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Ganesh S, Jasper A, Backianathan S, Moorthy RK, Balakrishnan R, Sebastian P, Moses V, Godson HF, Keshava SN, Rajshekhar V. Correlation Between Post-Radiosurgery Perinidal Hyperintensity and AVM Obliteration Following LINAC-Based Stereotactic Radiosurgery. World Neurosurg 2023; 178:e189-e201. [PMID: 37454908 DOI: 10.1016/j.wneu.2023.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE We studied the correlation between new-onset perinidal hyperintensity (PH) on T2-weighted magnetic resonance imaging and obliteration of intracranial arteriovenous malformation (AVM) after stereotactic radiosurgery (SRS). METHODS A retrospective study of 148 patients with an intracranial AVM who underwent SRS between September 2005 and June 2018 and had ≥1 radiological follow-up (early magnetic resonance imaging) 12-18 months after SRS was performed to analyze the correlation between PH (graded from 0 to 2) and AVM obliteration. RESULTS Of the 148 patients, 95 were male. The mean patient age was 27.7 ± 12.4 years. Of the 148 AVMs, 105 (70.9%) were obliterated at a median follow-up of 27 months (interquartile range, 14-48 months). The cumulative 3-, 5-, 10-year obliteration rate was 51.8%, 70.8%, and 91.8%, respectively. New-onset PH was observed in 58 AVMs (39.2%; 50 obliterated and 8 not obliterated). No association was found between the pretreatment variables or dose delivered and the development of PH. Grade 2 PH was associated with the risk of symptoms developing compared with grade 1 PH (37.5% vs. 4%; P = 0.002). Symptomatic PH was more likely to develop in patients with a larger AVM (P = 0.05). On multivariate analysis, the presence of a single draining vein (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.3-6.8), a lower median AVM volume (OR, 0.97; 95% CI, 0.6-0.89), a mean marginal radiation dose (OR, 1.29; 95% CI, 1.02-1.64), and the presence of PH (OR, 3.16; 95% CI, 1.29-7.71) were independent predictors of AVM obliteration. CONCLUSIONS The incidence of PH after SRS for AVM was 39.2%. PH was an independent predictor of AVM obliteration after SRS. Grade 2 PH and a larger AVM volume were associated with symptomatic PH.
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Affiliation(s)
- Swaminathan Ganesh
- Department of Neurological Sciences, Christian Medical College, Vellore, India
| | - Anitha Jasper
- Department of Radiodiagnosis, Christian Medical College, Vellore, India
| | | | - Ranjith K Moorthy
- Department of Neurological Sciences, Christian Medical College, Vellore, India.
| | | | - Patricia Sebastian
- Department of Radiation Oncology, Christian Medical College, Vellore, India
| | - Vinu Moses
- Department of Radiodiagnosis, Christian Medical College, Vellore, India
| | | | | | - Vedantam Rajshekhar
- Department of Neurological Sciences, Christian Medical College, Vellore, India
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Sasagasako T, Mori H, Hattori EY, Ikedo T, Hamano E, Shimonaga K, Kushi Y, Iihara K, Kataoka H. Radiation-Induced Changes Associated with Obliteration of Brain AVMs after Repeat Radiosurgery. AJNR Am J Neuroradiol 2023; 44:143-149. [PMID: 36702500 PMCID: PMC9891338 DOI: 10.3174/ajnr.a7772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/30/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE Radiation-induced changes can occur after stereotactic radiosurgery for brain AVMs, potentially causing symptomatic complications. We evaluated the incidence of such changes and the efficacy of repeat gamma knife radiosurgery for incompletely obliterated AVMs. MATERIALS AND METHODS We retrospectively evaluated 150 patients who underwent gamma knife radiosurgery for AVMs between 2002 and 2020; twenty-five underwent further radiosurgical procedures for incompletely obliterated AVMs. We recorded the median margin doses at the first (median, 20 Gy; range, 12-23 Gy; AVM volume, 0.026-31.3 mL) and subsequent procedures (median, 18 Gy; range, 12-23 Gy; AVM volume, 0.048-9.2 mL). RESULTS After the first treatment, radiologic radiation-induced changes developed in 48 (32%) patients, eight of whom had symptomatic changes. After repeat gamma knife radiosurgery, 16 of 25 patients achieved complete AVM obliteration (64%). The development of radiation-induced changes after the first treatment was significantly associated with successful obliteration by subsequent radiosurgery (OR = 24.0, 95% CI 1.20-483, P = .007). Radiation-induced changes occurred in only 5 (20%) patients who underwent a second gamma knife radiosurgery, one of whom experienced transient neurologic deficits. Between the first and repeat gamma knife radiosurgery procedures, there was no significant difference in radiologic and symptomatic radiation-induced changes (P = .35 and P = 1.0, respectively). CONCLUSIONS Radiation-induced changes after the first gamma knife radiosurgery were associated with AVM obliteration after a repeat procedure. The risk of symptomatic radiation-induced changes did not increase with retreatment. When the first procedure fails to achieve complete AVM obliteration, a favorable outcome can be achieved by a repeat gamma knife radiosurgery, even if radiation-induced changes occur after the first treatment.
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Affiliation(s)
- T Sasagasako
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - H Mori
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - E Y Hattori
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - T Ikedo
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - E Hamano
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - K Shimonaga
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Y Kushi
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - K Iihara
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - H Kataoka
- From the National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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3
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Hu YS, Yang HC, Lin CJ, Lee CC, Guo WY, Luo CB, Liu KD, Chung WY, Wu HM. Imaging Markers Associated With Radiation-Induced Changes in Brain Arteriovenous Malformations After Radiosurgery. Neurosurgery 2022; 90:464-474. [PMID: 35080514 DOI: 10.1227/neu.0000000000001864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 10/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Radiation-induced changes (RICs) in brain tissue, seen as increased perinidal T2-weighted hyperintensity on MRI, are commonly observed in patients with brain arteriovenous malformations (BAVMs) within 2 years after Gamma Knife (Elekta) radiosurgery (GKRS). OBJECTIVE To explore the imaging markers associated with RICs in patients with BAVMs. METHODS We retrospectively included 106 treatment-naïve patients with BAVMs who received GKRS alone between 2011 and 2018 and had ≥24 months of clinical and MRI follow-up. Pre-GKRS angiography and MRIs were analyzed for morphological characteristics and quantitative digital subtraction angiography parameters. RIC severity was categorized as mild (grade I), moderate (grade II), or severe (grade III). Firth logistic regression analysis was conducted to determine the associations between the parameters and RICs. RESULTS Among the 106 patients, 83 (78.3%) developed RICs, with 16 categorized as grade I, 62 as grade II, and 5 as grade III. RICs were symptomatic in 19 patients (17.9%). In multivariable models, BAVMs with a volume of >5 cm3 (odds ratio [OR]: 4.322, P = .024) and neoangiogenesis on angiography before treatment (OR: 3.846, P = .029), and thrombus within nidus or drainage vein on follow-up MRI (OR: 3.679, P = .001) were independently associated with grade II or III RICs. Symptomatic RICs were more likely to develop in basal ganglia or brainstem. CONCLUSION Large BAVMs and neoangiogenesis were associated with moderate to severe RICs in treatment-naïve patients with BAVMs. Our findings may assist with the complication risk assessment for these patients.
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Affiliation(s)
- Yong-Sin Hu
- Department of Radiology, Taoyuan Branch, Taipei Veterans General Hospital, Taoyuan, Taiwan
- Department of Radiology, Taipei Hospital, Ministry of Health and Welfare, New Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Huai-Che Yang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Jung Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Chia Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Yuo Guo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chao-Bao Luo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kang-Du Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Yuh Chung
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Neurosurgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Hsiu-Mei Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
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4
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Pollock BE. Blood Flow Out Must Equal Blood Flow In. Int J Radiat Oncol Biol Phys 2021; 111:854. [PMID: 34655561 DOI: 10.1016/j.ijrobp.2021.03.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/23/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
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5
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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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6
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Venous Stenosis and Hemorrhage After Radiosurgery for Cerebral Arteriovenous Malformations. World Neurosurg 2018; 122:e1615-e1625. [PMID: 30500592 DOI: 10.1016/j.wneu.2018.11.193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND The risk of hemorrhage remains after radiosurgery for patients with arteriovenous malformations (AVMs), especially during the latency period. The effect of venous outflow stenosis on postradiosurgery AVM hemorrhage has been understudied. The present study sought to clarify the effect of venous stenosis on postradiation hemorrhage. METHODS We retrospectively reviewed the records of patients with AVM seen at our institution from 1990 to 2015. Patients who had undergone radiosurgery were included, and those without sufficient data were excluded. We performed multivariable Cox regression to evaluate the predictors of postradiosurgery hemorrhage, with specific emphasis on venous stenosis. Patients were censored from the first radiosurgery to hemorrhage or the last follow-up visit. The baseline and angiographic characteristics were compared between those with venous stenosis and those without to address potential confounders. RESULTS The present study included 240 patients, of whom 29 (12.1%) had venous stenosis. The venous stenosis cohort included more patients with venous varices (P = 0.009) and fewer with deep venous drainage (P = 0.048) compared with those without venous stenosis. Most patients had grade III or higher AVMs (63.2%), with an obliteration rate of 32.9%. In an all-inclusive multivariable Cox regression, hemorrhage risk was associated with venous stenosis (hazard ratio [HR], 3.70; P = 0.034), age (HR, 1.05; P = 0.002), AVM volume (HR, 1.04; P = 0.004), and hemorrhage before treatment (HR, 4.11; P = 0.014). Male gender was protective (HR, 0.31; P = 0.036) against hemorrhage. CONCLUSIONS We identified statistically significant risk factors for postradiosurgery AVM hemorrhage, which included advanced age, female gender, the presence of venous stenosis, a larger AVM volume, and previous hemorrhage. We recommend cautious selection of patients for radiosurgery with close follow-up after treatment, especially for patients with these risk factors.
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7
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Meneghelli P, Pasqualin A, Zampieri P, Longhi M, Foroni R, Sini A, Tommasi N, Nicolato A. Surgical Management of Adverse Radiation Effects After Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformations: A Population-Based Cohort Study. World Neurosurg 2018; 114:e840-e850. [PMID: 29572169 DOI: 10.1016/j.wneu.2018.03.097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 03/12/2018] [Accepted: 03/14/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The goal of this study is to report our experience in the surgical treatment of cerebral arteriovenous malformations (cAVMs) related permanent symptomatic adverse radiation effects (PSAREs), to clarify an appropriate surgical management and to identify the risk factors related to their development. METHODS We evaluated 549 patients treated with Gamma Knife radiosurgery (GKRS) for cAVMs with a follow-up of at least 8 years. Univariate and multivariate analyses were used to test different risk factors related to the development of PSARE. We retrospectively reviewed the records of these patients to analyze the clinical outcome. RESULTS Fourteen patients (2.5%) developed PSARE and were submitted to surgery. Higher average treated volume represents a significant risk factors for the development of PSARE (P < 0.05); on the other hand, older age and higher average dose reduce the risk of PSARE (P < 0.05). A favorable clinical outcome was achieved in 13 patients (93%) after surgery; in 1 patient, the unfavorable outcome was due to hemorrhage that occurred months after GKRS. Serial MRI scans following either surgical removal of the nodule or Ommaya reservoir positioning showed progressive reduction of brain edema in all cases. CONCLUSIONS The management of PSARE is controversial, especially for cAVMs treated with SRS. Surgical removal is rarely needed, but-if unavoidable-it can be a valuable option in experienced hands. A careful preoperative planning is always necessary to detect pathologic blood flow through the PSARE.
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Affiliation(s)
- Pietro Meneghelli
- Institute of Neurosurgery, University and City Hospital, Verona, Italy.
| | - Alberto Pasqualin
- Section of Vascular Neurosurgery, Institute of Neurological Surgery, University and City Hospital, Verona, Italy
| | - Piergiuseppe Zampieri
- Section of Neuroradiology, Department of Diagnosis and Pathology, University and City Hospital, Verona, Italy
| | - Michele Longhi
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Roberto Foroni
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Antonio Sini
- Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Nicola Tommasi
- Centro interdipartimentale di documentazione economica, University of Verona, Verona, Italy
| | - Antonio Nicolato
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
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8
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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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9
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Oermann EK, Ding D, Yen CP, Starke RM, Bederson JB, Kondziolka D, Sheehan JP. Effect of Prior Embolization on Cerebral Arteriovenous Malformation Radiosurgery Outcomes: A Case-Control Study. Neurosurgery 2016; 77:406-17; discussion 417. [PMID: 25875580 DOI: 10.1227/neu.0000000000000772] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Embolization before stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations (AVM) has been shown to negatively affect obliteration rates, but its impact on the risks of radiosurgery-induced complications and latency period hemorrhage is poorly defined. OBJECTIVE To determine, in a case-control study, the effect of prior embolization on AVM SRS outcomes. METHODS We evaluated a database of AVM patients who underwent SRS. Propensity score analysis was used to match the case (embolized nidi) and control (nonembolized nidi) cohorts. AVM angioarchitectural complexity was defined as the sum of the number of major feeding arteries and draining veins to the nidus. Multivariate Cox proportional hazards regression analyses were performed on the overall study population to determine independent predictors of obliteration and radiation-induced changes. RESULTS The matching process yielded 242 patients in each cohort. The actuarial obliteration rates were significantly lower in the embolized (31%, 49% at 5, 10 years, respectively) compared with the nonembolized (48%, 64% at 5, 10 years, respectively) cohort (P = .003). In the multivariate analysis for obliteration, lower angioarchitectural complexity (P < .001) and radiologically evident radiation-induced changes (P = .016) were independent predictors, but embolization was not significant (P = .744). In the multivariate analysis for radiologic radiation-induced changes, lack of prior embolization (P = .009) and fewer draining veins (P = .011) were independent predictors. CONCLUSION The effect of prior embolization on AVM obliteration after SRS may be significantly confounded by nidus angioarchitectural complexity. Additionally, embolization could reduce the risk of radiation-induced changes. Thus, combined embolization and SRS may be warranted for appropriately selected nidi.
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Affiliation(s)
- Eric K Oermann
- *Mount Sinai Health System, Department of Neurosurgery, New York City, New York; ‡University of Virginia, Department of Neurosurgery, Charlottesville, Virginia; §New York University Langone Medical Center, Department of Neurosurgery, New York City, New York
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10
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Choudhri O, Ivan ME, Lawton MT. Transvenous Approach to Intracranial Arteriovenous Malformations. Neurosurgery 2015; 77:644-51; discussion 652. [DOI: 10.1227/neu.0000000000000869] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
A compartmental conceptualization of intracranial arteriovenous malformations (AVMs) allows recognition of feeding arteries, an intervening plexiform nidus, and draining veins. AVM therapy involves eliminating the nidus, which is the source of hemorrhage, without compromising normal arterial and venous drainage of the brain. Traditional methods of AVM therapy through microsurgery and endovascular embolization involve arterial devascularization, with preservation of AVM venous drainage, until the nidus is excluded. The transvenous approach in treating vascular malformations was popularized by successful treatment models for dural arteriovenous fistulas. More recently, high-flow intracranial AVMs are being managed with transvenous endovascular approaches, although this novel technique has its challenges and perils. We review the current literature on transvenous AVM therapy and highlight its role for AVM therapy in the present day.
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Affiliation(s)
- Omar Choudhri
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Michael E. Ivan
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Michael T. Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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11
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Haridass A, Maclean J, Chakraborty S, Sinclair J, Szanto J, Iancu D, Malone S. Dynamic CT angiography for cyberknife radiosurgery planning of intracranial arteriovenous malformations: a technical/feasibility report. Radiol Oncol 2015; 49:192-9. [PMID: 26029032 PMCID: PMC4387997 DOI: 10.1515/raon-2015-0006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 12/31/2014] [Indexed: 12/04/2022] Open
Abstract
Background. Successful radiosurgery for arteriovenous malformations (AVMs) requires accurate nidus delineation in the 3D treatment planning system (TPS). The catheter biplane digital subtraction angiogram (DSA) has traditionally been the gold standard for evaluation of the AVM nidus, but its 2D nature limits its value for contouring and it cannot be imported into the Cyberknife TPS. We describe a technique for acquisition and integration of 3D dynamic CT angiograms (dCTA) into the Cyberknife TPS for intracranial AVMs and review the feasibility of using this technique in the first patient cohort. Patients and methods. Dynamic continuous whole brain CT images were acquired in a Toshiba 320 volume CT scanner with data reconstruction every 0.5 sec. This multi-time-point acquisition enabled us to choose the CT data-set with the clearest nidus without significant enhancement of surrounding blood vessels. This was imported to the Cyberknife TPS and co-registered with planning CT and T2 MRI (2D DSA adjacent for reference). The feasibility of using dCTA was evaluated in the first thirteen patients with outcome evaluation from patient records. Results. dCTA data was accurately co-registered in the Cyberknife TPS and appeared to assist in nidus contouring for all patients. Imaging modalities were complementary. 85% of patients had complete (6/13) or continuing partial nidus obliteration (5/13) at 37 months median follow-up. Conclusions. dCTA is a promising imaging technique that can be successfully imported into the Cyberknife TPS and appears to assist in radiosurgery nidus definition. Further study to validate its role is warranted.
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12
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Cao C, Sourour N, Reina V, Nouet A, Di Maria F, Chiras J, Cornu P, Clarençon F. Spontaneous thrombosis of the main draining vein revealing an unruptured brain arteriovenous malformation. Interv Neuroradiol 2015; 21:222-6. [PMID: 25964440 DOI: 10.1177/1591019915581989] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Haemorrhage is the most frequent revealing condition of brain arteriovenous malformations (bAVMs). We report a rare case of unruptured parietal bAVM revealed by spontaneous thrombosis of the main draining vein, responsible for a focal neurological deficit. The bAVM was embolized in emergency conditions; complete regression of the neurological symptoms was observed within five days after the embolization. Potential mechanisms of such spontaneous thrombosis of the bAVM's main drainage pathway as well as an exhaustive review of the literature concerning this rare revealing condition are presented and discussed.
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Affiliation(s)
- Catherine Cao
- Department of Neurosurgery, Dijon University Hospital, France
| | - Nader Sourour
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris VI University, France
| | - Vincent Reina
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris VI University, France
| | - Aurélien Nouet
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris VI University, France
| | - Federico Di Maria
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris VI University, France
| | - Jacques Chiras
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris VI University, France
| | - Philippe Cornu
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris VI University, France
| | - Frédéric Clarençon
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris VI University, France
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13
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Ding D. Pathogenesis of radiosurgery-induced cyst formation in patients with cerebral arteriovenous malformations. Acta Neurochir (Wien) 2015; 157:775-7. [PMID: 25749841 DOI: 10.1007/s00701-015-2380-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 02/19/2015] [Indexed: 02/01/2023]
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14
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Kim DH, Kang DH, Park J, Hwang JH, Park SH, Son WS. Delayed Perilesional Ischemic Stroke after Gamma-knife Radiosurgery for Unruptured Deep Arteriovenous Malformation: Two Case Reports of Radiation-induced Small Artery Injury as Possible Cause. J Cerebrovasc Endovasc Neurosurg 2015; 17:36-42. [PMID: 25874184 PMCID: PMC4394118 DOI: 10.7461/jcen.2015.17.1.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 12/22/2014] [Accepted: 02/23/2015] [Indexed: 11/23/2022] Open
Abstract
Radiation-induced vasculopathy is a rare occurrence, however, it is one of the most serious complications that can occur after gamma-knife radiosurgery (GKRS). The authors present two cases of incidentally found deep cerebral arteriovenous malformation (AVM), which were treated by GKRS, where subsequently there occurred delayed-onset cerebral infarction (11 and 17 months after GKRS) at an area adjacent to the AVM. In both cases, perforators of the M1 segment of the middle cerebral artery were included in the radiation field and delayed injury to these is suggested to be the mechanism of the ischemic event.
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Affiliation(s)
- Dong-Han Kim
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea
| | - Dong-Hun Kang
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea. ; Department of Radiology, Kyungpook National University Hospital, Daegu, Korea
| | - Jaechan Park
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea
| | - Jeong-Hyun Hwang
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea
| | - Seong-Hyun Park
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea
| | - Won-Soo Son
- Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea
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15
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Safain MG, Rahal JP, Raval A, Rivard MJ, Mignano JE, Wu JK, Malek AM. Use of cone-beam computed tomography angiography in planning for gamma knife radiosurgery for arteriovenous malformations: a case series and early report. Neurosurgery 2015; 74:682-95; discussion 695-6. [PMID: 24584136 DOI: 10.1227/neu.0000000000000331] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The effectiveness of Gamma Knife radiosurgery (GKR) for cerebral arteriovenous malformations (AVMs) is predicated on inclusion of the entire nidus while excluding normal tissue. As such, GKR may be limited by the resolution and accuracy of the imaging modality used in targeting. OBJECTIVE We present the first case series to demonstrate the feasibility of using ultrahigh-resolution C-arm cone-beam computed tomography angiography (CBCT-A) in AVM targeting. METHODS From June 2009 to June 2013, CBCT-A was used for targeting of all patients with AVMs treated with GKR at our institution. Patients underwent Leksell stereotactic head frame placement followed by catheter-based biplane 2-dimensional digital subtraction angiography, 3-dimensional rotational angiography, as well as CBCT-A. The CBCT-A dataset was used for stereotactic planning for GKR. Patients were followed at 1, 3, 6, and 12 months and then annually thereafter. RESULTS CBCT-A-based targeting was used in 22 consecutive patients. CBCT-A provided detailed spatial resolution and sensitivity of nidal angioarchitecture enabling treatment. The average radiation dose to the margin of the AVM nidus corresponding to the 50% isodose line was 15.6 Gy. No patient had treatment-associated hemorrhage. At early follow-up (mean, 16 months), 84% of patients had a decreasing or obliterated AVM nidus. CONCLUSION CBCT-A-guided radiosurgery is feasible and useful because it provides sufficient detailed resolution and sensitivity for imaging brain AVMs.
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Affiliation(s)
- Mina G Safain
- *Cerebrovascular and Endovascular Division, Department of Neurosurgery, ‡Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts; §Boston Gamma Knife Center, Boston, Massachusetts
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16
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Bose R, Agrawal D, Singh M, Kale SS, Gopishankar N, Bisht RK, Sharma BS. Draining Vein Shielding in Intracranial Arteriovenous Malformations During Gamma-Knife. Neurosurgery 2015; 76:623-31; discussion 631-2. [DOI: 10.1227/neu.0000000000000660] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Following gamma knife (GK) therapy for intracranial arteriovenous malformations (AVMs), obliteration of the nidus occurs over several years. During this period, complications like rebleeding have been attributed to early draining vein occlusion.
OBJECTIVE:
To evaluate if shielding the draining vein(s) during GK therapy prevents early draining vein obliteration and complications following GK therapy.
METHODS:
This was a nonrandomized case-control study over 5 years (January 2009-February 2014) and included patients with intracranial AVM who underwent GK therapy at our center. All patients who underwent draining vein shielding by the senior author (D.A.) were included in the test group, and patients who did not undergo draining vein shielding were put in the control group. Patients were followed up for at least 6 months (and every 6 months thereafter) clinically as well as radiologically with computed tomography head scans/magnetic resonance imaging brain scans to check for postradiosurgery imaging (PRI) changes.
RESULTS:
One hundred eighty-five patients were included in this study, of which 96 were in the control group and 89 were in the test group. Both groups were well matched in demographics, comorbidities, adjuvant treatment, angioarchitecture, and radiation dosing. Because of shielding, the test group patients received significantly less radiation to the draining vein than the control group (P = .001). On follow-up, a significantly lower number of patients in the test group had new neurological deficits (P = .001), intracranial hemorrhage (P = .03), and PRI changes (P = .002).
CONCLUSION:
Shielding of the draining vein is a potent new strategy in minimizing PRI and hemorrhage as well as clinical deterioration following GK therapy for intracranial AVMs.
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Affiliation(s)
- Ratnadip Bose
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohanjit Singh
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Shashank S. Kale
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | | | - Raj K. Bisht
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
| | - Bhawani S. Sharma
- Department of Neurosurgery and Gamma Knife, All India Institute of Medical Sciences, New Delhi, India
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17
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Puccinelli F, Deiva K, Bellesme C, Durand P, Chevret L, Husson B, Sachet M, Ducreux D, Saliou G. Cerebral venous thrombosis after embolization of pediatric AVM with jugular bulb stenosis or occlusion: management and prevention. Eur J Paediatr Neurol 2014; 18:766-73. [PMID: 25130940 DOI: 10.1016/j.ejpn.2014.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 06/29/2014] [Accepted: 07/16/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Thrombosis of cerebral arteriovenous malformation after embolization is rare, but can involve the normal venous network with extensive venous thrombosis. We report angioarchitecture findings, our management and prevention strategy for this complication in pediatric AVMs. METHODS In this 5.5-year retrospective series, we reviewed records of 13 patients under 15 years who were anticoagulated after embolization. In our initial experience 4 children who didn't receive any prophylactic anticoagulation presented with extensive venous thrombosis after embolization (group 1). Following this, nine children with similar angioarchitecture and embolization modalities were treated with prophylactic anticoagulation immediately after embolization (group 2). We analyzed the type of AVM, angioarchitecture, dose of prophylactic anticoagulant, efficacy/complications of treatment and late outcome. RESULTS All patients in group 1 had severe jugular bulb stenosis/occlusion associated with cerebral venous dilatation. In group 2 with similar angioarchitecture, only three patients (33%) developed extensive thrombosis. In both groups, thrombosis occurred within two days of treatment in six children and two weeks in one child. The diagnosis was suspected on intracranial hypertension in five patients and occulomotor disorder in one. One was asymptomatic. All children were treated with therapeutic doses of LMWH (anti-Xa: 0.5-1). No hemorrhagic complications occurred. Good venous remodeling was observed in all but one patient. CONCLUSION Anticoagulation in extensive venous thrombosis after AVM embolization in children appears to be safe and effective. In cases with angioarchitectural features of dilatation of the cerebral venous network and occlusion/severe stenosis of the jugular bulbs, full dose anticoagulation may be required to prevent thrombosis.
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Affiliation(s)
- F Puccinelli
- Service de Neuroradiologie, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France; National Referral Center for Neurovascular Malformations in Children, France
| | - K Deiva
- Service de Neurologie pédiatrique, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - C Bellesme
- Service de Neurologie pédiatrique, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - P Durand
- Service de Réanimation pédiatrique, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - L Chevret
- Service de Réanimation pédiatrique, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - B Husson
- Service de Radiologie pédiatrique, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France
| | - M Sachet
- Service de Neuroradiologie, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France; National Referral Center for Neurovascular Malformations in Children, France
| | - D Ducreux
- Service de Neuroradiologie, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France; National Referral Center for Neurovascular Malformations in Children, France
| | - G Saliou
- Service de Neuroradiologie, CHU Bicêtre, 78 rue du General Leclerc, 94275 Le Kremlin Bicêtre Cedex, France; National Referral Center for Neurovascular Malformations in Children, France.
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Starke RM, Yen CP, Chen CJ, Ding D, Mohila CA, Jensen ME, Kassell NF, Sheehan JP. An Updated Assessment of the Risk of Radiation-Induced Neoplasia After Radiosurgery of Arteriovenous Malformations. World Neurosurg 2014; 82:395-401. [DOI: 10.1016/j.wneu.2013.02.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 09/17/2012] [Accepted: 02/01/2013] [Indexed: 10/27/2022]
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19
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Yoshida K, Ichikawa T, Kurozumi K, Yanai H, Onoda K, Date I. Fatal glioblastoma after Gamma Knife radiosurgery for arteriovenous malformation in a child. J Clin Neurosci 2014; 21:1453-5. [DOI: 10.1016/j.jocn.2013.10.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 10/19/2013] [Indexed: 10/25/2022]
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20
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Lin YC, Ou CH, Liang CL, Hsu HC, Tsai SH, Chen YM. Central retinal vein occlusion after gamma knife radiosurgery for cavernous sinus dural arteriovenous fistula. Taiwan J Ophthalmol 2013. [DOI: 10.1016/j.tjo.2013.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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21
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Yen CP, Matsumoto JA, Wintermark M, Schwyzer L, Evans AJ, Jensen ME, Shaffrey ME, Sheehan JP. Radiation-induced imaging changes following Gamma Knife surgery for cerebral arteriovenous malformations. J Neurosurg 2013; 118:63-73. [PMID: 23140155 DOI: 10.3171/2012.10.jns12402] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The objective of this study was to evaluate the incidence, severity, clinical manifestations, and risk factors of radiation-induced imaging changes (RIICs) following Gamma Knife surgery (GKS) for cerebral arteriovenous malformations (AVMs).
Methods
A total of 1426 GKS procedures performed for AVMs with imaging follow-up available were analyzed. Radiation-induced imaging changes were defined as newly developed increased T2 signal surrounding the treated AVM nidi. A grading system was developed to categorize the severity of RIICs. Grade I RIICs were mild imaging changes imposing no mass effect on the surrounding brain. Grade II RIICs were moderate changes causing effacement of the sulci or compression of the ventricles. Grade III RIICs were severe changes causing midline shift of the brain. Univariate and multivariate logistic regression analyses were applied to test factors potentially affecting the occurrence, severity, and associated symptoms of RIICs.
Results
A total of 482 nidi (33.8%) developed RIICs following GKS, with 281 classified as Grade I, 164 as Grade II, and 37 as Grade III. The median duration from GKS to the development of RIICs was 13 months (range 2–124 months). The imaging changes disappeared completely within 2–128 months (median 22 months) following the development of RIICs. The RIICs were symptomatic in 122 patients, yielding an overall incidence of symptomatic RIICs of 8.6%. Twenty-six patients (1.8%) with RIICs had permanent deficits. A negative history of prior surgery, no prior hemorrhage, large nidus, and a single draining vein were associated with a higher risk of RIICs.
Conclusions
Radiation-induced imaging changes are the most common adverse effects following GKS. Fortunately, few of the RIICs are symptomatic and most of the symptoms are reversible. Patients with a relatively healthy brain and nidi that are large, or with a single draining vein, are more likely to develop RIICs.
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Affiliation(s)
| | - Julie A. Matsumoto
- 2Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
| | - Max Wintermark
- 2Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
| | | | - Avery J. Evans
- 2Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
| | - Mary E. Jensen
- 2Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
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22
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Gross BA, Ropper AE, Du R. Vascular complications of stereotactic radiosurgery for arteriovenous malformations. Clin Neurol Neurosurg 2012; 115:713-7. [PMID: 22910397 DOI: 10.1016/j.clineuro.2012.08.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 05/16/2012] [Accepted: 08/05/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Although vasculopathy and de novo aneurysm formation are known complications of traditional radiation therapy, their occurrence following AVM SRS is rare and thus infrequently addressed in the literature. We sought to evaluate these phenomena through a review of our institutional experience. METHODS Our review afforded 32 patients treated with LINAC-based SRS over an eight year period. We noted obliteration rates, complication rates and long-term outcomes, with particular attention paid to follow-up angiographic studies. RESULTS After a mean follow-up of 4.3 years, the overall obliteration rate was 50%, increasing to 87% for AVMs less than 3cm. Eight patients had nine hemorrhages following SRS (25%). One occurred in the context of a de novo arterial pseudoaneurysm and another in the context of a new venous varix. Two patients with post-SRS hemorrhage had intranidal aneurysms that were not as apparent on initial angiography. Two patients that did not suffer from latency period hemorrhage developed dysplastic changes of feeding arteries, and one patient suffered from early venous thrombosis with resultant permanent hemiparesis from infarction. After a mean follow-up of 4.3 years, 8 patients were clinically improved (25%), 19 were the same (59%), and 5 were worse (16%), including 2 that died as a result of latency period hemorrhage. CONCLUSION While radiosurgery of AVMs is safe and successful in the vast majority of cases, vasculopathic complications including de novo aneurysm and varix development, early venous occlusion and stenotic vasculopathy, while infrequent, can occur. Closer long-term angiographic surveillance of these patients may thus be warranted.
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Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, United States
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23
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Williams BJ, Park DM, Sheehan JP. Bevacizumab used for the treatment of severe, refractory perilesional edema due to an arteriovenous malformation treated with stereotactic radiosurgery. J Neurosurg 2012; 116:972-7. [PMID: 22324417 DOI: 10.3171/2012.1.jns111627] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors present a case of an arteriovenous malformation of the central sulcus treated with Gamma Knife surgery. The patient developed perilesional edema 9 months after treatment and experienced severe headache and hemiparesis. Her symptoms were refractory to corticosteroid therapy and pain management. She was subsequently treated with bevacizumab with striking improvement in her symptoms and results of neuroimaging studies. This is the first time that bevacizumab has been used to control severe refractory perilesional edema related to an intracranial arteriovenous malformation.
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Kuffler DP. Hyperbaric oxygen therapy: can it prevent irradiation-induced necrosis? Exp Neurol 2012; 235:517-27. [PMID: 22465460 DOI: 10.1016/j.expneurol.2012.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 02/27/2012] [Accepted: 03/17/2012] [Indexed: 10/28/2022]
Abstract
Radiosurgery is an important non-invasive procedure for the treatment of tumors and vascular malformations. However, in addition to killing target tissues, cranial irradiation induces damage to adjacent healthy tissues leading to neurological deterioration in both pediatric and adult patients, which is poorly understood and insufficiently treatable. To minimize irradiation damage to healthy tissue, not the optimal therapeutic irradiation dose required to eliminate the target lesion is used but lower doses. Although the success rate of irradiation surgery is about 95%, 5% of patients suffer problems, most commonly neurological, that are thought to be a direct consequence of irradiation-induced inflammation. Although no direct correlation has been demonstrated, the appearance and disappearance of inflammation that develops following irradiation commonly parallel the appearance and disappearance of neurological side effects that are associated with the neurological function of the irradiated brain regions. These observations have led to the hypothesis that brain inflammation is causally related to the observed neurological side effects. Studies indicate that hyperbaric oxygen therapy (HBOT) applied after the appearance of irradiation-induced neurological side effects reduces the incidence and severity of those side effects. This may result from HBOT reducing inflammation, promoting angiogenesis, and influencing other cellular functions thereby suppressing events that cause the neurological side effects. However, it would be significantly better for the patient if rather than waiting for neurological side effects to become manifest they could be avoided. This review examines irradiation-induced neurological side effects, methods that minimize or resolve those side effects, and concludes with a discussion of whether HBOT applied following irradiation, but before manifestation of neurological side effects may prevent or reduce the appearance of irradiation-induced neurological side effects.
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Affiliation(s)
- Damien P Kuffler
- Institute of Neurobiology, University of Puerto Rico, Medical Sciences Campus, Puerto Rico.
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Transarterial embolization of cerebral arteriovenous malformations: A durable treatment for venous side hemorrhage? Med Hypotheses 2011; 76:827-30. [DOI: 10.1016/j.mehy.2011.02.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2010] [Accepted: 02/14/2011] [Indexed: 11/21/2022]
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