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Shaaban A, Tos SM, Mantziaris G, Kotecha R, Fariselli L, Gorgulho A, Levivier M, Ma L, Paddick I, Pollock BE, Regis J, Suh JH, Yomo S, Sahgal A, Sheehan JP. Repeat Single-Session Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations: A Systematic Review, Meta-Analysis, and International Stereotactic Radiosurgery Society Practice Guidelines. Neurosurgery 2024:00006123-990000000-01234. [PMID: 38912814 DOI: 10.1227/neu.0000000000003049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/25/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Repeat stereotactic radiosurgery (SRS) for residual arteriovenous malformations (AVMs) can be considered as a salvage approach after failure of initial SRS. There are no published guidelines regarding patient selection, timing, or SRS parameters to guide clinical practice. This systematic review aimed to review outcomes and complications from the published literature to inform practice recommendations provided on behalf of the International Stereotactic Radiosurgery Society. METHODS We performed a systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of MEDLINE, Scopus, Web of Science, and Embase was conducted. Fourteen studies with 925 patients met the inclusion criteria. Patients were treated between 1985 and 2022. All studies were retrospective, except for one prospective cohort. RESULTS The median patient age at repeat SRS ranged from 32 to 60 years. Four studies (630 patients) reported detailed information on Spetzler-Martin grade at the time of repeat SRS; 12.54% of patients had Spetzler-Martin grade I AVMs (79/630 patients), 46.51% had grade II (293/630), 34.92% had grade III (220/630), 5.08% had grade IV (32/630), and 0.95% had grade V (6/630). The median prescription doses varied between 15 and 25 Gy (mean, 13.06-22.8 Gy). The pooled overall obliteration rate at the last follow-up after repeat SRS was 59% (95% CI 51%-67%) with a median follow-up between 21 and 50 months. The pooled hemorrhage incidence at the last follow-up was 5% (95% CI 4%-7%), and the pooled overall radiation-induced change incidence was 12% (95% CI 7%-20%). CONCLUSION For an incompletely obliterated AVM, repeat radiosurgery after 3 to 5 years of follow-up from the first SRS provides a reasonable benefit to the risk profile. After repeat SRS, obliteration is achieved in the majority of patients. The risk of hemorrhage or radiation-induced change appears low, and International Stereotactic Radiosurgery Society recommendations are presented.
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Affiliation(s)
- Ahmed Shaaban
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Salem M Tos
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Laura Fariselli
- Department of Neurosurgery, Unit of Radiotherapy, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alessandra Gorgulho
- Department of Neurosurgery, State University of São Paulo, NeuroSapiens Group, São Paulo, Brazil
- D'Or Institute for Research and Education, São Paulo, Brazil
| | - Marc Levivier
- Department of Neurosurgery and Gamma Knife Center, Lausanne University Hospital, Lausanne, Switzerland
| | - Lijun Ma
- Department of Neurosurgery, State University of São Paulo, NeuroSapiens Group, São Paulo, Brazil
- D'Or Institute for Research and Education, São Paulo, Brazil
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Ian Paddick
- Queen Square Radiosurgery Centre, National Hospital for Neurology and Neurosurgery, London, UK
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jean Regis
- Department of Functional Neurosurgery and Gamma Knife Radiosurgery, Timone University Hospital, Aix-Marseille University, APHM, CHU Timone, Marseille, France
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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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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Punyawai P, Radomsutthikul N, Dhanachai M, Kobkitsuksakul C, Hansasuta A. Long-term outcomes of 170 brain arteriovenous malformations treated by frameless image-guided robotic stereotactic radiosurgery: Ramathibodi hospital experience. Medicine (Baltimore) 2021; 100:e25752. [PMID: 34106604 PMCID: PMC8133224 DOI: 10.1097/md.0000000000025752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 04/08/2021] [Indexed: 11/25/2022] Open
Abstract
This study was conducted to report long-term outcomes of the frameless robotic stereotactic radiosurgery (SRS) for brain arteriovenous malformation (AVM) at Ramathibodi Hospital.Retrospective data of patients with brain AVM (bAVM), who underwent CyberKnife SRS (CKSRS) at Ramathibodi Hospital from 2009 to 2014, were examined. Exclusion criteria were insufficient follow-up time (<36 months) or incomplete information. Patients' demographics, clinical presentation, treatment parameters, and results were analyzed. Excellent outcome was defined as AVM obliteration without a new neurological deficit. Risk factors for achieving excellent outcome were assessed.From a total of 277 CKSRS treatments for bAVM during the 6 years, 170 AVMs in 166 patients met the inclusion criteria. One hundred and thirty-nine cases (81.76%) presented with hemorrhages from ruptured bAVMs. Almost two-thirds underwent embolization before radiosurgery. With the median AVM volume of 4.17 mL, three-quarters of the cohort had single-fraction CKSRS, utilizing the median prescribed dose of 15 Gray (Gy). In the multisession group (25.29%), the median prescribed dose and the AVM volume were 27.5 Gy and 22.3 mL, respectively. An overall excellent outcome, at a median follow-up period of 72.45 months, was observed in 99 cases (58.24%). Seven AVMs (4.12%) ruptured after CKSRS but 1 patient suffered a new neurological deficit. Two patients (1.18%) were classified into the poor outcome category but there were no deaths. Negative factors for excellent outcome, by multivariate regression analysis, were the male sex and multisession SRS delivery, but not age, history of AVM rupture, previous embolization, or AVM volume.Despite relatively larger bAVM and utilizing a lower prescribed radiation dose, the excellent outcome was within the reported range from previous literature. This study offers one of the longest follow-ups and the largest cohorts from the frameless image-guided robotic SRS community.
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Affiliation(s)
- Pritsana Punyawai
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samut Prakan
| | | | - Mantana Dhanachai
- Department of Diagnostic and Therapeutic Radiology, Division of Radiation Oncology
| | - Chai Kobkitsuksakul
- Department of Diagnostic and Therapeutic Radiology, Division of Interventional Neuroradiology
| | - Ake Hansasuta
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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4
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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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5
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Frager MJ, Glazener EM, Rahimian J, Zhi M, Lodin K, Feng L, Chen JC, Girvigian MR. A comparative outcomes analysis of patients treated for arteriovenous malformation with LINAC-based stereotactic radiosurgery by a standard frame-based technique or a frameless technique utilizing 3-dimensional rotational angiography. J Clin Neurosci 2020; 77:185-190. [DOI: 10.1016/j.jocn.2020.04.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/16/2020] [Indexed: 11/26/2022]
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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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Schmidhalter D, Henzen D, Herrmann E, Volken W, Mackeprang PH, Ermis E, Hemmatazad H, Honegger J, Haas B, Fix MK, Manser P. Evaluation of a new software prototype for frameless radiosurgery of arteriovenous malformations. Radiat Oncol 2019; 14:217. [PMID: 31791365 PMCID: PMC6889560 DOI: 10.1186/s13014-019-1422-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 11/20/2019] [Indexed: 11/12/2022] Open
Abstract
Background In order to locate an arteriovenous malformation, typically, a digital subtraction angiography (DSA) is carried out. To use the DSA for target definition an accurate image registration between CT and DSA is required. Carrying out a non-invasive, frameless procedure, registration of the 2D-DSA images with the CT is critical. A new software prototype is enabling this frameless procedure. The aim of this work was to evaluate the prototype in terms of targeting accuracy and reliability based on phantom measurements as well as with the aid of patient data. In addition, the user’s ability to recognize registration mismatches and quality was assessed. Methods Targeting accuracy was measured with a simple cubic, as well as with an anthropomorphic head phantom. Clearly defined academic targets within the phantoms were contoured on the CT. These reference structures were compared with the structures generated within the prototype. A similar approach was used with patient data, where the clinically contoured target served as the reference structure. An important error source decreasing the target accuracy comes from registration errors between CT and 2D-DSA. For that reason, the tools in BC provided to the user to check these registrations are very important. In order to check if the user is able to recognize registration errors, a set of different registration errors was introduced to the correctly registered CT and 2D-DSA image data sets of three different patients. Each of six different users rated the whole set of registrations within the prototype. Results The target accuracy of the prototype was found to be below 0.04 cm for the cubic phantom and below 0.05 cm for the anthropomorphic head phantom. The mean target accuracy for the 15 patient cases was found to be below 0.3 cm. In the registration verification part, almost all introduced registration errors above 1° or 0.1 cm were detected by the six users. Nevertheless, in order to quantify and categorize the possibility to detect mismatches in the registration process more data needs to be evaluated. Conclusion Our study shows, that the prototype is a useful tool that has the potential to fill the gap towards a frameless procedure when treating AVMs with the aid of 2D-DSA images in radiosurgery. The target accuracy of the prototype is similar to other systems already established in clinical routine.
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Affiliation(s)
- Daniel Schmidhalter
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland.
| | - Dominik Henzen
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Evelyn Herrmann
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Werner Volken
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Paul-Henry Mackeprang
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Ekin Ermis
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Hossein Hemmatazad
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Jonas Honegger
- Varian Medical Systems Imaging Laboratory GmbH, CH-5405, Dättwil, Switzerland
| | - Benjamin Haas
- Varian Medical Systems Imaging Laboratory GmbH, CH-5405, Dättwil, Switzerland
| | - Michael K Fix
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
| | - Peter Manser
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, and University of Bern, Berne, Switzerland
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Modern radiosurgical and endovascular classification schemes for brain arteriovenous malformations. Neurosurg Rev 2018; 43:49-58. [PMID: 29728873 DOI: 10.1007/s10143-018-0983-8] [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: 03/20/2018] [Revised: 04/22/2018] [Accepted: 04/25/2018] [Indexed: 10/17/2022]
Abstract
Stereotactic radiosurgery (SRS) and endovascular techniques are commonly used for treating brain arteriovenous malformations (bAVMs). They are usually used as ancillary techniques to microsurgery but may also be used as solitary treatment options. Careful patient selection requires a clear estimate of the treatment efficacy and complication rates for the individual patient. As such, classification schemes are an essential part of patient selection paradigm for each treatment modality. While the Spetzler-Martin grading system and its subsequent modifications are commonly used for microsurgical outcome prediction for bAVMs, the same system(s) may not be easily applicable to SRS and endovascular therapy. Several radiosurgical- and endovascular-based grading scales have been proposed for bAVMs. However, a comprehensive review of these systems including a discussion on their relative advantages and disadvantages is missing. This paper is dedicated to modern classification schemes designed for SRS and endovascular techniques.
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Fennell VS, Martirosyan NL, Atwal GS, Kalani MYS, Ponce FA, Lemole GM, Dumont TM, Spetzler RF. Hemodynamics Associated With Intracerebral Arteriovenous Malformations: The Effects of Treatment Modalities. Neurosurgery 2017; 83:611-621. [DOI: 10.1093/neuros/nyx560] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 10/13/2017] [Indexed: 12/22/2022] Open
Abstract
Abstract
The understanding of the physiology of cerebral arteriovenous malformations (AVMs) continues to expand. Knowledge of the hemodynamics of blood flow associated with AVMs is also progressing as imaging and treatment modalities advance. The authors present a comprehensive literature review that reveals the physical hemodynamics of AVMs, and the effect that various treatment modalities have on AVM hemodynamics and the surrounding cortex and vasculature. The authors discuss feeding arteries, flow through the nidus, venous outflow, and the relative effects of radiosurgical monotherapy, endovascular embolization alone, and combined microsurgical treatments. The hemodynamics associated with intracranial AVMs is complex and likely changes over time with changes in the physical morphology and angioarchitecture of the lesions. Hemodynamic change may be even more of a factor as it pertains to the vast array of single and multimodal treatment options available. An understanding of AVM hemodynamics associated with differing treatment modalities can affect treatment strategies and should be considered for optimal clinical outcomes.
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Affiliation(s)
- Vernard S Fennell
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nikolay L Martirosyan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
- Division of Neurosurgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Gursant S Atwal
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - M Yashar S Kalani
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Francisco A Ponce
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - G Michael Lemole
- Division of Neurosurgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Travis M Dumont
- Division of Neurosurgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Feutren T, Huertas A, Salleron J, Anxionnat R, Bracard S, Klein O, Peiffert D, Bernier-Chastagner V. Modern robot-assisted radiosurgery of cerebral angiomas-own experiences, system comparisons, and comprehensive literature overview. Neurosurg Rev 2017; 41:787-797. [PMID: 29105011 DOI: 10.1007/s10143-017-0926-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 10/07/2017] [Accepted: 10/23/2017] [Indexed: 02/05/2023]
Abstract
Cerebral arteriovenous malformations (AVMs) are rare vascular lesions potentially responsible for substantial neurological morbidity and mortality. Over the past four decades, radiosurgery has become a valid therapeutic option for many patients with small intracranial AVMs, but reports describing the use of robotic stereotactic radiosurgery (SRS) are rare. The purposes of this study are to describe the efficacy and toxicity of robotic SRS for AVMs and to review the literature. The reports of 48 consecutive patients treated with SRS were reviewed. A total dose of 18 Gy in a single fraction was prescribed to the 70% isodose line. Efficacy (i.e., total obliteration of the AVM) and toxicity were analyzed. Literature search was performed on Embase and PubMed for the terms "Radiosurgery and AVMs", "Cyberknife and AVMs" and "Radiation therapy and AVMs." The median follow-up was 41 months. The median AVM volume was 2.62 cm3. The incidence of obliteration was 59% at 3 years. Regarding toxicity, 92% of patients remained symptom-free, 66% developed radiogenic edema on MRI, and none developed radionecrosis. Forty-one patients (85%) had embolization prior to SRS. Our study was incorporated in an exhaustive review of 25 trials categorized by SRS technique. In this review, the median follow-up was 60 months. The median nidus volume was 2 cm3. The median overall obliteration rate for SRS was 68% (range 36 to 92). The median embolization rate prior to SRS was 31% (range 8.23 to 90). Compared to other studies, tolerability was excellent and the obliteration rate was acceptable but probably affected by the high embolization rate prior to radiosurgery. Our study suggests that a higher dose is feasible. A larger cohort with a longer follow-up period will be needed to confirm the safety and effectiveness, and subsequently validate different prognosis and predictive scores with this treatment modality to maximize the benefits of this technology for selected patients in the long term.
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Affiliation(s)
- Thomas Feutren
- Department of Radiotherapy, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne, 54519, Vandœuvre-lès-Nancy, France.
| | - Andres Huertas
- Department of Radiotherapy, Hôpital Européen Georges Pompidou, Paris, France
| | - Julia Salleron
- Department of Biostatistics and Data Management, Institut de Cancérologie de Lorraine, Vandœuvre-lès-Nancy, France
| | - René Anxionnat
- Department of Neuroradiology, Hôpital Central CHU de Nancy, Nancy, France
| | - Serge Bracard
- Department of Neuroradiology, Hôpital Central CHU de Nancy, Nancy, France
| | - Olivier Klein
- Department of Neurosurgery, Hôpital Central CHU de Nancy, Nancy, France
| | - Didier Peiffert
- Department of Radiotherapy, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne, 54519, Vandœuvre-lès-Nancy, France
| | - Valérie Bernier-Chastagner
- Department of Radiotherapy, Institut de Cancérologie de Lorraine, 6 Avenue de Bourgogne, 54519, Vandœuvre-lès-Nancy, France
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11
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Marks MP, Marcellus ML, Santarelli J, Dodd RL, Do HM, Chang SD, Adler JR, Mlynash M, Steinberg GK. Embolization Followed by Radiosurgery for the Treatment of Brain Arteriovenous Malformations (AVMs). World Neurosurg 2017; 99:471-476. [PMID: 28017742 DOI: 10.1016/j.wneu.2016.12.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/10/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Michael P Marks
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA.
| | - Mary L Marcellus
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Justin Santarelli
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Robert L Dodd
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Huy M Do
- Department of Radiology, Stanford University Medical Center, Stanford, California, USA; Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Steven D Chang
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - John R Adler
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Michael Mlynash
- Department of Neurology, Stanford University Medical Center, Stanford, California, USA
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA; Department of Neurology, Stanford University Medical Center, Stanford, California, USA
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12
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Gross BA, Moon K, Mcdougall CG. Endovascular management of arteriovenous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:59-68. [PMID: 28552159 DOI: 10.1016/b978-0-444-63640-9.00006-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Arteriovenous malformation (AVM) embolization can serve as a crucial adjunct before surgical resection, a partial approach to target high-risk features, or, rarely, as a curative approach for high-risk, surgically inaccessible lesions. Specifically, embolization is a welcome surgical adjunct to reduce the size of medium to large AVMs, to target perforator supply, and/or to target the deep portion of a nidus. In addition, a crucial role for embolization is the targeting of associated aneurysms, particularly in the setting of a ruptured lesion, regardless of the subsequent therapeutic modality. Rarely, a deep, small ruptured AVM that cannot be accessed surgically may be embolized with intent to cure. This chapter will review patient selection, technical nuances, and published results for AVM embolization. With appropriate patient selection and well-defined goals of embolization, the risk of procedural morbidity can be outweighed by its benefit.
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Affiliation(s)
- Bradley A Gross
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
| | - Karam Moon
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Cameron G Mcdougall
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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Rajshekhar V, Moorthy RK, Jeyaseelan V, John S, Rangad F, Viswanathan P, Ravindran P, Singh R. Results of a Conservative Dose Plan Linear Accelerator–Based Stereotactic Radiosurgery for Pediatric Intracranial Arteriovenous Malformations. World Neurosurg 2016; 95:425-433. [DOI: 10.1016/j.wneu.2016.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 06/02/2016] [Accepted: 06/03/2016] [Indexed: 11/15/2022]
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Pollock BE, Storlie CB, Link MJ, Stafford SL, Garces YI, Foote RL. Comparative analysis of arteriovenous malformation grading scales in predicting outcomes after stereotactic radiosurgery. J Neurosurg 2016; 126:852-858. [PMID: 27058199 DOI: 10.3171/2015.11.jns151300] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Successful stereotactic radiosurgery (SRS) for the treatment of arteriovenous malformations (AVMs) results in nidus obliteration without new neurological deficits related to either intracranial hemorrhage (ICH) or radiation-induced complications (RICs). In this study the authors compared 5 AVM grading scales (Spetzler-Martin grading scale, radiosurgery-based AVM score [RBAS], Heidelberg score, Virginia Radiosurgery AVM Scale [VRAS], and proton radiosurgery AVM scale [PRAS]) at predicting outcomes after SRS. METHODS The study group consisted of 381 patients with sporadic AVMs who underwent Gamma Knife SRS between January 1990 and December 2009; none of the patients underwent prior radiation therapy. The primary end point was AVM obliteration without a decline in modified Rankin Scale (mRS) score (excellent outcome). Comparison of the area under the receiver operating characteristic curve (AUC) and accuracy was performed between the AVM grading scales and the best linear regression model (generalized linear model, elastic net [GLMnet]). RESULTS The median radiological follow-up after initial SRS was 77 months; the median clinical follow-up was 93 months. AVM obliteration was documented in 297 patients (78.0%). Obliteration was 59% at 4 years and 85% at 8 years. Fifty-five patients (14.4%) had a decline in mRS score secondary to RICs (n = 29, 7.6%) or ICH (n = 26, 6.8%). The mRS score declined by 10% at 4 years and 15% at 8 years. Overall, 274 patients (71.9%) had excellent outcomes. There was no difference between the AUC for the GLMnet (0.69 [95% CI 0.64-0.75]), RBAS (0.68 [95% CI 0.62-0.74]), or PRAS (0.69 [95% CI 0.62-0.74]). Pairwise comparison for accuracy showed no difference between the GLMnet and the RBAS (p = 0.08) or PRAS (p = 0.16), but it did show a significant difference between the GLMnet and the Spetzler-Martin grading system (p < 0.001), Heidelberg score (p < 0.001), and the VRAS (p < 0.001). The RBAS and the PRAS were more accurate when compared with the Spetzler-Martin grading scale (p = 0.03 and p = 0.01), Heidelberg score (p = 0.02 and p = 0.02), and VRAS (p = 0.03 and p = 0.02). CONCLUSIONS SRS provides AVM obliteration without functional decline in the majority of treated patients. AVM grading scales having continuous scores (RBAS and PRAS) outperformed integer-based grading systems in the prediction of AVM obliteration without mRS score decline after SRS.
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Affiliation(s)
| | | | - Michael J Link
- Departments of 1 Neurological Surgery.,Otorhinolaryngology, Mayo Clinic College of Medicine, Rochester, Minnesota
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15
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The Diagnosis and Management of Brain Arteriovenous Malformations in a Single Regional Center. World Neurosurg 2015; 84:1621-8. [PMID: 26100164 DOI: 10.1016/j.wneu.2015.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 06/08/2015] [Accepted: 06/11/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Cerebral arteriovenous malformations are vascular abnormalities in which arteriovenous shunting occurs through an abnormal vascular network (nidus) in the parenchyma. These lesions typically present by the third decade of life with cerebral bleeding, seizures, headache, or neurologic deficits; however, they are sometimes found incidentally. METHODS A retrospective analysis of intracranial AVMs referred to a single regional center, over a 7-year period, was performed to review the clinical presentation, pathologic features and management outcomes from January 2005 to December 2012. RESULTS We identified 142 patients (56% female, age range 4-69 years). Emergency referrals accounted for 87% of the cohort with the most frequent presentation being headache and/or hemorrhage. More than half (52%) of the cases were observed to have a neurologic deficit on examination. The modal Spetzler-Martin Grade was 3 with 76% of lesions located in areas of eloquent brain and 57% of cases in the dominant hemisphere. Half of the cases had multiple feeder vessels, and 29% were associated with aneurysms. The nidus was obliterated in 91% of cases actively managed. Two thirds of patients were successfully treated with a single modality, the most common being embolization. Only 8% of cases were managed conservatively. Additionally, 93% of aneurysms identified were treated successfully. The complication rate was 7% with 2% of reported infection. CONCLUSIONS The burden of AVM management is significantly enhanced by the number of emergency referrals. Interestingly, complication rates are higher in the unruptured cohort. Surgical management is the most effective modality, but it carries the highest complication rate. This accompanied by the challenges of AVM anatomy and associated pathology argue for expert service provision in a single center.
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Awad AJ, Walcott BP, Stapleton CJ, Ding D, Leed CC, Loeffler JS. Repeat radiosurgery for cerebral arteriovenous malformations. J Clin Neurosci 2015; 22:945-950. [PMID: 25913746 DOI: 10.1016/j.jocn.2015.01.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 12/30/2014] [Accepted: 01/01/2015] [Indexed: 10/23/2022]
Abstract
We perform a systematic review of repeat radiosurgery for cerebral arteriovenous malformations (AVM) with an emphasis on lesion obliteration rates and complications. Radiosurgery is an accepted treatment modality for AVM located in eloquent cortex or deep brain structures. For residual or persistent lesions, repeat radiosurgery can be considered if sufficient time has passed to allow for a full appreciation of treatment effects, usually at least 3years. A systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. References for this review were identified by searches of MEDLINE, Web of Science and Google Scholar databases. A total of 14 studies comprising 733 patients met the review criteria and were included. For series that reported target dose at both first and repeat treatments, the weighted means were 19.42Gy and 19.06Gy, respectively. The mean and median obliteration rate for the repeat radiosurgery treatments were 61% (95% confidence interval 51.9-71.7%) and 61.5%, respectively. The median follow up following radiosurgery ranged from 19.5 to 80months. Time to complete obliteration after the repeat treatment ranged from 21 to 40.8months. The most common complications of repeat radiosurgery for AVM included hemorrhage (7.6%) and radiation-induced changes (7.4%). Repeat radiosurgery can be used to treat incompletely obliterated AVM with an obliteration rate of 61%. Complications are related to treatment effect latency (hemorrhage risk) as well as radiation-induced changes. Repeat radiosurgery can be performed at 3 years following the initial treatment, allowing for full realization of effects from the initial treatment prior to commencing therapy.
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Affiliation(s)
- Ahmed J Awad
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Brian P Walcott
- Department of Neurological Surgery, Massachusetts General Hospital, White Building Room 502, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher J Stapleton
- Department of Neurological Surgery, Massachusetts General Hospital, White Building Room 502, 55 Fruit Street, Boston, MA 02114, USA
| | - Dale Ding
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Cheng-Chia Leed
- Department of Neurological Surgery, Massachusetts General Hospital, White Building Room 502, 55 Fruit Street, Boston, MA 02114, USA
| | - Jay S Loeffler
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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17
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Stereotactic radiosurgery for pediatric patients with intracranial arteriovenous malformations: Variables that may affect obliteration time and probability. Clin Neurol Neurosurg 2015; 129:62-6. [DOI: 10.1016/j.clineuro.2014.11.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 11/21/2014] [Accepted: 11/27/2014] [Indexed: 11/18/2022]
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18
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Abstract
Purpose:To identify the predictors of symptomatic post-radiation T2 signal change in patients with arteriovenous malformations (AVM) treated with radiosurgery.Materials and Methods:The charts of 211 consecutive patients with arteriovenous malformations treated with either gamma knife radisurgery or linear accelerator radiosurgery between 2000-2009 were retrospectively reviewed. 168 patients had a minimum of 12 months of clinical and radiologic follow-up following the procedure and complete dosage data. Pretreatment characteristics and dosimetric variables were analyzed to identify predictors of adverse radiation effects.Results:141 patients had no clinical symptomatic complications. 21 patients had global or focal neurological deficits attributed to symptomatic edema. Variables associated with development of symptomatic edema included a non-hemorrhagic symptomatic presentation compared to presentation with hemorrhage, p=0.001; OR (95%CI) = 6.26 (1.99, 19.69); the presence of venous rerouting compared to the lack of venous rerouting, p=0.031; OR (95% CI) = 3.25 (1.20, 8.80); radiosurgery with GKS compared to linear accelerator radiosurgery p = 0.012; OR (95% CI) = 4.58 (1.28, 16.32); and the presence of more than one draining vein compared to a single draining vein p = 0.032; OR (95% CI) = 2.82 (1.06, 7.50).Conclusions:We postulated that the higher maximal doses used with gamma knife radiosurgery may be responsible for the greater number of adverse radiation effects with this modality compared to linear accelerator radiosurgery. We found that AVMs with greater venous complexity and therefore instability resulted in more adverse treatment outcomes, suggesting that AVM angioarchitecture should be considered when making treatment decisions.
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Hattangadi-Gluth JA, Chapman PH, Kim D, Niemierko A, Bussière MR, Stringham A, Daartz J, Ogilvy C, Loeffler JS, Shih HA. Single-Fraction Proton Beam Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations. Int J Radiat Oncol Biol Phys 2014; 89:338-46. [DOI: 10.1016/j.ijrobp.2014.02.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 02/13/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
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20
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Stereotactic radiosurgery with neoadjuvant embolization of larger arteriovenous malformations: an institutional experience. BIOMED RESEARCH INTERNATIONAL 2014; 2014:306518. [PMID: 24579080 PMCID: PMC3919115 DOI: 10.1155/2014/306518] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 11/28/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study investigates the safety and efficacy of a multimodality approach combining staged endovascular embolizations with subsequent SRS for the management of larger AVMs. METHODS Ninety-five patients with larger AVMs were treated with staged endovascular embolization followed by SRS between 1996 and 2011. RESULTS The median volume of AVM in this series was 28 cm(3) and 47 patients (48%) were Spetzler-Martin grade IV or V. Twenty-seven patients initially presented with hemorrhage. Sixty-one patients underwent multiple embolizations while a single SRS session was performed in 64 patients. The median follow-up after SRS session was 32 months (range 9-136 months). Overall procedural complications occurred in 14 patients. There were 13 minor neurologic complications and 1 major complication (due to embolization) while four patients had posttreatment hemorrhage. Thirty-eight patients (40%) were cured radiographically. The postradiosurgery actuarial rate of obliteration was 45% at 5 years, 56% at 7 years, and 63% at 10 years. In multivariate analysis, larger AVM size, deep venous drainage, and the increasing number of embolization/SRS sessions were negative predictors of obliteration. The number of embolizations correlated positively with the number of stereotactic radiosurgeries (P < 0.005). CONCLUSIONS Multimodality endovascular and radiosurgical approach is an efficacious treatment strategy for large AVM.
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21
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Gross BA, Du R. Diagnosis and Treatment of Vascular Malformations of the Brain. Curr Treat Options Neurol 2013; 16:279. [PMID: 24318447 DOI: 10.1007/s11940-013-0279-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Bradley A Gross
- Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
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Murray AL, Dally M, Jeffreys A, Hwang P, Anderson JFI. Neuropsychological outcomes of stereotactic radiotherapy for cerebral arteriovenous malformations. J Clin Neurosci 2013; 21:601-6. [PMID: 24216063 DOI: 10.1016/j.jocn.2013.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 08/13/2013] [Accepted: 08/19/2013] [Indexed: 11/18/2022]
Abstract
To our knowledge, this is the first study to investigate cognitive outcome in patients with large or surgically inaccessible cerebral arteriovenous malformations (AVMs), who were treated with hypo-fractionated stereotactic radiotherapy (HSRT). A sample of 10 patients with AVMs was assessed up to 3.5 years post-HSRT. All patients were treated with HSRT to a total dose of 55 Gy in 11 fractions over a treatment period of 2.5 weeks. Neuropsychological assessments were given prior to radiotherapy and then at three time points following radiotherapy: 6 weeks, 6 months and 2.5-3.5 years post-treatment. The cognitive domains of attention, processing speed, learning, memory, semantic processing, naming, verbal fluency, visuospatial and executive function were assessed. Findings revealed that prior to radiotherapy the patient group was impaired in five of the nine cognitive domains. Post-treatment performances remained stable in the majority of domains; however, there was some fluctuation in semantic processing and memory performances. At 6 weeks post-treatment, a mild decrement was found in semantic processing ability; however, restoration to baseline levels was observed from 6 months onwards. At 2.5-3.5 years post-treatment, improvement was seen in the cohort's ability to remember new information when performances were compared with earlier time points. This study demonstrated improvements in memory several years after HSRT treatment. Further, this form of treatment was not associated with long-term, harmful cognitive side effects for these 10 patients encouraging further study of this treatment method. Further evaluation of the entire cohort is required to assess efficacy in terms of AVM obliteration and other potential side effects.
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Affiliation(s)
- Andrea L Murray
- Melbourne School of Psychological Sciences, Redmond Barry Building, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia
| | - Michael Dally
- Radiation Oncology, Alfred Hospital, Melbourne, VIC, Australia; Department of Surgery, Monash University, Melbourne, VIC, Australia
| | - Aimee Jeffreys
- Melbourne School of Psychological Sciences, Redmond Barry Building, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia
| | - Peter Hwang
- Department of Surgery, Monash University, Melbourne, VIC, Australia; Department of Neurosurgery, Alfred Hospital, Melbourne, VIC, Australia
| | - Jacqueline F I Anderson
- Melbourne School of Psychological Sciences, Redmond Barry Building, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia; Psychology Department, Alfred Health, Melbourne, VIC, Australia.
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24
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Abstract
Stereotactic radiosurgery for intracranial arteriovenous malformations (AVMs) has been performed since the 1970s. When an AVM is treated with radiosurgery, radiation injury to the vascular endothelium induces the proliferation of smooth muscle cells and the elaboration of extracellular collagen, which leads to progressive stenosis and obliteration of the AVM nidus. Obliteration after AVM radiosurgery ranges from 60% to 80%, and relates to the size of the AVM and the prescribed radiation dose. The major drawback of radiosurgical AVM treatment is the risk of bleeding during the latent period (typically 2 years) between treatment and AVM thrombosis.
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Affiliation(s)
- William A Friedman
- Department of Neurological Surgery, University of Florida, PO Box 100265, MBI, Gainesville, FL 32610, USA.
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25
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Fokas E, Henzel M, Wittig A, Grund S, Engenhart-Cabillic R. Stereotactic radiosurgery of cerebral arteriovenous malformations: long-term follow-up in 164 patients of a single institution. J Neurol 2013; 260:2156-62. [DOI: 10.1007/s00415-013-6936-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 04/20/2013] [Accepted: 04/22/2013] [Indexed: 12/20/2022]
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Pollock BE, Link MJ, Brown RD. The Risk of Stroke or Clinical Impairment After Stereotactic Radiosurgery for ARUBA-Eligible Patients. Stroke 2013; 44:437-41. [DOI: 10.1161/strokeaha.112.670232] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The best management of patients with unruptured brain arteriovenous malformations (BAVM) is controversial. In this study, we analyzed the stroke rate and functional outcomes of patients having stereotactic radiosurgery (SRS) for unruptured BAVM using the same eligibility criteria and primary end points as the ARUBA trial.
Methods—
Retrospective observational study of 174 ARUBA-eligible patients having SRS from 1990 to 2005.
Results—
The median follow-up after SRS was 64 months. Fifteen patients (8.7%) had a hemorrhagic stroke at a median of 21 months after SRS. Six patients (3.5%) had a focal neurological deficit and 4 patients died (2.3%). The risk of stroke or death was 10.3% at 5 years and 11.5% at 10 years. Twelve additional patients (6.9%) had a focal neurological deficit from either radiation-related complications (n=7) or subsequent resection (n=5). The risk of patients’ having clinical impairment (modified Rankin Score ≥2) was 8.4% at 5 years and 12.0% at 10 years. Increasing BAVM volume was associated with both stroke or death (hazard ratio=1.06; 95% confidence interval, 1.0–1.11;
P
=0.04) and clinical impairment (hazard ratio=1.06; 95% confidence interval, 1.01–1.09;
P
=0.01). The 10-year risk of stroke or death and clinical impairment for patients with BAVM ≤5.6 cm
3
was 5% and 4%, respectively.
Conclusions—
The observed risk of stroke or death after SRS was approximately 2% per year for the first 5 years after SRS, declining to 0.2% annually for years 6 to 10. Patients with small volume BAVM may benefit from SRS compared with the natural history of unruptured BAVM over the planned follow-up interval of the ARUBA trial (5–10 years).
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Affiliation(s)
- Bruce E. Pollock
- From the Departments of Neurological Surgery, Neurology, and Radiation Oncology, Mayo Clinic College of Medicine, Rochester, MN
| | - Michael J. Link
- From the Departments of Neurological Surgery, Neurology, and Radiation Oncology, Mayo Clinic College of Medicine, Rochester, MN
| | - Robert D. Brown
- From the Departments of Neurological Surgery, Neurology, and Radiation Oncology, Mayo Clinic College of Medicine, Rochester, MN
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Koltz MT, Polifka AJ, Saltos A, Slawson RG, Kwok Y, Aldrich EF, Simard JM. Long-term outcome of Gamma Knife stereotactic radiosurgery for arteriovenous malformations graded by the Spetzler-Martin classification. J Neurosurg 2012; 118:74-83. [PMID: 23082882 DOI: 10.3171/2012.9.jns112329] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The object of this study was to assess outcomes in patients with arteriovenous malformations (AVMs) treated by Gamma Knife stereotactic radiosurgery (SRS); lesions were stratified by size, symptomatology, and Spetzler-Martin (S-M) grade. METHODS The authors performed a retrospective analysis of 102 patients treated for an AVM with single-dose or staged-dose SRS between 1993 and 2004. Lesions were grouped by S-M grade, as hemorrhagic or nonhemorrhagic, and as small (< 3 cm) or large (≥ 3 cm). Outcomes included death, morbidity (new neurological deficit, new-onset seizure, or hemorrhage/rehemorrhage), nidus obliteration, and Karnofsky Performance Scale score. RESULTS The mean follow-up was 8.5 years (range 5-16 years). Overall nidus obliteration (achieved in 75% of patients) and morbidity (19%) correlated with lesion size and S-M grade. For S-M Grade I-III AVMs, nonhemorrhagic and hemorrhagic combined, treatment yielded obliteration rates of 100%, 89%, and 86%, respectively; high functional status (Karnofsky Performance Scale Score ≥ 80); and 1% mortality. For S-M Grade IV and V AVMs, outcomes were less favorable, with obliteration rates of 54% and 0%, respectively. The AVMs that were not obliterated had a mean reduction in nidus volume of 69% (range 35%-96%). On long-term follow-up, 10% of patients experienced hemorrhage/rehemorrhage (6% mortality rate), which correlated with lesion size and S-M grade; the mean interval to hemorrhage was 81 months. CONCLUSIONS For patients with S-M Grade I-III AVMs, SRS offers outcomes that are favorable and that, except for the timing of obliteration, appear to be comparable to surgical outcomes reported for the same S-M grades. Staged-dose SRS results in lesion obliteration in half of patients with S-M Grade IV lesions.
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Affiliation(s)
- Michael T Koltz
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland 21201-1595, USA
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Lorenzana L, Sallabanda K, Samblás J, García R, Peraza C, Gutiérrez-Díaz JÁ, Bustos JC. [Linear accelerator radiosurgery for brainstem arteriovenous malformations. Long-term results]. Neurocirugia (Astur) 2012; 23:234-43. [PMID: 22954619 DOI: 10.1016/j.neucir.2012.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Revised: 06/06/2012] [Accepted: 06/16/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Arteriovenous malformations (AVM) in the brainstem carry a high risk of recurrent haemorrhage, mortality and morbidity. Treatment options are limited and mainly based on stereotactic radiosurgery. We studied the results of our series of brainstem AVM treated with linear accelerator (LINAC) and with a long-term follow-up. METHODS We retrospectively analysed the clinical and radiological data of 41 consecutive patients with brainstem AVM treated by radiosurgery with a 6MV linear accelerator between 1992 and 2010. Twenty five lesions were located in the mesencephalon, 14 in the pons, one in the medulla oblongata and one was bulbopontine. We analysed the treatment results in relation to survival, rate of radiological obliteration, rebleeding, and treatment toxicity. RESULTS The obliteration rate confirmed by angiography/MRA was 59.5% on 38 controlled patients. The mean follow-up period was 61 months (range: 6.7-178) and the margin dose was 14Gy in most treatments. Up to 39% of patients received more than one radiosurgery procedure to achieve closure of the malformation. No statistical correlation was found with the margin dose, presence of pretreatment haemorrhage, nidus diameter or score on the Pollock-Flickinger grading system. The annual haemorrhage rate after radiosurgery was 3.2%. Three patients died from rebleeding and actuarial survival rate was 88% at 5 and 10 years after treatment. Four patients suffered new transient neurological deficits due to toxicity, and only one presented a permanent deficit (2.6%). CONCLUSIONS Nidus obliteration in brainstem AVM must be achieved according to three main criteria: maximum obliteration rate forced by the high rate of rebleeding, minimal morbidity given its critical location, and the greatest possible accuracy. Stereotactic radiosurgery with our moderate-dose protocol, which we believe achieved these three premises, may become an elective therapeutic modality for these patients.
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Affiliation(s)
- Luis Lorenzana
- Unidad de Radiocirugía-Neurooncología, Hospital San Francisco de Asís, Grupo IMO, Madrid, España.
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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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30
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Surgical and radiosurgical results of the treatment of cerebral arteriovenous malformations. J Clin Neurosci 2012; 19:1001-4. [PMID: 22608804 DOI: 10.1016/j.jocn.2012.01.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2011] [Accepted: 01/01/2012] [Indexed: 11/23/2022]
Abstract
Microsurgical resection of a cerebral arteriovenous malformation (AVM) allows for an immediate therapeutic cure. Stereotactic radiosurgery (SRS) is a reasonable alternative for inoperable or high-risk lesions requiring treatment. Few series evaluate overall results that include data from both modalities as they more often focus on their treatment method of choice. In this study, we evaluated our AVM database of 129 patients seen over the past eight years at our institution: 73 were treated with microsurgery (57%) while 37 (29%) were treated with SRS. We reviewed angiographic obliteration rates, complication rates, and outcome data, excluding seven patients treated with SRS as they did not have at least two years of angiographic follow-up. Patients undergoing microsurgery had smaller AVM (mean 2.2 cm compared to 3.5 cm for SRS), a smaller proportion of eloquent AVM (53% compared to 83% for SRS), a greater proportion of AVM with superficial drainage only (75% compared to 40% for SRS), and more grade 1 and 2 AVM (78% compared to 17% for SRS). The overall obliteration rate was 80%: 92% for microsurgery and 50% for SRS. The latter increased to 92% for AVM <3 cm, but the obliteration rate was 18% for those AVM >3 cm. Transient complications, including post-SRS hemorrhage, were seen in 11% of patients overall (8% after microsurgery, 17% after SRS). At follow-up, 53% of patients had improved, 37% remained the same, 7% had become worse and 3% had died. As a result of post-SRS hemorrhage, a greater proportion of patients was worse or had died after SRS (20%) compared to those who had been treated with microsurgery (5%).
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Gross BA, Ropper AE, Popp AJ, Du R. Stereotactic radiosurgery for cerebral dural arteriovenous fistulas. Neurosurg Focus 2012; 32:E18. [DOI: 10.3171/2012.1.focus11354] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Given the feasibility of curative surgical and endovascular therapy for cerebral dural arteriovenous fistulas (DAVFs), there is a relative paucity of radiosurgical series for these lesions as compared with their arteriovenous malformation counterparts.
Methods
The authors reviewed records of 56 patients with 70 cerebral DAVFs treated at their institution over the past 6 years. Ten DAVFs (14%) in 9 patients were treated with stereotactic radiosurgery (SRS), with follow-up obtained for 8 patients with 9 DAVFs. They combined their results with those obtained from a comprehensive review of the literature, focusing on obliteration rates, post-SRS hemorrhage rates, and other complications.
Results
In the authors' group of 9 DAVFs, angiographic obliteration was seen in 8 cases (89%), and no post-SRS hemorrhage or complications were observed after a mean follow-up of 2.9 years. Combining the results in these cases with data obtained from their review of the literature, they found 558 DAVFs treated with SRS across 14 series. The overall obliteration rate was 71%; transient worsening occurred in 9.1% of patients, permanent worsening in 2.4% (including 1 death, 0.2% of cases), and post-SRS hemorrhage occurred in 1.6% of cases (4.8% of those with cortical venous drainage [CVD]). The obliteration rate for cavernous DAVFs was 84%, whereas the rates for transversesigmoid and for tentorial DAVFs were 58% and 59%, respectively (adjusted p values, pcav,TS = 1.98 × 10−4, pcav,tent = 0.032). Obliteration rates were greater for DAVFs without CVD (80%, compared with 60% for those with CVD, p = 7.59 × 10−4). Both transient worsening and permanent worsening were less common in patients without CVD than in those with CVD (3.4% vs 7.3% for transient worsening and 0.9% vs 2.4% for permanent worsening).
Conclusions
Stereotactic radiosurgery with or without adjunctive embolization is an effective therapy for DAVFs that are not amenable to surgical or endovascular monotherapy. It is best suited for lesions without CVD and for cavernous DAVFs.
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See AP, Raza S, Tamargo RJ, Lim M. Stereotactic radiosurgery of cranial arteriovenous malformations and dural arteriovenous fistulas. Neurosurg Clin N Am 2012; 23:133-46. [PMID: 22107864 DOI: 10.1016/j.nec.2011.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Cranial arteriovenous malformations (AVM) and cranial dural arteriovenous fistulas (AVF) carry a significant risk of morbidity and mortality when they hemorrhage. Current treatment options include surgery, embolization, radiosurgery, or a combination of these treatments. Radiosurgery is thought to reduce the risk hemorrhage in AVMs and AVFs by obliterating of the nidus of abnormal vasculature over the course of 2 to 3 years. Success in treating AVMs is variable depending on the volume of the lesion, the radiation dose, and the pattern of vascular supply and drainage. This article discusses the considerations for selecting radiosurgery as a treatment modality in patients who present with AVMs and AVFs.
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Affiliation(s)
- Alfred P See
- Department of Neurosurgery, The Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287, USA
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Flores GL, Sallabanda K, dos Santos MA, Gutiérrez J, Salcedo JCBP, Beltrán C, Fernández CP, Atienza MG, Samblás J. Linac stereotactic radiosurgery for the treatment of small arteriovenous malformations: lower doses can be equally effective. Stereotact Funct Neurosurg 2011; 89:338-45. [PMID: 22005899 DOI: 10.1159/000330837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 07/12/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the efficacy and toxicity of treating small arteriovenous malformations (AVMs) (≤3 cm in diameter) with a median marginal applied dose of 14 Gy. METHODS Two hundred and thirteen patients diagnosed with AVMs were treated between January 1991 and December 2005. Seventy-three percent of the patients had hemorrhaged prior to treatment, 13% had had previous surgery and 19.2% had had previous embolization. The median follow-up duration was 48.1 months. RESULTS The Kaplan-Meier analysis estimated that the 36-month obliteration rate was 65.5% for patients undergoing their first stereotactic radiosurgery (SRS) and 68.3% for those undergoing repeated SRS. The Kaplan-Meier analysis estimated the 60-month AVMs obliteration rate for the entire cohort to be 82.4%. The median time to AVM obliteration was 40 ± 2.8 months. We found a statistically significant relationship between the time of obliteration and the following factors: site of the AVMs (sites other than brainstem), a higher prescribed dose and a positive history of previous hemorrhage. Thirteen patients (7.6%) experienced toxicities. CONCLUSIONS SRS was an effective and safe treatment for AVMs ≤3 cm in diameter, with acceptable toxicity.
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Affiliation(s)
- G L Flores
- Radiotherapy Department, Instituto Madrileño de Oncologia/Grupo IMO, Madrid, Spain
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Stahl JM, Chi YY, Friedman WA. Repeat Radiosurgery for Intracranial Arteriovenous Malformations. Neurosurgery 2011; 70:150-4; discussion 154. [PMID: 21743357 DOI: 10.1227/neu.0b013e31822c5740] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Despite a high success rate in the stereotactic radiosurgical treatment of intracranial arteriovenous malformations (AVMs) that cannot be safely resected with microsurgery, some patients must be managed after treatment failure.
OBJECTIVE
To provide an update on the use of repeat linear accelerator radiosurgery as a treatment for failed AVM radiosurgery at the University of Florida.
METHODS
We reviewed 103 patients who underwent repeat radiosurgical treatment for residual AVM at the University of Florida between December 1991 and December 2007. Each of these patients had at least 2 radiosurgical treatments for the same AVM. Patient information, including AVM nidus volume, prescription dose, age, and sex, was collected at the time of initial treatment and again at the time of retreatment. Patients were followed up after treatment with magnetic resonance, computed tomography, and angiographic imaging at standard intervals to determine the status of their AVM. The median follow-up after retreatment was 31 months.
RESULTS
Between the first and second treatments, the median AVM nidus volume was decreased by 69% (from a median volume of 12.7 to 4.0 cm3), allowing the median prescribed dose to be increased from 1500 cGy on initial treatment to 1750 cGy on retreatment. The final obliteration rate on retreatment was 65.3%. After salvage retreatment, 5 patients (4.9%) experienced radiation-induced complications, and 6 patients (5.8%) experienced posttreatment hemorrhage.
CONCLUSION
Repeat radiosurgery is a safe and effective salvage treatment for AVMs.
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Affiliation(s)
- John M. Stahl
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Yueh-Yun Chi
- Department of Epidemiology and Health Policy Research, University of Florida, Gainesville, Florida
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Dehdashti AR, Thines L, Willinsky RA, terBrugge KG, Schwartz ML, Tymianski M, Wallace MC. Multidisciplinary care of occipital arteriovenous malformations: effect on nonhemorrhagic headache, vision, and outcome in a series of 135 patients. J Neurosurg 2010; 113:742-8. [DOI: 10.3171/2009.11.jns09884] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In this study, the authors evaluated how an appropriate allocation of patients with occipital arteriovenous malformations (AVMs) who were treated according to different strategies would affect nonhemorrhagic headache, visual function, and hemorrhage risk levels.
Methods
Of the 712 patients with brain AVMs in the Toronto Western Hospital prospective database, 135 had occipital AVMs. The treatment decision was based on patients' characteristics, presentation, and morphology of the AVM. The management modalities were correlated with their outcomes.
Results
The mean follow-up period was 6.78 years. Nonhemorrhagic headache was the most frequent symptom (82 [61%] of 135 patients). Ninety-four patients underwent treatment with one or a combination of embolization, surgery, or radiosurgery, and 41 were simply observed. Of the 40 nontreated patients with nonhemorrhagic headache, only 12 (30%) showed improvement. In the observation group 2 patients (22%) had worsening of visual symptoms, and 2 experienced hemorrhage, for an annual hemorrhage rate of 0.7% per year; 1 patient died. In the treatment group, the improvement in nonhemorrhagic headache in 35 patients (83%) was significant (p < 0.0001). Visual deficit at presentation worsened in 2 (8%), and there were 8 new visual field deficits (9%). The visual worsening was not significantly different. There were 2 other neurological deficits (2%) and 2 deaths (2%) related to the AVM treatment. One AVM hemorrhaged. The annual hemorrhage rate was 0.1% per year. The hemorrhage risk in the observation and treatment groups was lower than the observed hemorrhage risk of all patients with AVMs (4.6%) at the authors' institution.
Conclusions
Appropriate selection of patients with occipital AVMs for one or a combination of treatment modalities yields a significant decrease in nonhemorrhagic headache without significant visual worsening. The multidisciplinary care of occipital AVMs can aim for an apparent decrease in hemorrhage risk.
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Affiliation(s)
- Amir R. Dehdashti
- 1Divisions of Neurosurgery and
- 3Department of Neurosurgery, Geisinger Neurosciences Institute, Danville, Pennsylvania
| | | | - Robert A. Willinsky
- 2Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Ontario, Canada; and
| | - Karel G. terBrugge
- 2Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Ontario, Canada; and
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