1
|
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.
Collapse
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
| |
Collapse
|
2
|
Mansur A, Radovanovic I. Defining the Role of Oral Pathway Inhibitors as Targeted Therapeutics in Arteriovenous Malformation Care. Biomedicines 2024; 12:1289. [PMID: 38927496 PMCID: PMC11201820 DOI: 10.3390/biomedicines12061289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/30/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
Arteriovenous malformations (AVMs) are vascular malformations that are prone to rupturing and can cause significant morbidity and mortality in relatively young patients. Conventional treatment options such as surgery and endovascular therapy often are insufficient for cure. There is a growing body of knowledge on the genetic and molecular underpinnings of AVM development and maintenance, making the future of precision medicine a real possibility for AVM management. Here, we review the pathophysiology of AVM development across various cell types, with a focus on current and potential druggable targets and their therapeutic potentials in both sporadic and familial AVM populations.
Collapse
Affiliation(s)
- Ann Mansur
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
- Department of Laboratory Medicine and Pathobiology, School of Graduate Studies, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Ivan Radovanovic
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
- Department of Laboratory Medicine and Pathobiology, School of Graduate Studies, University of Toronto, Toronto, ON M5S 1A8, Canada
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, ON M5T 2S8, Canada
| |
Collapse
|
3
|
Liao Y, Bai X, Cao Y, Zhang M. Effect of low-dose bevacizumab on health-related quality of life in patients with recurrent high-grade glioma: A retrospective clinical study. J Clin Neurosci 2024; 120:196-203. [PMID: 38277995 DOI: 10.1016/j.jocn.2024.01.018] [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: 09/07/2023] [Revised: 12/23/2023] [Accepted: 01/14/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND We retrospectively analyzed the effects of low-dose bevacizumab (BEV) combined with temozolomide (TMZ) on health-related quality of life (HRQL) in patients with recurrent high-grade glioma (rHGG). METHODS A total of 129 patients with rHGG were included in this study. Patients were divided into a combination group and TMZ group based on the treatment they received. The Quality of Life Questionnaire Core 30 (QLQ-C30) and EORTC Brain Cancer Module (QLQ-BN20) were used to evaluate HRQL in all patients before and after treatment. Categorical variables were compared using the chi-squared test. The data for all continuous variables were first tested for a normal distribution. If the data conformed to a normal distribution, a T test was used for comparison. If the data did not conform to a normal distribution, the rank-sum test was used. RESULTS There were differences in PFS and PFS-6 between the BEV + TMZ and TMZ groups (P<0.05). However, there was no difference in the OS between the two groups (P>0.05). The BEV + TMZ group performed better than the TMZ group in both the QLQ-C30 and QLQ-BN20. In addition, the KPS score was higher in the BEV + TMZ group than in the TMZ group. Steroid doses given were lower in the BEV + TMZ group than in the TMZ group (P < 0.05). CONCLUSIONS Low-dose BEV + TMZ can relieve the clinical symptoms of rHGG patients, reduce their steroid dose, improve HRQL, and prolong PFS, but does not bear any benefit on OS.
Collapse
Affiliation(s)
- Yonghong Liao
- Neurosurgery of The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Xuexue Bai
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yiyao Cao
- Neurosurgery of The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Maoying Zhang
- Neurosurgery of The First Affiliated Hospital, Jinan University, Guangzhou, China.
| |
Collapse
|
4
|
Bai X, Zhou M. The benefit of bevacizumab therapy in patients with refractory vasogenic edema caused by brain metastasis from lung and colon cancers. Front Oncol 2022; 12:838670. [PMID: 36249059 PMCID: PMC9559828 DOI: 10.3389/fonc.2022.838670] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 09/06/2022] [Indexed: 11/28/2022] Open
Abstract
Objective This retrospective study investigated the efficacy of bevacizumab in refractory brain edema caused by brain metastasis from lung cancer and colon cancer. Methods A total of 72 patients with refractory brain edema were divided into the lung cancer and colon cancer groups according to their primary tumor. All patients received a single bevacizumab treatment for refractory brain edema. MRI was performed 1 week before the treatment and 4 weeks after the treatment. The edema and tumor volumes were calculated using imaging modalities. Results After a single bevacizumab treatment, the refractory brain edema of 61 patients was controlled, and the clinical symptoms of 65 patients were improved. The average edema volume before treatment was 201,708.97 ± 61,426.04 mm3, which has decreased to 116,947.01 ± 43,879.16 mm3 after treatment (P < 0.05). After treatment, the edema index decreased from 25.97 ± 7.15 to 17.32 ± 5.24 (P < 0.05).We found that brain edema was controlled in 40 patients (93.02%) in the lung cancer group and 21 patients (72.41%) in the colon cancer group (P<0.05). In addition, 22 patients (88.00%) in the radiotherapy group achieved edema control, compared to 39 (82.98%) in the non-radiotherapy group (P>0.05). Nine patients experienced hypertension after treatment, two patients exhibited decreased platelet counts, and no hemorrhage cases were observed. Conclusion Bevacizumab can significantly alleviate refractory brain edema, and there is a significant difference in the efficacy of bevacizumab on refractory brain edema caused by brain metastasis from lung and colon cancers.
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Bai X, Zhang Y, Ding W, Wang S. Efficacy of bevacizumab in the treatment of refractory brain edema of metastatic tumors from different sources. Neurol Res 2021; 43:955-960. [PMID: 34766548 DOI: 10.1080/01616412.2021.1948740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Aim: This retrospective study investigated bevacizumab in treating refractory brain edema in patients with brain-metastatic tumors from different sources.Methods: From January 2013 to December 2019, 83 patients with brain metastases and refractory brain edema were treated with bevacizumab. They were divided into lung cancer group and breast cancer group. The clinical data, the efficacy, and the side effects of bevacizumab were recorded. Magnetic resonance imaging was performed before and after bevacizumab treatment. The volume of tumor and brain edema were measured respectively.Results: After treatment with bevacizumab, 72 cases of refractory brain edema were significantly relieved. The edema control rate was 93.75% in the lung cancer group and 77.14% in the breast cancer group (P < .05). The brain edema volume was significantly reduced after bevacizumab treatment from 198,286.84 ± 60,564.40 to 114,677.71 ± 42,337.38mm3 (P < .01), and the edema index was reduced from 26.14 ± 7.24 to 17.18 ± 5.14 (P < .01). Hypertension was observed in 14 cases.Conclusion: Bevacizumab could significantly reduce refractory brain edema with a control rate of 86.75%. The efficacy of bevacizumab in the treatment of refractory brain edema caused by lung cancer is better than that of breast cancer.
Collapse
Affiliation(s)
- Xuexue Bai
- The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Yuan Zhang
- Peking University Health Science Center, Peking University, Beijing, China
| | - Weilong Ding
- The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Shiyong Wang
- The First Affiliated Hospital, Jinan University, Guangzhou, China
| |
Collapse
|
7
|
Wang M, Jiao Y, Zeng C, Zhang C, He Q, Yang Y, Tu W, Qiu H, Shi H, Zhang D, Kang D, Wang S, Liu AL, Jiang W, Cao Y, Zhao J. Chinese Cerebrovascular Neurosurgery Society and Chinese Interventional & Hybrid Operation Society, of Chinese Stroke Association Clinical Practice Guidelines for Management of Brain Arteriovenous Malformations in Eloquent Areas. Front Neurol 2021; 12:651663. [PMID: 34177760 PMCID: PMC8219979 DOI: 10.3389/fneur.2021.651663] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/20/2021] [Indexed: 11/13/2022] Open
Abstract
Aim: The aim of this guideline is to present current and comprehensive recommendations for the management of brain arteriovenous malformations (bAVMs) located in eloquent areas. Methods: An extended literature search on MEDLINE was performed between Jan 1970 and May 2020. Eloquence-related literature was further screened and interpreted in different subcategories of this guideline. The writing group discussed narrative text and recommendations through group meetings and online video conferences. Recommendations followed the Applying Classification of Recommendations and Level of Evidence proposed by the American Heart Association/American Stroke Association. Prerelease review of the draft guideline was performed by four expert peer reviewers and by the members of Chinese Stroke Association. Results: In total, 809 out of 2,493 publications were identified to be related to eloquent structure or neurological functions of bAVMs. Three-hundred and forty-one publications were comprehensively interpreted and cited by this guideline. Evidence-based guidelines were presented for the clinical evaluation and treatment of bAVMs with eloquence involved. Topics focused on neuroanatomy of activated eloquent structure, functional neuroimaging, neurological assessment, indication, and recommendations of different therapeutic managements. Fifty-nine recommendations were summarized, including 20 in Class I, 30 in Class IIa, 9 in Class IIb, and 2 in Class III. Conclusions: The management of eloquent bAVMs remains challenging. With the evolutionary understanding of eloquent areas, the guideline highlights the assessment of eloquent bAVMs, and a strategy for decision-making in the management of eloquent bAVMs.
Collapse
Affiliation(s)
- Mingze Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuming Jiao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaofan Zeng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chaoqi Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Wenjun Tu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hancheng Qiu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dezhi Kang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - A-Li Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Gamma Knife Center, Beijing Neurosurgical Institute, Beijing, China
| | - Weijian Jiang
- Department of Vascular Neurosurgery, Chinese People's Liberation Army Rocket Army Characteristic Medical Center, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
| |
Collapse
|
8
|
Kwong F, Scarpelli DB, Barajas RF, Monaco D, Tanyi JA, McClelland S, Jaboin JJ. Resolution of Radiation-Induced Necrosis in Arteriovenous Malformation with Bevacizumab: A Case Report and Review of Current Literature. Case Rep Neurol 2021; 13:297-304. [PMID: 34177536 PMCID: PMC8215952 DOI: 10.1159/000513560] [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: 10/22/2020] [Accepted: 11/29/2020] [Indexed: 11/24/2022] Open
Abstract
Stereotactic radiosurgery (SRS) is a proven treatment modality for inoperable arteriovenous malformations (AVMs). However, the rate of radiation-induced necrosis (RIN) is as high as 10%. A 6-year-old female patient presented with severe headache, emesis, and syncope, and workup revealed a Spetzler-Martin grade 4 AVM with intraventricular hemorrhage and hydrocephalus. The patient underwent a right frontal ventriculostomy followed by a linear accelerator-based SRS of 16.9 Gy. At 19 years, she developed progressive neurological symptoms. Diagnostic magnetic resonance imaging (MRI) revealed a recurrent parietal AVM nidus. We delivered the linear accelerator-based SRS of 18.5 Gy to the AVM nidus. Within 9 months, she experienced episodic headaches and left-sided weakness and spasticity; symptoms were initially managed with dexamethasone. Follow-up MRI was notable for edema and nondetectable blood flow, consistent with RIN and AVM obliteration. The second course of steroids did not provide the symptom control. Persistent RIN was noted on MRI, and she had stigmata of steroid toxicity (centripetal obesity, depression, and sleep disorder). Two infusions of bevacizumab (5 mg/kg) were administered concurrently with a tapering dose of dexamethasone. The patient noted a near immediate improvement in her headaches, and 2 months following the second bevacizumab infusion, she reported a near-complete resolution of her symptoms and displayed improved ambulation. The development of RIN remains a noteworthy concern post-SRS of AVMs. While steroids aid with initial management of RIN, for persistent and recurrent symptoms, bevacizumab infusions serve as a viable treatment course, with the added benefit of reducing the likelihood of adverse effects resulting from prolonged steroid therapy.
Collapse
Affiliation(s)
- Forrest Kwong
- School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Daphne B Scarpelli
- Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Ramon F Barajas
- Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Oregon, USA.,Advanced Imaging Research Center, Oregon Health & Science University, Portland, Oregon, USA.,Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Debra Monaco
- Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - James A Tanyi
- Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Shearwood McClelland
- Department of Radiation Oncology, Indiana University, Indianapolis, Indiana, USA
| | - Jerry J Jaboin
- Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Muster R, Ko N, Smith W, Su H, Dickey MA, Nelson J, McCulloch CE, Sneed PK, Clarke JL, Saloner DA, Eisenmenger L, Kim H, Cooke DL. Proof-of-concept single-arm trial of bevacizumab therapy for brain arteriovenous malformation. BMJ Neurol Open 2021; 3:e000114. [PMID: 34189463 PMCID: PMC8204171 DOI: 10.1136/bmjno-2020-000114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 12/13/2022] Open
Abstract
Brain arteriovenous malformations (bAVMs) are relatively rare, although their potential for secondary intracranial haemorrhage (ICH) makes their diagnosis and management essential to the community. Currently, invasive therapies (surgical resection, stereotactic radiosurgery and endovascular embolisation) are the only interventions that offer a reduction in ICH risk. There is no designated medical therapy for bAVM, although there is growing animal and human evidence supporting a role for bevacizumab to reduce the size of AVMs. In this single-arm pilot study, two patients with large bAVMs (deemed unresectable by an interdisciplinary team) received bevacizumab 5 mg/kg every 2 weeks for 12 weeks. Due to limitations of external funding, the intended sample size of 10 participants was not reached. Primary outcome measure was change in bAVM volume from baseline at 26 and 52 weeks. No change in bAVM volume was observed 26 or 52 weeks after bevacizumab treatment. No clinically important adverse events were observed during the 52-week study period. There were no observed instances of ICH. Sera vascular endothelial growth factor levels were reduced at 26 weeks and returned to baseline at 52 weeks. This pilot study is the first to test bevacizumab for patients with bAVMs. Bevacizumab therapy was well tolerated in both subjects. No radiographic changes were observed over the 52-week study period. Subsequent larger clinical trials are in order to assess for dose-dependent efficacy and rarer adverse drug effects. Trial registration number: NCT02314377.
Collapse
Affiliation(s)
- Rachel Muster
- School of Medicine, UCSF, San Francisco, California, USA
| | - Nerissa Ko
- Neurology, UCSF, San Francisco, California, USA
| | - Wade Smith
- Neurology, UCSF, San Francisco, California, USA
| | - Hua Su
- Anesthesia and Perioperative Care, UCSF, San Francisco, California, USA
| | - Melissa A Dickey
- Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
| | - Jeffrey Nelson
- Anesthesia and Perioperative Care, UCSF, San Francisco, California, USA
| | | | | | | | - David A Saloner
- Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
| | | | - Helen Kim
- Anesthesia and Perioperative Care, UCSF, San Francisco, California, USA
| | - Daniel L Cooke
- Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
| |
Collapse
|
11
|
Raper DMS, Winkler EA, Rutledge WC, Cooke DL, Abla AA. An Update on Medications for Brain Arteriovenous Malformations. Neurosurgery 2021; 87:871-878. [PMID: 32433738 DOI: 10.1093/neuros/nyaa192] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/17/2020] [Indexed: 02/07/2023] Open
Abstract
Despite a variety of treatment options for brain arteriovenous malformations (bAVMs), many lesions remain challenging to treat and present significant ongoing risk for hemorrhage. In Vitro investigations have recently led to a greater understanding of the formation, growth, and rupture of bAVMs. This has, in turn, led to the development of therapeutic targets for medications for bAVMs, some of which have begun testing in clinical trials in humans. These include bevacizumab, targeting the vascular endothelial growth factor driven angiogenic pathway; thalidomide or lenalidomide, targeting blood-brain barrier impairment; and doxycycline, targeting matrix metalloproteinase overexpression. A variety of other medications appear promising but either requires adaptation from other disease states or development from early bench studies into the clinical realm. This review aims to provide an overview of the current state of development of medications targeting bAVMs and to highlight their likely applications in the future.
Collapse
Affiliation(s)
- Daniel M S Raper
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Daniel L Cooke
- Department of Radiology and Biomedical Engineering, University of California, San Francisco, San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| |
Collapse
|
12
|
Giarretta I, Sturiale CL, Gatto I, Pacioni S, Gaetani E, Porfidia A, Puca A, Palucci I, Tondi P, Olivi A, Pallini R, Pola R. Sonic hedgehog is expressed in human brain arteriovenous malformations and induces arteriovenous malformations in vivo. J Cereb Blood Flow Metab 2021; 41:324-335. [PMID: 32169015 PMCID: PMC8369994 DOI: 10.1177/0271678x20912405] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abnormalities in arterial versus venous endothelial cell identity and dysregulation of angiogenesis are deemed important in the pathophysiology of brain arteriovenous malformations (AVMs). The Sonic hedgehog (Shh) pathway is crucial for both angiogenesis and arterial versus venous differentiation of endothelial cells, through its dual role on the vascular endothelial growth factor/Notch signaling and the nuclear orphan receptor COUP-TFII. In this study, we show that Shh, Gli1 (the main transcription factor of the Shh pathway), and COUP-TFII (a target of the non-canonical Shh pathway) are aberrantly expressed in human brain AVMs. We also show that implantation of pellets containing Shh in the cornea of Efnb2/LacZ mice induces growth of distinct arteries and veins, interconnected by complex sets of arteriovenous shunts, without an interposed capillary bed, as seen in AVMs. We also demonstrate that injection in the rat brain of a plasmid containing the human Shh gene induces the growth of tangles of tortuous and dilated vessels, in part positive and in part negative for the arterial marker αSMA, with direct connections between αSMA-positive and -negative vessels. In summary, we show that the Shh pathway is active in human brain AVMs and that Shh-induced angiogenesis has characteristics reminiscent of those seen in AVMs in humans.
Collapse
Affiliation(s)
- Igor Giarretta
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carmelo L Sturiale
- Division of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ilaria Gatto
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simone Pacioni
- Division of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eleonora Gaetani
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Angelo Porfidia
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfredo Puca
- Division of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ivana Palucci
- Istitute of Microbiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Paolo Tondi
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Olivi
- Division of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberto Pallini
- Division of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberto Pola
- Department of Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Division of Cardiovascular Research, St. Elizabeth's Medical Center, Boston, MA, USA
| |
Collapse
|
13
|
Uysal E, Başkurt O, Avcı İ, Peker HO, Çelik SE. Late recovery of stereotactic radiosurgery induced perilesional edema of an arteriovenous malformation after bevacizumab treatment. Br J Neurosurg 2020; 35:22-26. [PMID: 32216590 DOI: 10.1080/02688697.2020.1742294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
MATERIALS AND METHODS We present a 41-year old male patient who was admitted to our clinic with epileptic seizures, headaches and hemiparesis 14 months after SRS treatment for a left fronto-parietal Spetzler-Martin Grade III arteriovenous malformation (AVM). On his first-year follow-up perilesional edema was observed for which the patient received steroid treatment, but the patient did not show any benefit from it. In the cases of steroid resistant perilesional edemas, bevacizumab can be used for reducing symptoms and even radiological perilesional edema as well. RESULTS In our case, we have seen the effect of bevacizumab for symptomatic perilesional edema in a AVM patient after SRS treatment after radiological / neurological recovery. Our patient's headaches decreased rapidly after 2 days after treatment and was able to mobilize himself after 2 months but total resolution of symptoms and radiological findings observed after 1,5 years. CONCLUSIONS The duration and optimum dose of bevacizumab therapy needed to further investigation. Our study showed that bevacizumab was a long-term and effective treatment option for the cases with peritumoral edema resistant to glucocorticoid treatment, where the patient had conditions such as severe headache and neurological deficits.
Collapse
Affiliation(s)
- Ece Uysal
- Department of Neurological Surgery, Okmeydani Research and Educational Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ozan Başkurt
- Department of Neurological Surgery, Okmeydani Research and Educational Hospital, University of Health Sciences, Istanbul, Turkey
| | - İdris Avcı
- Department of Neurological Surgery, Okmeydani Research and Educational Hospital, University of Health Sciences, Istanbul, Turkey
| | - Halil Olgun Peker
- Department of Neurological Surgery, Okmeydani Research and Educational Hospital, University of Health Sciences, Istanbul, Turkey
| | - Suat Erol Çelik
- Department of Neurological Surgery, Okmeydani Research and Educational Hospital, University of Health Sciences, Istanbul, Turkey
| |
Collapse
|
14
|
Hong CS, Cord BJ, Kundishora AJ, Elsamadicy AA, Beckta JM, Huttner A, Chiang VL, Matouk CC. MRI-Guided Laser Interstitial Thermal Therapy for Radiation Necrosis in Previously Irradiated Brain Arteriovenous Malformations. Pract Radiat Oncol 2020; 10:e298-e303. [PMID: 32068154 DOI: 10.1016/j.prro.2020.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/30/2020] [Accepted: 02/02/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Christopher S Hong
- Departments of Neurosurgery, Yale School of Medicine, New Haven, Connecticut.
| | - Branden J Cord
- Departments of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Adam J Kundishora
- Departments of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | | | - Jason M Beckta
- Departments of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Anita Huttner
- Departments of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Veronica L Chiang
- Departments of Neurosurgery, Yale School of Medicine, New Haven, Connecticut; Departments of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Charles C Matouk
- Departments of Neurosurgery, Yale School of Medicine, New Haven, Connecticut; Departments of Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
15
|
Kong L, Gao J, Hu J, Lu R, Yang J, Qiu X, Hu W, Lu JJ. Carbon ion radiotherapy boost in the treatment of glioblastoma: a randomized phase I/III clinical trial. Cancer Commun (Lond) 2019; 39:5. [PMID: 30786916 PMCID: PMC6383247 DOI: 10.1186/s40880-019-0351-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/14/2019] [Indexed: 12/22/2022] Open
Abstract
Background Glioblastoma (GBM) is a highly virulent tumor of the central nervous system, with a median survival < 15 months. Clearly, an improvement in treatment outcomes is needed. However, the emergence of these malignancies within the delicate brain parenchyma and their infiltrative growth pattern severely limit the use of aggressive local therapies. The particle therapy represents a new promising therapeutic approach to circumvent these prohibitive conditions with improved treatment efficacy. Methods and design Patients with newly diagnosed malignant gliomas will have their tumor tissue samples submitted for the analysis of the status of O-6-methylguanine-DNA methyltransferase (MGMT) promoter methylation. In Phase I, the patients will undergo an induction carbon ion radiotherapy (CIRT) boost followed by 60 GyE of proton irradiation with concurrent temozolomide (TMZ) at 75 mg/m2. To determine the maximal dose of safe induction boost, the tolerance, and acute toxicity rates in a dose-escalation manner from 9 to 18 GyE in three fractions will be used. In Phase III, GBM-only patients will be randomized to receive either 60 GyE (2 GyE per fraction) of proton irradiation with concurrent TMZ (control arm) or a CIRT boost (dose determined in Phase I of this trial) followed by 60 GyE of proton irradiation with concurrent TMZ. The primary endpoints are overall survival (OS) and toxicity rates (acute and long-term). Secondary endpoints are progression-free survival (PFS), and tumor response (based upon assessment with C-methionine/fluoro-ethyl-tyrosine positron emission tomography [MET/FET PET] or magnetic resonance imaging [MRI] and detection of serologic immune markers). We hypothesize that the induction CIRT boost will result in a greater initial tumor-killing ability and prime the tumor microenvironment for enhanced immunologic tumor clearance, resulting in an expected 33% improvement in OS rates. Discussion The prognosis of GBM remains grim. The mechanism underpinning the poor prognosis of this malignancy is its chronic state of tumor hypoxia, which promotes both immunosuppression/immunologic evasion and radio-resistance. The unique physical and biological properties of CIRT are expected to overcome these microenvironmental limitations to confer an improved tumor-killing ability and anti-tumor immune response, which could result in an improvement in OS with minimal toxicity. Trial registration number This trial has been registered with the China Clinical Trials Registry, and was allocated the number ChiCTR-OID-17013702.
Collapse
Affiliation(s)
- Lin Kong
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Fudan University Shanghai Cancer Center, Shanghai, 201321, P. R. China
| | - Jing Gao
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Pudong, 4365 Kangxin Road, Shanghai, 201321, P. R. China
| | - Jiyi Hu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Pudong, 4365 Kangxin Road, Shanghai, 201321, P. R. China
| | - Rong Lu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Pudong, 4365 Kangxin Road, Shanghai, 201321, P. R. China
| | - Jing Yang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Pudong, 4365 Kangxin Road, Shanghai, 201321, P. R. China
| | - Xianxin Qiu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Pudong, 4365 Kangxin Road, Shanghai, 201321, P. R. China
| | - Weixu Hu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Pudong, 4365 Kangxin Road, Shanghai, 201321, P. R. China
| | - Jiade J Lu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, Pudong, 4365 Kangxin Road, Shanghai, 201321, P. R. China.
| |
Collapse
|
16
|
Xiangying M, Rugang Z, Lijuan D, Yaowei Z, Bing S, Junliang W, Dan L, Shikai W. Low-dose bevacizumab as an effective pre-treatment for peri-tumoral brain edema prior to CyberKnife radiosurgery: A case report. Cancer Biol Ther 2018; 19:461-464. [PMID: 29420112 DOI: 10.1080/15384047.2018.1433499] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
A 75-y-old Chinese female patient diagnosed with lung adenocarcinoma with brain metastasis suffered severe nausea and vomiting, and these symptoms were contraindications for CyberKnife treatment. Neither mannitol, nor dexamethasone, relieved the symptoms. However, after the patient received a single dose of bevacizumab (200 mg, 2.9 mg/kg), the patient's symptoms were significantly relieved. The patient subsequently completed a successful CyberKnife treatment. In addition, the patient received an oral treatment of gefitinib. At 15 months post treatment, the patient's brain tumor was controlled. Thus, administration of bevacizumab at a low dose (2.9 mg/kg) may significantly alleviate peri-tumoral brain edema and its symptoms, thereby facilitating radiosurgery treatment.
Collapse
Affiliation(s)
- Meng Xiangying
- a Radiotherapy Department , 307 Hospital of PLA , #8 Dongda Street, Fengtai District , Beijing , China
| | - Zhao Rugang
- b Radiotherapy Department , Navy General Hospital , Beijing , China
| | - Ding Lijuan
- a Radiotherapy Department , 307 Hospital of PLA , #8 Dongda Street, Fengtai District , Beijing , China
| | - Zhao Yaowei
- a Radiotherapy Department , 307 Hospital of PLA , #8 Dongda Street, Fengtai District , Beijing , China
| | - Sun Bing
- a Radiotherapy Department , 307 Hospital of PLA , #8 Dongda Street, Fengtai District , Beijing , China
| | - Wang Junliang
- a Radiotherapy Department , 307 Hospital of PLA , #8 Dongda Street, Fengtai District , Beijing , China
| | - Li Dan
- a Radiotherapy Department , 307 Hospital of PLA , #8 Dongda Street, Fengtai District , Beijing , China
| | - Wu Shikai
- c Radiotherapy Department , 307 Hospital of PLA , Beijing , China
| |
Collapse
|
17
|
Meng X, Zhao R, Shen G, Dong D, Ding L, Wu S. Efficacy and safety of bevacizumab treatment for refractory brain edema: Case report. Medicine (Baltimore) 2017; 96:e8280. [PMID: 29095257 PMCID: PMC5682776 DOI: 10.1097/md.0000000000008280] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE This retrospective study investigated the efficacy and safety of bevacizumab treatment for refractory brain edema. METHODS Between March 2009 and December 2015, bevacizumab was used to treat 59 cases of brain metastatic patients with refractory brain edema. The median dose of bevacizumab was 4.68 mg/kg (range 2.8-6.52 mg/kg). The clinical-pathological data, the efficacy, and the side effects of bevacizumab were recorded. Magnetic resonance imaging (MRI) was performed before and after bevacizumab treatment. Tumor and edema volumes were measured separately. RESULTS The clinical symptoms of 50 out of 59 cases (84.74%) improved the day after the bevacizumab treatment, and the edema volumes of 55 (93.22%) cases were reduced after the bevacizumab treatment. The average edema volume was significantly reduced after bevacizumab treatment from 125,583.43 ± 14,093.27 to 71,613.42 ± 9473.42 mm (Mann-Whitney rank test, P < .01), and the average edema index was significantly reduced from 25.66 ± 11.54 to 17.87 ± 6.87 (Mann-Whitney rank test, P < .01). One patient died from a hemorrhage due to a cancerous-ulcer of the maxillary sinus. The main complication observed was hypertension, which was observed in 11 cases (18.6%). CONCLUSION The effective rate of bevacizumab for refractory brain edema is 84.74%. Hypertension was the main side effect of the bevacizumab treatment. Bevacizumab is an effective and relatively safe treatment for brain edema.
Collapse
Affiliation(s)
- Xiangying Meng
- Radiotherapy Department, Affiliated Hospital of Academy of Military Medical Sciences
| | - Rugang Zhao
- Radiotherapy Department, Navy General Hospital
| | - Ge Shen
- Radiotherapy Department, Affiliated Hospital of Academy of Military Medical Sciences
| | - Dapeng Dong
- Radiotherapy Department, Affiliated Hospital of Academy of Military Medical Sciences
| | - Lijuan Ding
- Radiotherapy Department, Affiliated Hospital of Academy of Military Medical Sciences
| | - Shikai Wu
- Radiotherapy Department, Affiliated Hospital of Academy of Military Medical Sciences, Beijing, China
| |
Collapse
|
18
|
Derdeyn CP, Zipfel GJ, Albuquerque FC, Cooke DL, Feldmann E, Sheehan JP, Torner JC. Management of Brain Arteriovenous Malformations: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2017. [DOI: 10.1161/str.0000000000000134] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
19
|
Harat M, Lebioda A, Lasota J, Makarewicz R. Evaluation of Brain Edema Formation Defined By MRI After LINAC-based Stereotactic Radiosurgery. Radiol Oncol 2017; 51:137-141. [PMID: 28740448 PMCID: PMC5514653 DOI: 10.1515/raon-2017-0018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 03/02/2017] [Indexed: 11/15/2022] Open
Abstract
Background Peri-lesional edema is a serious and well-known complication of stereotactic radiosurgery (SRS). Here we evaluated edema risk after SRS and assessed its formation and resolution dynamics. Patients and methods 107 patients underwent SRS for heterogeneous diagnoses: 34 (29%) with arteriovenous malformations, 38 (35%) with meningiomas, 16 (15%) with metastatic tumors, 16 (15%) with acoustic neuromas, 3 with (3%) cavernomas, and 2 (2%) each with anaplastic astrocytomas and anaplastic oligoastrocytomas. Edema area was delineated in MRI T2-FLAIR sequences 0, 6, 12, 18, 24, 30, and 38 months after treatment. Lesion location was defined as either above (n = 80) or below (n = 32) the “Frankfurt modified line” (FML). Results 17% of patients developed or had worsening post-treatment edema. Edema volume was maximal at 6 months (mean 7.2, SD 1.2) post radiosurgery. Post-SRS edema was 5.1 (1.06 – 24.53) times more likely in patients with lesions above the FML. There was no association between edema development and age, PTV size, number of beams, and diagnosis (p = 0.07). Conclusions Radiosurgery-associated edema develops within 6 months of treatment and decreases over time. Edema occurrence is strongly related to lesion location, and its presence is much more likely when the treated lesions are situated above the Frankfurt line.
Collapse
Affiliation(s)
- Maciej Harat
- Department of Radiotherapy, The Franciszek Lukaszczyk Oncology Center, Bydgoszcz, Poland
| | - Andrzej Lebioda
- Department of Oncology and Brachytherapy, Nicolaus Copernicus University, Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland.,Department of Oncology and Brachytherapy, The Franciszek Lukaszczyk Oncology Center, Bydgoszcz, Poland
| | - Judyta Lasota
- Department of Medical Physics, The Franciszek Lukaszczyk Oncology Centre, Bydgoszcz, Poland
| | - Roman Makarewicz
- Department of Oncology and Brachytherapy, Nicolaus Copernicus University, Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland.,Department of Oncology and Brachytherapy, The Franciszek Lukaszczyk Oncology Center, Bydgoszcz, Poland
| |
Collapse
|
20
|
Turner RC, Lucke-Wold BP, Josiah D, Gonzalez J, Schmidt M, Tarabishy AR, Bhatia S. Stereotactic radiosurgery planning based on time-resolved CTA for arteriovenous malformation: a case report and review of the literature. Acta Neurochir (Wien) 2016; 158:1555-62. [PMID: 27334738 PMCID: PMC4944162 DOI: 10.1007/s00701-016-2874-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 06/02/2016] [Indexed: 02/05/2023]
Abstract
Stereotactic radiosurgery has long been recognized as the optimal form of management for high-grade arteriovenous malformations not amenable to surgical resection. Radiosurgical plans have generally relied upon the integration of stereotactic magnetic resonance angiography (MRA), standard contrast-enhanced magnetic resonance imaging (MRI), or computed tomography angiography (CTA) with biplane digital subtraction angiography (DSA). Current options are disadvantageous in that catheter-based biplane DSA is an invasive test associated with a small risk of complications and perhaps more importantly, the two-dimensional nature of DSA is an inherent limitation in creating radiosurgical contours. The necessity of multiple scans to create DSA contours for radiosurgical planning puts patients at increased risk. Furthermore, the inability to import two-dimensional plans into some radiosurgery programs, such as Cyberknife TPS, limits treatment options for patients. Defining the nidus itself is sometimes difficult in any of the traditional modalities as all draining veins and feeding arteries are included in the images. This sometimes necessitates targeting a larger volume, than strictly necessary, with stereotactic radiosurgery for treatment of the AVM. In this case report, we show the ability to use a less-invasive and three-dimensional form of angiography based on time-lapsed CTA (4D-CTA) rather than traditional DSA for radiosurgical planning. 4D-CTA may allow generation of a series of images, which can show the flow of contrast through the AVM. A review of these series may allow the surgeon to pick and use a volume set that best outlines the nidus with least interference from feeding arteries or draining veins. In addition, 4D-CTA scans can be uploaded into radiosurgery programs and allow three-dimensional targeting. This is the first reported case demonstrating the use of a 4D CTA and an MRI to delineate the AVM nidus for Gamma Knife radiosurgery, with complete obliteration of the nidus over time and subsequent management of associated radiation necrosis with bevacizumab.
Collapse
Affiliation(s)
- Ryan C Turner
- Department of Neurosurgery, West Virginia University School of Medicine, One Medical Center Drive, Suite 9183, Morgantown, WV, 26506, USA
- Center for Neuroscience, West Virginia University School of Medicine, Morgantown, WV, 26506, USA
| | - Brandon P Lucke-Wold
- Department of Neurosurgery, West Virginia University School of Medicine, One Medical Center Drive, Suite 9183, Morgantown, WV, 26506, USA
- Center for Neuroscience, West Virginia University School of Medicine, Morgantown, WV, 26506, USA
| | - Darnell Josiah
- Department of Neurosurgery, West Virginia University School of Medicine, One Medical Center Drive, Suite 9183, Morgantown, WV, 26506, USA
- Center for Neuroscience, West Virginia University School of Medicine, Morgantown, WV, 26506, USA
| | - Javier Gonzalez
- Department of Neurology, West Virginia University School of Medicine, Morgantown, WV, 26506, USA
| | - Matthew Schmidt
- Department of Radiology, West Virginia University School of Medicine, Morgantown, WV, 26506, USA
| | - Abdul Rahman Tarabishy
- Department of Radiology, West Virginia University School of Medicine, Morgantown, WV, 26506, USA
| | - Sanjay Bhatia
- Department of Neurosurgery, West Virginia University School of Medicine, One Medical Center Drive, Suite 9183, Morgantown, WV, 26506, USA.
- Center for Neuroscience, West Virginia University School of Medicine, Morgantown, WV, 26506, USA.
| |
Collapse
|
21
|
Le Rhun E, Dhermain F, Vogin G, Reyns N, Metellus P. Radionecrosis after stereotactic radiotherapy for brain metastases. Expert Rev Neurother 2016; 16:903-14. [DOI: 10.1080/14737175.2016.1184572] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
22
|
Shen G, Wang YJ, Guan YJ, Dong DP, Yang G, Li D, Hao RM, Sun HR, Zhou M, Wang KP, Zhou SX, Wang QW, Wu SK, Zeng YJ. Relief Effect of Bevacizumab on Severe Edema Induced by Re-irradiation in Brain Tumor Patients. Chin Med J (Engl) 2016; 128:2126-9. [PMID: 26228232 PMCID: PMC4717957 DOI: 10.4103/0366-6999.161403] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Ge Shen
- Department of Radiation Oncology, Affiliated Hospital of Academy of Military Medical Sciences, Beijing 100071, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Yomo S, Hayashi M. Salvage stereotactic radiosurgery with adjuvant use of bevacizumab for heavily treated recurrent brain metastases: a preliminary report. J Neurooncol 2015; 127:119-26. [DOI: 10.1007/s11060-015-2019-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 11/25/2015] [Indexed: 10/22/2022]
|
24
|
Sheehan JP, Cohen-Inbar O, Ruangkanchanasetr R, Bulent Omay S, Hess J, Chiang V, Iorio-Morin C, Alonso-Basanta M, Mathieu D, Grills IS, Lee JYK, Lee CC, Dade Lunsford L. Post-radiosurgical edema associated with parasagittal and parafalcine meningiomas: a multicenter study. J Neurooncol 2015; 125:317-24. [PMID: 26329323 DOI: 10.1007/s11060-015-1911-1] [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: 04/24/2015] [Accepted: 08/29/2015] [Indexed: 11/29/2022]
Abstract
Stereotactic radiosurgery (SRS) offers a high degree of tumor control for benign meningiomas. However, radiosurgery can occasionally incite edema or exacerbate pre-existing peri-tumoral edema. The current study investigates the incidence, timing, and extent of edema around parasagittal or parafalcine meningiomas following SRS. A retrospective multicenter review was undertaken through participating centers in the International Gamma Knife Research Foundation (previously the North American Gamma Knife Consortium or NAGKC). All included patients had a parafalcine or parasagittal meningioma and a minimum of 6 months follow up. The median follow up was 19.6 months (6-158 months). Extent of new or worsening edema was quantitatively analyzed using volumetric analysis; edema indices were longitudinally computed following radiosurgery. Analysis was performed to identify prognostic factors for new or worsening edema. A cohort of 212 patients comprised of 51.9 % (n = 110) females, 40.1 % upfront SRS and 59.9 % underwent adjuvant SRS for post-surgical residual tumor. The median tumor volume at SRS was 5.2 ml. Venous sinus compression or invasion was demonstrated in 25 % (n = 53). The median marginal dose was 14 Gy (8-20 Gy). Tumor volume control was determined in 77.4 % (n = 164 out of 212 patients). Tumor edema progressed and then regressed in 33 % (n = 70), was stable or regressed in 52.8 % (n = 112), and progressively worsened in 5.2 % (n = 11). Tumor location, tumor volume, venous sinus invasion, margin, and maximal dose were found to be significantly related to post-SRS edema in multivariate analysis. SRS affords a high degree of tumor control for patients with parasagittal or parafalcine meningiomas. Nevertheless, SRS can lead to worsening peritumoral edema in a subset of patients such as those with larger tumors (>10 cc) and venous sinus invasion/compression. Long-term follow up is required to detect and appropriately manage post-SRS edema.
Collapse
Affiliation(s)
- Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA.
| | - Or Cohen-Inbar
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA
| | | | | | | | | | | | | | - David Mathieu
- Université de Sherbrooke and Centre de recherche du CHUS, Sherbrooke, Canada
| | | | | | - Cheng-Chia Lee
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, 22908, USA
| | | |
Collapse
|
25
|
Park JC, Ahn JS, Kwon DH, Kwun BD. Growing Organized Hematomas Following Gamma Knife Radiosurgery for Cerebral Arteriovenous Malformation : Five Cases of Surgical Excision. J Korean Neurosurg Soc 2015; 58:83-8. [PMID: 26279820 PMCID: PMC4534746 DOI: 10.3340/jkns.2015.58.1.83] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 06/27/2014] [Accepted: 06/29/2014] [Indexed: 12/02/2022] Open
Abstract
Organized hematoma is a rare complication that can develop following gamma knife radiosurgery (GKS) for cerebral arteriovenous malformation (AVM). Here, we describe 5 patients with growing organized hematomas that developed from completely obliterated AVMs several years after GKS. The patients were 15, 16, 30, 36, and 38 years old at the time of GKS, respectively, and 3 patients were female. Four AVMs were located in the lobe of the brain, and the remaining AVM were in the thalamus. Between 2-12 years after GKS, patients developed progressive symptoms such intractable headache or hemiparesis and enhancing mass lesions were identified. Follow-up visits revealed the slow expansion of the hematomas and surrounding edema. Steroids were ineffective, and thus surgery was performed. Histology revealed organized hematomas with a capsule, but there was no evidence of residual AVMs or vascular malformation. After surgery, the neurological symptoms of all patients improved and the surrounding edema resolved. However, the hematoma continued to expand and intraventricular hemorrhage developed in 1 patient whose hematoma was only partially removed. GKS for cerebral AVM can be complicated by growing, organized hematomas that develop after complete obliteration. Growing hematomas should be surgically evacuated if they are symptomatic. Radical resection of the hematoma capsule is also strongly recommended.
Collapse
Affiliation(s)
- Jung Cheol Park
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Sung Ahn
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Do Hoon Kwon
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Byung Duk Kwun
- Department of Neurosurgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| |
Collapse
|
26
|
Sheehan JP, Lee CC, Xu Z, Przybylowski CJ, Melmer PD, Schlesinger D. Edema following Gamma Knife radiosurgery for parasagittal and parafalcine meningiomas. J Neurosurg 2015; 123:1287-93. [PMID: 26115473 DOI: 10.3171/2014.12.jns142159] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Stereotactic radiosurgery (SRS) has been shown to offer a high probability of tumor control for Grade I meningiomas. However, SRS can sometimes incite edema or exacerbate preexisting edema around the targeted meningioma. The current study evaluates the incidence, timing, and degree of edema around parasagittal or parafalcine meningiomas following SRS. METHODS A retrospective review was undertaken of a prospectively maintained database of patients treated with Gamma Knife radiosurgery at the University of Virginia Health System. All patients with WHO Grade I parafalcine or parasagittal meningiomas with at least 6 months of clinical follow-up were identified, resulting in 61 patients included in the study. The median radiographic follow-up was 28 months (range 6-158 months). Rates of new or worsening edema were quantitatively assessed using volumetric analysis; edema indices were computed as a function of time following radiosurgery. Statistical methods were used to identify favorable and unfavorable prognostic factors for new or worsening edema. RESULTS Progression-free survival at 2 and 5 years was 98% and 90%, respectively, according to Kaplan-Meier analysis. After SRS, new peritumoral edema occurred or preexisting edema worsened in 40% of treated meningiomas. The median time to onset of peak edema was 36 months post-SRS. Persistent and progressive edema was associated with 11 tumors, and resection was undertaken for these lesions. However, 20 patients showed initial edema progression followed by regression at a median of 18 months after radiosurgery (range 6-24 months). Initial tumor volume greater than 10 cm3, absence of prior resection, and higher margin dose were significantly (p<0.05) associated with increased risk of new or progressive edema after SRS. CONCLUSIONS Stereotactic radiosurgery offers a high rate of tumor control in patients with parasagittal or parafalcine meningiomas. However, it can lead to worsening peritumoral edema in a minority of patients. Following radiosurgery, transient edema occurs earlier than persistent and progressive edema. Longitudinal follow-up of meningioma patients after SRS is required to detect and appropriately treat transient as well as progressive edema.
Collapse
Affiliation(s)
- Jason P Sheehan
- Departments of 1 Neurological Surgery and.,Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
| | | | - Zhiyuan Xu
- Departments of 1 Neurological Surgery and
| | | | | | - David Schlesinger
- Departments of 1 Neurological Surgery and.,Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
| |
Collapse
|
27
|
Affiliation(s)
- Jason Sheehan
- Departments of 1 Neurological Surgery and.,Radiation Oncology, University of Virginia, Charlottesville, Virginia
| | - Dale Ding
- Departments of 1 Neurological Surgery and
| | | |
Collapse
|
28
|
Inhibition of pathological brain angiogenesis through systemic delivery of AAV vector expressing soluble FLT1. Gene Ther 2015; 22:893-900. [PMID: 26090874 PMCID: PMC4636448 DOI: 10.1038/gt.2015.57] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 05/27/2015] [Accepted: 06/05/2015] [Indexed: 12/21/2022]
Abstract
The soluble vascular endothelial growth factor (VEGF) receptor 1 (sFLT1) has been tested in both animals and humans for anti-angiogenic therapies, e.g., age-related macular degeneration. We hypothesized that adeno-associated viral vector (AAV)-mediated sFLT1 expression could be used to inhibit abnormal brain angiogenesis. We tested the anti-angiogenic effect of sFLT1 and the feasibility of using AAV serotype 9 to deliver sFLT1 through intravenous injection (IV) to the brain angiogenic region. AAV vectors were packaged in AAV serotypes 1 and 2 (stereotactic injection) and 9 (IV-injection). Brain angiogenesis was induced in adult mice through stereotactic injection of AAV1-VEGF. AAV2-sFLT02 containing sFLT1 VEGF-binding domain (domain 2) was injected into the brain angiogenic region, and AAV9-sFLT1 was injected into the jugular vein at the time of or 4 weeks after AAV1-VEGF injection. We showed that AAV2-sFLT02 inhibited brain angiogenesis at both time points. Intravenous injection of AAV9-sFLT1 inhibited angiogenesis only when the vector was injected 4 weeks after angiogenic induction. Neither lymphocyte infiltration nor neuron loss was observed in AAV9-sFLT1-treated mice. Our data show that systemically delivered AAV9-sFLT1 inhibits angiogenesis in the mouse brain, which could be utilized to treat brain angiogenic diseases such as brain arteriovenous malformation.
Collapse
|
29
|
Chemotherapy alleviates subacute recurrent glioma-associated refractory cerebral edema by downregulating vascular endothelial growth factor. Med Oncol 2014; 31:13. [PMID: 24861916 DOI: 10.1007/s12032-014-0013-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 04/28/2014] [Indexed: 10/25/2022]
Abstract
To identify a novel treatment modality for postoperative, glioma-related refractory cerebral edema (RCE), eight patients with postoperative RCE received chemotherapy between January 2008 and July 2012 were enrolled. There were five males and three females aged between 24 and 65 years (mean 45.7 years). Vascular endothelial growth factor (VEGF) levels in the cerebrospinal fluid were measured by enzyme-linked immuno-sorbent assay pre- and postchemotherapy. After 3 days postchemotherapy, midline shift improved from 13.14 ± 0.65 to 7.21 ± 0.55 mm and compressed or effaced basilar cisterns disappeared based on cranial computed tomographic scans. Glascow Coma Scale scores in patients significantly improved from 11.13 ± 0.52 to 14.50 ± 0.27 after chemotherapy. Two patients developed grade 1 leukopenia after 3 weeks, and one patient had grade 1 thrombocytopenia 2 weeks after chemotherapy. No fatal complications occurred. The edematous volume reduced from 77,074 ± 6,813 to 27,874 ± 5,073 mm(3) (p < 0.001). VEGF levels were significantly downregulated after chemotherapy (from 543.8 ± 76.39 to 122.2 ± 59.30 pg/ml, p < 0.001). Chemotherapy may serve to alleviate glioma-related RCE by reducing VEGF levels, especially in patients who were insensitive to decompressive craniectomy.
Collapse
|
30
|
Boikov AS, Schweitzer AD, Young RJ, Lavi E, Tsiouris AJ, Gupta A. Glioblastoma-arteriovenous fistula complex: imaging characteristics and treatment considerations. Clin Imaging 2014; 38:187-90. [DOI: 10.1016/j.clinimag.2013.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 11/15/2013] [Accepted: 11/25/2013] [Indexed: 10/26/2022]
|
31
|
Rubin BA, Brunswick A, Riina H, Kondziolka D. Advances in Radiosurgery for Arteriovenous Malformations of the Brain. Neurosurgery 2014; 74 Suppl 1:S50-9. [DOI: 10.1227/neu.0000000000000219] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Arteriovenous malformations of the brain are a considerable source of morbidity and mortality for patients who harbor them. Although our understanding of this disease has improved, it remains in evolution. Advances in our ability to treat these malformations and the modes by which we address them have also improved substantially. However, the variety of patient clinical and disease scenarios often leads us into challenging and complex management algorithms as we balance the risks of treatment against the natural history of the disease. The goal of this article is to provide a focused review of the natural history of cerebral arteriovenous malformations, to examine the role of stereotactic radiosurgery, to discuss the role of endovascular therapy as it relates to stereotactic radiosurgery, and to look toward future advances.
Collapse
|
32
|
Bevacizumab for refractory adverse radiation effects after stereotactic radiosurgery. J Neurooncol 2013; 115:217-23. [DOI: 10.1007/s11060-013-1214-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 07/28/2013] [Indexed: 11/26/2022]
|
33
|
Preuss M, Hirsch W, Hoffmann KT, Bernhard MK, Siekmeyer M, Kiess W, Meixensberger J, Wurm RE, Merkenschlager A. Effectiveness of bevacizumab for radiation-induced cerebral necrosis in children. Pediatr Neurosurg 2013; 49:81-5. [PMID: 24435068 DOI: 10.1159/000357447] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 11/15/2013] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Bevacizumab has been reported to effectively reduce cerebral edema caused by radiation therapy. However, only limited data with a short follow-up in tumor patients are available so far. PATIENTS AND METHODS Two children suffering from hemorrhage from arteriovenous malformation (AVM) have been treated with stereotactic radiotherapy and developed radiation-induced cerebral edema with deteriorating neurological status despite maximized steroid therapy. Bevacizumab administration at 5 mg/kg body weight was initiated every 2 weeks. RESULTS Bevacizumab treatment rapidly ameliorated the neurological deficits, malignant edema and prevented catastrophic complications. Corticoid therapy could be reduced and discontinued. However, after 18 months, both patients showed identical or worse neurological status than before bevacizumab therapy. AVM radiation therapy had been successful to completely obliterate AVMs. DISCUSSION In our limited experience, bevacizumab may be an effective and safe option for rescue therapy for malignant cerebral edema on the basis of radiation-induced necrosis especially in patients who experience rapid deterioration despite corticoid therapy and/or intolerable steroid side effects. Despite the fact that functional improvement could not be achieved in long-term outcome patients significantly stabilized and improved during periods of acute deterioration. In order to determine the long-term effectiveness of bevacizumab further investigation in placebo-controlled studies with a higher number of patients are required.
Collapse
Affiliation(s)
- M Preuss
- Department of Neurosurgery, University Hospital Leipzig, Leipzig, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Walker EJ, Su H, Shen F, Degos V, Amend G, Jun K, Young WL. Bevacizumab attenuates VEGF-induced angiogenesis and vascular malformations in the adult mouse brain. Stroke 2012; 43:1925-30. [PMID: 22569934 DOI: 10.1161/strokeaha.111.647982] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Vascular endothelial growth factor (VEGF) expression is elevated in human brain arteriovenous malformations (bAVM). We have developed a bAVM model in the adult mouse by focal Alk1 gene deletion and human VEGF stimulation. We hypothesized that once the abnormal vasculature has been established, tonic VEGF stimulation is necessary to maintain the abnormal phenotype, and VEGF antagonism by bevacizumab (Avastin) would reduce vessel density and attenuate the dysplastic vascular phenotype. METHODS Angiogenesis and bAVM were induced by injection of adeno-associated viral vector expressing human VEGF alone into the brain of wild-type mice or with adenoviral vector expressing Cre recombinase (Ad-Cre) into Alk1(2f/2f) mice. Six weeks later, bevacizumab or trastuzumab (Herceptin, bevacizumab control) was administered. Vessel density, dysplasia index, vascular cell proliferation and apoptosis, and human IgG were assessed (n=6/group). RESULTS Compared with trastuzumab (15 mg/kg), administration of 5, 10, and 15 mg/kg of bevacizumab to adeno-associated viral vector expressing human VEGF treated wild-type mice reduced focal vessel density (P<0.05); administration of 5 mg/kg bevacizumab decreased proliferating vascular cells (P=0.04) and increased TUNEL-positive vascular cells (P=0.03). More importantly, bevacizumab (5 mg/kg) treatment reduced both vessel density (P=0.01) and dysplasia index (P=0.02) in our bAVM model. Human IgG was detected in the vessel wall and in the parenchyma in the angiogenic foci of bevacizumab-treated mice. CONCLUSIONS We provide proof-of-principle that, once abnormal AVM vessels have formed, VEGF antagonism may reduce the number of dysplastic vessels and should be evaluated further as a therapeutic strategy for the human disease.
Collapse
Affiliation(s)
- Espen J Walker
- Center for Cerebrovascular Research, University of California, San Francisco, Department of Anesthesia and Perioperative Care, 1001 Potrero Avenue, Room 3C-38, San Francisco, CA 94110, USA
| | | | | | | | | | | | | |
Collapse
|