hemorrhage.
CONCLUSION
The outcomes for large AVMs were generally favorable when treated with ablative doses. Single-session SRS could be acceptable for AVMs up to ≈20 mL if treated with ablative doses.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Shunya Hanakita
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Masahiro Shin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
- Department of Public Health/Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mariko Kawashima
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Wataru Takahashi
- Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan
| | - Osamu Ishikawa
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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Baharvahdat H, Blanc R, Fahed R, Smajda S, Ciccio G, Desilles JP, Redjem H, Escalard S, Mazighi M, Chauvet D, Robert T, Sasannejad P, Piotin M. Endovascular Treatment for Low-Grade (Spetzler-Martin I-II) Brain Arteriovenous Malformations. AJNR Am J Neuroradiol 2019; 40:668-672. [PMID: 30792251 DOI: 10.3174/ajnr.a5988] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/08/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Surgical resection is usually considered as the first-line curative strategy for low-grade (Spetzler-Martin grade I-II) brain arteriovenous malformations because it has a high cure rate and low complications. The role of endovascular treatment remains to be clarified in this indication, especially after A Randomized Trial of Unruptured Brain Arteriovenous Malformations. Our objective was to assess the safety and efficacy of first-line endovascular treatment in low-grade brain arteriovenous malformation management at our institution. MATERIALS AND METHODS Patients with low-grade brain arteriovenous malformations treated primarily with embolization in our department between January 2005 and December 2015 were retrieved from our prospectively collected registry. The primary outcome was the brain arteriovenous malformation obliteration rate, and secondary outcomes were disability or death secondary to brain arteriovenous malformation embolization assessed through modification of the modified Rankin Scale. RESULTS Two hundred twenty-four patients completed endovascular treatment during the study period and represent our study population. Complete exclusion of brain arteriovenous malformations was achieved in 205 patients (92%), including 62.1% of brain arteriovenous malformation exclusions after a single endovascular treatment session. One patient died of a hemorrhagic complication after endovascular treatment, leading to a mortality rate of 0.4%. Twelve patients (5%) kept a permanent neurologic deficit secondary to a complication of the endovascular treatment. An overall good outcome (mRS 0-2) was reported in 179 patients (80%). CONCLUSIONS Endovascular treatment might be a suitable alternative to surgical resection for complete exclusion of selected low-grade brain arteriovenous malformations.
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Affiliation(s)
- H Baharvahdat
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - R Blanc
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - R Fahed
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - S Smajda
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - G Ciccio
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - J-P Desilles
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - H Redjem
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - S Escalard
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - M Mazighi
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - D Chauvet
- Neurosurgical Department (D.C.), Rothschild Foundation, Paris, France
| | - T Robert
- Neurosurgical Department (T.R.), Ente-Ospedaliero-Cantonale Ospedale Civico di Lugano, Lugano, Switzerland
| | - P Sasannejad
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
| | - M Piotin
- From the Department of Interventional Neuroradiology (H.B., R.B., R.F., S.S., G.C., J.-P.D, H.R., S.E., M.M., P.S., M.P.)
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31
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Nagy G, Yianni J, Bhattacharyya D, Rowe JG, Kemeny AA, Radatz MWR. Repeat Radiosurgery Treatment After Cavernous Malformation Radiosurgery. World Neurosurg 2018; 118:e296-e303. [PMID: 29969736 DOI: 10.1016/j.wneu.2018.06.183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 06/20/2018] [Accepted: 06/21/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Of cavernous malformations (CMs) treated with radiosurgery (RS), 5% bleed after 2-year initial latency period. This rate is similar to failure rate of RS for other pathologies, which often require repeat RS for favorable outcome. The aim of this pilot study was to define failure of CM RS and to assess safety of second RS. METHODS Retrospective analysis was performed of 7 of 345 CMs retreated with RS; 6 CMs were deep-seated, and 1 was superficial. Median time between the 2 treatments was 8 years (range, 3-16 years), and median follow-up time after second RS was 3 years (range, 1-9 years). RESULTS Following the 2-year latency period after RS, 6% of deep-seated and 5% of hemispheric CMs, and 6% of deep-seated and 2% of hemispheric lesions caused transient neurologic deficits without hemorrhage. A second treatment was indicated for rebleed in 5 cases and for recurrent transient neurologic deficits in 2 cases. Prescribed dose was 15 Gy (range, 12-20 Gy) at first treatment and 12 Gy (range, 12-18 Gy) at second treatment. Target volumes were 692 mm3 (range, 54-2400 mm3) and 935 mm3 (range, 150-1550 mm3) at first and second treatments, respectively, and treatment volumes were 811 mm3 (range, 79-2500 mm3) and 962 mm3 (range, 194-1750 mm3), respectively. Differences in treatment parameters were not significant. Reason for failure was inaccurate target definition in only 2 cases. There were no bleeds, morbidity, or mortality after second RS. CONCLUSIONS Second RS applied to previously treated CMs is safe and may be effective. Further investigations are needed to verify these findings and assess long-term benefit of second RS.
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Affiliation(s)
- Gábor Nagy
- National Institute of Clinical Neurosciences, Budapest, Hungary
| | - John Yianni
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | - Debapriya Bhattacharyya
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | - Jeremy G Rowe
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; Thornbury Radiosurgery Centre, Sheffield, United Kingdom
| | | | - Matthias W R Radatz
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom; Thornbury Radiosurgery Centre, Sheffield, United Kingdom.
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32
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Ilyas A, Chen CJ, Ding D, Buell TJ, Lee CC, Sheehan JP. In Reply: Radiation-Induced Changes After Stereotactic Radiosurgery for Brain Arteriovenous Malformations. Neurosurgery 2018; 82:E77-E78. [PMID: 29294125 DOI: 10.1093/neuros/nyx599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Adeel Ilyas
- Department of Neurosurgery University of Alabama at Birmingham Birmingham, Alabama.,Department of Neurological Surgery University of Virginia Health System Charlottesville, Virginia
| | - Ching-Jen Chen
- Department of Neurological Surgery University of Virginia Health System Charlottesville, Virginia
| | - Dale Ding
- Department of Neurological Surgery University of Virginia Health System Charlottesville, Virginia.,Department of Neurosurgery Barrow Neurologic Institute St. Joseph's Hospital and Medical Center Phoenix, Arizona
| | - Thomas J Buell
- Department of Neurological Surgery University of Virginia Health System Charlottesville, Virginia
| | - Cheng-Chia Lee
- Department of Neurological Surgery Taipei Veterans General Hospital Taipei, Taiwan
| | - Jason P Sheehan
- Department of Neurological Surgery University of Virginia Health System Charlottesville, Virginia
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33
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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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Ilyas A, Chen CJ, Ding D, Buell TJ, Raper DMS, Lee CC, Xu Z, Sheehan JP. Radiation-Induced Changes After Stereotactic Radiosurgery for Brain Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2017; 83:365-376. [DOI: 10.1093/neuros/nyx502] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 09/11/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
- Department of Neurosurgery, Barrow Neurologic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Daniel M S Raper
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- Department of Neurological Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Zhiyuan Xu
- 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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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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Thenier-Villa JL, Galárraga-Campoverde RA, Martínez Rolán RM, De La Lama Zaragoza AR, Martínez Cueto P, Muñoz Garzón V, Salgado Fernández M, Conde Alonso C. Linear Accelerator Stereotactic Radiosurgery of Central Nervous System Arteriovenous Malformations: A 15-Year Analysis of Outcome-Related Factors in a Single Tertiary Center. World Neurosurg 2017; 103:291-302. [PMID: 28435119 DOI: 10.1016/j.wneu.2017.04.081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/10/2017] [Accepted: 04/12/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Linear accelerator stereotactic radiosurgery is one of the modalities available for the treatment of central nervous system arteriovenous malformations (AVMs). The aim of this study was to describe our 15-year experience with this technique in a single tertiary center and the analysis of outcome-related factors. METHODS From 1998 to 2013, 195 patients were treated with linear accelerator-based radiosurgery; we conducted a retrospective study collecting patient- and AVM-related variables. Treatment outcomes were obliteration, posttreatment hemorrhage, symptomatic radiation-induced changes, and 3-year neurologic status. We also analyzed prognostic factors of each outcome and predictability analysis of 5 scales: Spetzler-Martin grade, Lawton-Young supplementary and Lawton combined scores, radiosurgery-based AVM score, Virginia Radiosurgery AVM Scale, and Heidelberg score. RESULTS Overall obliteration rate was 81%. Nidus diameter and venous drainage were predictive of obliteration (P < 0.05), ruptured status and previous embolization were not related to rate of obliteration, and low-grade AVMs had higher obliteration rates. Posttreatment hemorrhage incidence was 8.72%; nidus diameter was the only predictor (P = 0.05). Symptomatic radiation-induced changes occurred in 11.79% of patients and were significantly associated with unruptured status (P < 0.05). Treatment success as a composite measure was obtained in 70.77% of patients. Receiver operating characteristic curves were presented for each scoring system and outcome measure; best area under the curve was 0.687 for Lawton combined score in the obliteration outcome. CONCLUSIONS In the long-term, linear accelerator-based radiosurgery is a useful, valid, effective, and safe modality for treatment of brain AVMs.
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Affiliation(s)
- José Luis Thenier-Villa
- Department of Neurosurgery, University Hospital Complex of Vigo-Álvaro Cunqueiro Hospital, Vigo, Pontevedra, Spain.
| | | | - Rosa María Martínez Rolán
- Department of Neurosurgery, University Hospital Complex of Vigo-Álvaro Cunqueiro Hospital, Vigo, Pontevedra, Spain
| | | | - Pedro Martínez Cueto
- Department of Neuroradiology, University Hospital Complex of Vigo-Álvaro Cunqueiro Hospital, Vigo, Pontevedra, Spain
| | - Víctor Muñoz Garzón
- Department of Radiation Oncology, University Hospital Complex of Vigo-Meixoeiro Hospital, Vigo, Pontevedra, Spain
| | - Manuel Salgado Fernández
- Department of Radiophysics, University Hospital Complex of Vigo-Meixoeiro Hospital, Vigo, Pontevedra, Spain
| | - Cesáreo Conde Alonso
- Department of Neurosurgery, University Hospital Complex of Vigo-Álvaro Cunqueiro Hospital, Vigo, Pontevedra, Spain
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Pollock BE, Link MJ, Branda ME, Storlie CB. Incidence and Management of Late Adverse Radiation Effects After Arteriovenous Malformation Radiosurgery. Neurosurgery 2017; 81:928-934. [DOI: 10.1093/neuros/nyx010] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 01/13/2016] [Indexed: 11/14/2022] Open
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39
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Morgan MK, Hermann Wiedmann MK, Stoodley MA, Heller GZ. Microsurgery for Spetzler-Ponce Class A and B arteriovenous malformations utilizing an outcome score adopted from Gamma Knife radiosurgery: a prospective cohort study. J Neurosurg 2016; 127:1105-1116. [PMID: 28009228 DOI: 10.3171/2016.8.jns161275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to adapt and apply the extended definition of favorable outcome established for Gamma Knife radiosurgery (GKRS) to surgery for brain arteriovenous malformations (bAVMs). The aim was to derive both an error around the point estimate and a model incorporating angioarchitectural features in order to facilitate comparison among different treatments. METHODS A prospective microsurgical cohort was analyzed. This cohort included patients undergoing embolization who did not proceed to microsurgery and patients denied surgery because of perceived risk of treatment. Data on bAVM residual and recurrence during long-term follow-up as well as complications of surgery and preoperative embolization were analyzed. Patients with Spetzler-Ponce Class C bAVMs were excluded because of extreme selection bias. First, patients with a favorable outcome were identified for both Class A and Class B lesions. Patients were considered to have a favorable outcome if they were free of bAVM recurrence or residual at last follow-up, with no complication of surgery or preoperative embolization, and a modified Rankin Scale score of more than 1 at 12 months after treatment. Patients who were denied surgery because of perceived risk, but would otherwise have been candidates for surgery, were included as not having a favorable outcome. Second, the authors analyzed favorable outcome from microsurgery by means of regression analysis, using as predictors characteristics previously identified to be associated with complications. Third, they created a prediction model of favorable outcome for microsurgery dependent upon angioarchitectural variables derived from the regression analysis. RESULTS From a cohort of 675 patients who were either treated or denied surgery because of perceived risk of surgery, 562 had Spetzler-Ponce Class A or B bAVMs and were included in the analysis. Logistic regression for favorable outcome found decreasing maximum diameter (continuous, OR 0.62, 95% CI 0.51-0.76), the absence of eloquent location (OR 0.23, 95% CI 0.12-0.43), and the absence of deep venous drainage (OR 0.19, 95% CI 0.10-0.36) to be significant predictors of favorable outcome. These variables are in agreement with previous analyses of microsurgery leading to complications, and the findings support the use of favorable outcome for microsurgery. The model developed for angioarchitectural features predicts a range of favorable outcome at 8 years following microsurgery for Class A bAVMs to be 88%-99%. The same model for Class B bAVMs predicts a range of favorable outcome of 62%-90%. CONCLUSIONS Favorable outcome, derived from GKRS, can be successfully used for microsurgical cohort series to assist in treatment recommendations. A favorable outcome can be achieved by microsurgery in at least 90% of cases at 8 years following microsurgery for patients with bAVMs smaller than 2.5 cm in maximum diameter and, in the absence of either deep venous drainage or eloquent location, patients with Spetzler-Ponce Class A bAVMs of all diameters. For patients with Class B bAVMs, this rate of favorable outcome can only be approached for lesions with a maximum diameter just above 6 cm or smaller and without deep venous drainage or eloquent location.
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Affiliation(s)
| | | | | | - Gillian Z Heller
- Statistics, Macquarie University, Sydney, New South Wales, Australia
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40
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Knippen S, Putz F, Semrau S, Lambrecht U, Knippen A, Buchfelder M, Schlaffer S, Struffert T, Fietkau R. Predictors for occlusion of cerebral AVMs following radiation therapy : Radiation dose and prior embolization, but not Spetzler-Martin grade. Strahlenther Onkol 2016; 193:185-191. [PMID: 27757503 DOI: 10.1007/s00066-016-1056-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 09/21/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intracranial arteriovenous malformations (AVMs) may show a harmful development. AVMs are treated by surgery, embolization, or radiation therapy. OBJECTIVE This study investigated obliteration rates and side effects in patients with AVMs treated by radiation therapy. METHODS A total of 40 cases treated between 2005 and 2013 were analyzed. Single-dose stereotactic radiosurgery (SRS) was received by 13 patients and 27 received hypofractionated stereotactic radiation therapy (HSRT). In 20 patients, endovascular embolization had been performed prior to irradiation and 24 patients (60 %) had a history of previous intracranial hemorrhage. RESULTS Treatment resulted in complete obliteration (CO) in 23/40 cases and partial obliteration in 8/40. CO was achieved in 85 % of patients receiving SRS compared to 44 % of those receiving HSRT. In the HSRT group, a first indication of an influence of AVM volume on obliteration rate was found. Equivalent 2 Gy fraction doses (EQD2) >70 Gy showed an obliteration rate of 50 %. Prior embolization was significantly associated with a higher portion of CO (p = 0.032). Median latency period (24.2 vs. 26 months) until CO was similar in both groups (SRS vs. HSRT). The rate of intracranial hemorrhage in patients with no prior bleeding events was 0 %. CONCLUSION Excellent obliteration rates were achieved by SRS. Consistent with the literature, this data analysis suggests that the results of HSRT are volume-dependent. Furthermore, regimens with EQD2 doses >70 Gy appear more likely to achieve obliteration than schemes with lower doses. The findings indicate that radiation therapy does not increase the risk of bleeding. Prior embolization may have a good prognostic impact.
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Affiliation(s)
- Stefan Knippen
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany.
| | - Florian Putz
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Ulrike Lambrecht
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Arzu Knippen
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Sven Schlaffer
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Tobias Struffert
- Department of Neuroradiology, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
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