1
|
Ming X, Qiuyue W, Yujun L, Guanghai M, Xiancheng C, Hongzhi X. Risk factors of seizure presentation in brain arteriovenous malformation patients and seizure outcomes after single-modality treatments. Int J Neurosci 2023; 133:356-364. [PMID: 33896340 DOI: 10.1080/00207454.2021.1921765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Epileptic seizures are common symptoms in brain arteriovenous malformation patients and seizure control was an important issue in the treatments. This retrospective study attempted to define the risk factors of seizure presentation and to evaluate the effects of treatment modalities on seizure outcomes. METHODS Patients receiving single treatment modality during 2013-2016 years, followed up more than 2 years were recruited. Logistic regression analysis was used to detect independent predictors. The factors associated with seizure control were analyzed in patients with pre-treatment seizures, and the factors associated with de novo seizures were analyzed in patents without pre-treatment seizures. RESULTS Multivariate analysis identified that the independent predictors of seizure presentation were unruptured (ruptured vs. unruptured, OR = 0.314), and in the frontal (frontal vs. parietal, OR = 3.982) or temporal lobe (temporal vs parietal, OR = 3.313). In 47 patients with seizure presentation, good seizure outcomes were achieved in 26 cases. Partial obliteration of nidus (partial vs complete, OR = 32.301) and headache presentation were independent predictors of poor outcome. In 169 patients without seizure presentation, de novo seizures occurred in 22 cases. Treatments of microsurgery or radiosurgery led to a higher incidence of de novo seizures than intravascular embolization. CONCLUSIONS Patients with unruptured and frontal/temporal lobe located nidus were more likely to manifest seizure presentation. Incomplete nidus obliteration was an independent risk factor of poor outcomes in patients with pre-existing seizures. However, compared to microsurgery or radiosurgery, endovascular embolization was less likely to cause de novo seizures in patients without pre-existing seizures.
Collapse
Affiliation(s)
- Xu Ming
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Wu Qiuyue
- Department of Nursing, Huashan Hospital, Fudan University, Shanghai, China
| | - Liao Yujun
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Mei Guanghai
- Department of Neurosurgery, Cyberknife Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Chen Xiancheng
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Xu Hongzhi
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
2
|
Sen RD, Nistal D, McGrath M, Barros G, Shenoy VS, Sekhar LN, Levitt MR, Kim LJ. De novo epilepsy after microsurgical resection of brain arteriovenous malformations. Neurosurg Focus 2022; 53:E6. [DOI: 10.3171/2022.4.focus2288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/12/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Seizures are the second most common presenting symptom of brain arteriovenous malformations (bAVMs) after hemorrhage. Risk factors for preoperative seizures and subsequent seizure control outcomes have been well studied. There is a paucity of literature on postoperative, de novo seizures in initially seizure-naïve patients who undergo resection. Whereas this entity has been documented after craniotomy for a wide variety of neurosurgically treated pathologies including tumors, trauma, and aneurysms, de novo seizures after bAVM resection are poorly studied. Given the debilitating nature of epilepsy, the purpose of this study was to elucidate the incidence and risk factors associated with de novo epilepsy after bAVM resection.
METHODS
A retrospective review of patients who underwent resection of a bAVM over a 15-year period was performed. Patients who did not present with seizure were included, and the primary outcome was de novo epilepsy (i.e., a seizure disorder that only manifested after surgery). Demographic, clinical, and radiographic characteristics were compared between patients with and without postoperative epilepsy. Subgroup analysis was conducted on the ruptured bAVMs.
RESULTS
From a cohort of 198 patients who underwent resection of a bAVM during the study period, 111 supratentorial ruptured and unruptured bAVMs that did not present with seizure were included. Twenty-one patients (19%) developed de novo epilepsy. One-year cumulative rates of developing de novo epilepsy were 9% for the overall cohort and 8.5% for the cohort with ruptured bAVMs. There were no significant differences between the epilepsy and no-epilepsy groups overall; however, the de novo epilepsy group was younger in the cohort with ruptured bAVMs (28.7 ± 11.7 vs 35.1 ± 19.9 years; p = 0.04). The mean time between resection and first seizure was 26.0 ± 40.4 months, with the longest time being 14 years. Subgroup analysis of the ruptured and endovascular embolization cohorts did not reveal any significant differences. Of the patients who developed poorly controlled epilepsy (defined as Engel class III–IV), all had a history of hemorrhage and half had bAVMs located in the temporal lobe.
CONCLUSIONS
De novo epilepsy after bAVM resection occurs at an annual cumulative risk of 9%, with potentially long-term onset. Younger age may be a risk factor in patients who present with rupture. The development of poorly controlled epilepsy may be associated with temporal lobe location and a delay between hemorrhage and resection.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Michael R. Levitt
- Departments of Neurological Surgery,
- Radiology, and
- Mechanical Engineering; and
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington
| | - Louis J. Kim
- Departments of Neurological Surgery,
- Radiology, and
- Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington
| |
Collapse
|
3
|
Khumtong R, Katawatee K, Amornpojnimman T, Riabroi K, Sungkaro K, Korathanakhun P. Predictors of seizure control in patients with cerebral arteriovenous malformation. Epilepsy Behav 2022; 128:108575. [PMID: 35123239 DOI: 10.1016/j.yebeh.2022.108575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE We aimed to define the predictors of a 2-year seizure-free outcome among patients with cerebral arteriovenous malformation (AVM). METHODS A retrospective cohort study recruited patients diagnosed with AVM admitted in the hospital between 2002 and 2020. The demographic data, clinical presentations, seizure semiology, neuro-imaging findings, modality of treatment, and clinical outcomes were compared between the 2-year seizure-free and non-2-year seizure-free groups. A logistic regression model was applied to determine the significant predictors of a 2-year seizure-free outcome. RESULTS Of 372 radiologically confirmed patients with cerebral AVM, 105 (28.23%) experienced seizure and a 2-year seizure-free outcome was achieved in 76.19%. Most seizures presented as the initial symptom. Generalized onset seizure was the most common seizure semiology. A nidus diameter < 3 cm (adjusted odds ratio [aOR] 3.102; 95% CI 1.129-9.683; p = 0.046) was the independent predictor of a 2-year seizure-free period, whereas underlying epilepsy (aOR 0.141; 95% CI 0.010-0.688; p = 0.015) was an independent predictor against a 2-year seizure-free outcome. CONCLUSION A nidus diameter < 3 cm was the independent predictor of a 2-year seizure-free outcome, whereas underlying epilepsy was the factor against a 2-year seizure-free outcome.
Collapse
Affiliation(s)
- Rujimas Khumtong
- Neurointerventional Radiology Unit, Department of Radiology, Faculty of Medicine, Prince of Songkla University, Thailand
| | - Kesinee Katawatee
- Neurology Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Thailand
| | - Thanyalak Amornpojnimman
- Neurology Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Thailand
| | - Kittipong Riabroi
- Neurointerventional Radiology Unit, Department of Radiology, Faculty of Medicine, Prince of Songkla University, Thailand
| | - Kanisorn Sungkaro
- Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Thailand
| | - Pat Korathanakhun
- Neurology Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Thailand.
| |
Collapse
|
4
|
Mamaril-Davis JC, Aguilar-Salinas P, Avila MJ, Nakaji P, Bina RW. Complete seizure-free rates following interventional treatment of intracranial arteriovenous malformations: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:1313-1326. [PMID: 34988732 DOI: 10.1007/s10143-021-01724-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/09/2021] [Accepted: 12/20/2021] [Indexed: 11/27/2022]
Abstract
Seizures are common presenting symptoms of intracranial arteriovenous malformations (AVMs). This systematic review and meta-analysis aims to assess the current evidence regarding complete seizure freedom rates following surgical resection, stereotactic radiosurgery (SRS), and/or endovascular embolization of intracranial AVMs. A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included manuscripts were methodically scrutinized for quality, spontaneous AVM-associated or hemorrhage-associated seizures, complete seizure-free rates following each interventional treatment, follow-up duration; determination methods of seizure outcomes, and average time-to-onset of recurrent seizures after each treatment. Manuscripts that described patients with nondisabling seizures or reduced seizure frequency in their seizure-free calculations were excluded. Seizure freedom rates following surgical resection, SRS, and endovascular embolization were compared via random-effect analysis. Thirty-four studies with a total of 1765 intracranial AVM patients presenting with spontaneous AVM-associated seizures and 408 patients presenting with hemorrhage-associated seizures were qualitatively analyzed. For patients presenting with AVM-associated seizures, the complete seizure-free rates were 73.0% (321/440 patients; 95% CI 68.8-77.1%) following surgical resection, 60.5% (376/622 patients; 95% CI 56.6-64.3%) following SRS, and 44.6% (29/65 patients; 95% CI 32.5-56.7%) following endovascular embolization alone. For patients presenting with either AVM-associated or hemorrhage-associated seizures, the complete seizure-free rates were 73.0% (584/800 patients; 95% CI 69.9-76.1%) following surgical resection, 46.4% (572/1233 patients; 95% CI 43.6-49.2%) following SRS, and 44.6% (29/65 patients; 95% CI 32.5-56.7%) following embolization. For patients presenting with either AVM-associated or hemorrhage-associated seizures, the overall improvements in seizure outcomes regardless of complete seizure freedom were 82.6% (661/800 patients; 95% CI 80.0-85.3%), 70.6% (870/1233 patients; 95% CI 68.0-73.1%), and 70.8% (46/65 patients; 95% CI 59.7-81.1%) following surgical resection, SRS, and embolization, respectively. No study reported information about the time-to-onset for recurrent seizures in any patient following treatment, as seizure outcomes were only described at the last follow-up visit. The available data suggests that surgical resection results in the highest rate of complete seizure freedom. The rate of seizure improvement following surgery increased further to 82.3% when including patients who had improved seizure frequency without achieving true seizure freedom. Complete seizure-free rates following SRS or embolization were more ambiguous and lower when compared to surgical resection. There is a need for high quality studies evaluating AVM treatment modalities and clearly defined seizure outcomes, as the current literature consists mostly of heterogenous patient populations.
Collapse
Affiliation(s)
- James C Mamaril-Davis
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, Tucson, AZ, USA
| | - Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, Tucson, AZ, USA
| | - Mauricio J Avila
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, Tucson, AZ, USA
| | - Peter Nakaji
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, 755 E. McDowell Rd., Phoenix, AZ, 85006, USA
| | - Robert W Bina
- Department of Neurosurgery, Banner University Medical Center/University of Arizona, 755 E. McDowell Rd., Phoenix, AZ, 85006, USA.
| |
Collapse
|
5
|
Garcia JH, Winkler EA, Morshed RA, Lu A, Ammanuel SG, Saggi S, Wang EJ, Braunstein S, Fox CK, Fullerton HJ, Kim H, Cooke DL, Hetts SW, Lawton MT, Abla AA, Gupta N. Factors associated with seizures at initial presentation in pediatric patients with cerebral arteriovenous malformations. J Neurosurg Pediatr 2021; 28:663-668. [PMID: 34560640 DOI: 10.3171/2021.6.peds21126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/07/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Children with cerebral arteriovenous malformations (AVMs) can present with seizures, potentially increasing morbidity and impacting clinical management. However, the factors that lead to seizures as a presenting sign are not well defined. While AVM-related seizures have been described in case series, most studies have focused on adults and have included patients who developed seizures after an AVM rupture. To address this, the authors sought to analyze demographic and morphological characteristics of AVMs in a large cohort of children. METHODS The demographic, clinical, and AVM morphological characteristics of 189 pediatric patients from a single-center database were studied. Univariate and multivariate logistic regression models were used to test the effect of these characteristics on seizures as an initial presenting symptom in patients with unruptured brain AVMs. RESULTS Overall, 28 of 189 patients initially presented with seizures (14.8%). By univariate comparison, frontal lobe location (p = 0.02), larger AVM size (p = 0.003), older patient age (p = 0.04), and the Supplemented Spetzler-Martin (Supp-SM) grade (0.0006) were associated with seizure presentation. Multivariate analysis confirmed an independent effect of frontal lobe AVM location and higher Supp-SM grade. All patients presenting with seizures had AVMs in the cortex or subcortical white matter. CONCLUSIONS While children and adults share some risk factors for seizure presentation, their risk factor profiles do not entirely overlap. Pediatric patients with cortical AVMs in the frontal lobe were more likely to present with seizures. Additionally, the Supp-SM grade was highly associated with seizure presentation. Future clinical research should focus on the effect of therapeutic interventions targeting AVMs on seizure control in these patients.
Collapse
Affiliation(s)
- Joseph H Garcia
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Ethan A Winkler
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Ramin A Morshed
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Alex Lu
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Simon G Ammanuel
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Satvir Saggi
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Elaina J Wang
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Steve Braunstein
- 2Department of Radiation Oncology, University of California San Francisco, San Francisco
| | - Christine K Fox
- 3Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology, University of California San Francisco, San Francisco
| | - Heather J Fullerton
- 3Pediatric Stroke and Cerebrovascular Disease Center, Department of Neurology, University of California San Francisco, San Francisco
| | - Helen Kim
- 4Center for Cerebrovascular Research, Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco
| | - Daniel L Cooke
- 5Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco
| | - Steven W Hetts
- 5Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco
| | - Michael T Lawton
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
- 6Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Adib A Abla
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
| | - Nalin Gupta
- 1Department of Neurological Surgery, University of California San Francisco, San Francisco
- 7Department of Pediatrics, University of California San Francisco, San Francisco, California; and
| |
Collapse
|
6
|
Capocci R, Bustuchina Vlaicu M, Shotar E, Mathon B, Delaitre M, Premat K, Talaat M, Talbi A, Boch AL, Lenck S, Carpentier A, Degos V, Sourour NA, Clarençon F. Benefits from Exclusion Treatment of Unruptured Brain Arteriovenous Malformations on Epilepsy in Adults. Clin Neuroradiol 2021; 32:749-760. [PMID: 34807285 DOI: 10.1007/s00062-021-01119-w] [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] [Received: 07/27/2021] [Accepted: 10/26/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE In approximately 30% of the patients, brain arteriovenous malformations (bAVMs) are revealed by seizures, which may alter the patients' quality of life. Our objective was to evaluate the benefits of exclusion treatment (radiosurgery, embolization and/or surgery) on posttherapeutic epilepsy in bAVM patients without intracranial hemorrhage prior to treatment. METHODS Our retrospective observational single-center study included all consecutive adult patients with an unruptured bAVM and epilepsy, treated at our institution from 1995 to 2019 and who were followed for at least 1 year. Data on angioarchitectural characteristics of bAVMs, on epilepsy and posttreatment modified Rankin Scale (mRS) were collected. The primary endpoint was a seizure-free status (defined as Engel class IA) after exclusion treatment versus conservative management. RESULTS In this study one hundred and one consecutive adult patients with bAVMs, epilepsy and without bAVM rupture before any treatment were included; 21 (21%) in the conservative management group vs. 80 (79%) in the exclusion treatment group. After exclusion treatment, 55% of the patients from the group were Engel IA after treatment vs. 10% of the conservative management group (odds ratio [OR] 11.37, 95% confidence interval [CI] 2.48-107.24, p < 0.001). CONCLUSION Our results suggest that exclusion treatment in unruptured bAVMs with epilepsy is associated with a higher seizure-free rate in comparison with conservative management. Data from randomized controlled studies are necessary to confirm these findings.
Collapse
Affiliation(s)
- Romain Capocci
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | | | - Eimad Shotar
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Bertrand Mathon
- Department of Neurosurgery, Pitie-Salpêtrière Hospital, Paris, France.,Sorbonne University Medical School, Paris, France
| | | | - Kévin Premat
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne University Medical School, Paris, France
| | - Maichael Talaat
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.,Department of Radiology, Zagazig University Hospital, Zagazig, Egypt
| | - Atika Talbi
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Anne-Laure Boch
- Department of Neurosurgery, Pitie-Salpêtrière Hospital, Paris, France
| | - Stéphanie Lenck
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Alexandre Carpentier
- Department of Neurosurgery, Pitie-Salpêtrière Hospital, Paris, France.,Sorbonne University Medical School, Paris, France
| | - Vincent Degos
- Sorbonne University Medical School, Paris, France.,Department of Neuro-Intensive Care, Pitie-Salpêtrière Hospital, Paris, France.,GRC BioFast. Paris VI University, Paris, France
| | - Nader Antoine Sourour
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitie-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France. .,Sorbonne University Medical School, Paris, France. .,GRC BioFast. Paris VI University, Paris, France.
| |
Collapse
|
7
|
Mooney J, Erickson N, Salehani A, Thomas E, Ilyas A, Rahm S, Eustace N, Maleknia P, Yousuf O, Saccomano B, Bredel M, Fiveash J, Dobelbower C, Fisher WS. Seizure Rates After Stereotactic Radiosurgery for Cerebral AVMs: A Single Center Study. World Neurosurg 2021; 158:e583-e591. [PMID: 34775089 DOI: 10.1016/j.wneu.2021.11.021] [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: 10/08/2021] [Accepted: 11/05/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Seizure control after stereotactic radiosurgery (SRS) for arteriovenous malformations (AVMs) is an area of growing interest, with previous studies reporting up to 70% seizure freedom after treatment. The goals of this study were to identify specific patient and AVM characteristics associated with seizure presentation and seizure outcomes after SRS treatment. METHODS A retrospective review of consecutive patients undergoing SRS for brain AVMs between 2009 and 2019 at our institution was conducted. Chi-squared and logistic regression analyses were utilized to identify patient and AVM factors associated with preoperative seizure presentation and development of new onset seizures after SRS. RESULTS Two hundred ten consecutive patients presenting with AVMs treated with SRS were reviewed. Factors associated with seizure presentation included larger AVM size (P = 0.02), superficial venous drainage (P < 0.05), and parietal location (P = 0.04). Of 188 patients with follow-up (90%), 30 patients presented with seizures and 14 (47%) were seizure-free post-SRS. Of 158 patients presenting without seizure, 29 (18%) developed de novo seizures during follow-up. De novo post-SRS seizures were associated with prior craniotomy for resection of AVM (P = 0.04), post-treatment hemorrhage (P = 0.02), parietal location (P = 0.05), adverse effect requiring steroids (P < 0.01), and adverse effect requiring surgery (P < 0.01). CONCLUSIONS Seizures are a common presentation of brain AVMs and can be treated effectively with SRS. However, seizures can also be a complication of SRS and are associated with post-treatment hemorrhage, edema, and need for future open surgery.
Collapse
Affiliation(s)
- James Mooney
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA.
| | - Nicholas Erickson
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA
| | - Arsalaan Salehani
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA
| | - Evan Thomas
- Department of Radiation Oncology, University of Alabama at Birmingham, Alabama, USA
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA
| | - Sage Rahm
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA
| | - Nicholas Eustace
- School of Medicine, University of Alabama at Birmingham, Alabama, USA
| | - Pedram Maleknia
- School of Medicine, University of Alabama at Birmingham, Alabama, USA
| | - Omer Yousuf
- School of Medicine, University of Alabama at Birmingham, Alabama, USA
| | - Ben Saccomano
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA
| | - Markus Bredel
- Department of Radiation Oncology, University of Alabama at Birmingham, Alabama, USA
| | - John Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Alabama, USA
| | - Chris Dobelbower
- Department of Radiation Oncology, University of Alabama at Birmingham, Alabama, USA
| | - Winfield S Fisher
- Department of Neurosurgery, University of Alabama at Birmingham, Alabama, USA
| |
Collapse
|
8
|
Ruigrok YM. Management of Unruptured Cerebral Aneurysms and Arteriovenous Malformations. Continuum (Minneap Minn) 2020; 26:478-498. [PMID: 32224762 DOI: 10.1212/con.0000000000000835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Unruptured intracranial aneurysms and brain arteriovenous malformations (AVMs) may be detected as incidental findings on cranial imaging. This article provides a practical approach to the management of unruptured intracranial aneurysms and unruptured brain AVMs and reviews the risk of rupture, risk factors for rupture, preventive treatment options with their associated risks, and the approach of treatment versus observation for both types of vascular malformations. RECENT FINDINGS For unruptured intracranial aneurysms, scoring systems on the risk of rupture can help with choosing preventive treatment or observation with follow-up imaging. Although the literature provides detailed information on the complication risks of preventive treatment of unruptured intracranial aneurysms, individualized predictions of these procedural complication risks are not yet available. With observation with imaging, growth of unruptured intracranial aneurysms can be monitored, and prediction scores for growth can help determine the optimal timing of monitoring. The past years have revealed more about the risk of complications of the different treatment modalities for brain AVMs. A randomized clinical trial and prospective follow-up data have shown that preventive interventional therapy in patients with brain AVMs is associated with a higher rate of neurologic morbidity and mortality compared with observation. SUMMARY The risk of hemorrhage from both unruptured intracranial aneurysms and brain AVMs varies depending on the number of risk factors associated with hemorrhage. For both types of vascular malformations, different preventive treatment options are available, and all carry risks of complications. For unruptured intracranial aneurysms, the consideration of preventive treatment versus observation is complex, and several factors should be included in the decision making. Overall, it is recommended that patients with unruptured asymptomatic brain AVMs should be observed.
Collapse
|
9
|
Foundations of the Diagnosis and Surgical Treatment of Epilepsy. World Neurosurg 2020; 139:750-761. [DOI: 10.1016/j.wneu.2020.03.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 03/02/2020] [Indexed: 12/29/2022]
|
10
|
Florian IA, Popovici L, Timis TL, Florian IS, Berindan-Neagoe I. Intracranial Gorgon: Surgical Case Report of a Large Calcified Brain Arteriovenous Malformation. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e922872. [PMID: 32341328 PMCID: PMC7200094 DOI: 10.12659/ajcr.922872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Patient: Male, 55-year-old Final Diagnosis: Right frontal arteriovenous malformation, partially calcified • multiple generalised epileptic seizures • chronic headache Symptoms: Epilectic seizure • headache Medication: — Clinical Procedure: Neurosurgical resection of the right frontal AVM Specialty: Neurosurgery
Collapse
Affiliation(s)
- Ioan Alexandru Florian
- Clinic of Neurosurgery, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania.,Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Laura Popovici
- Department of General Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Teodora Larisa Timis
- Department of Physiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ioan Stefan Florian
- Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ioana Berindan-Neagoe
- MEDFUTURE Research Center for Advanced Medicine, Cluj-Napoca, Romania.,Research Center for Functional Genomics, Biomedicine, and Translational Medicine, Institute of Doctoral Studies, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Experimental Pathology, "Prof. Ion Chiricuta", The Oncology Institute, Cluj-Napoca, Romania
| |
Collapse
|
11
|
Soldozy S, Norat P, Yağmurlu K, Sokolowski JD, Sharifi KA, Tvrdik P, Park MS, Kalani MYS. Arteriovenous malformation presenting with epilepsy: a multimodal approach to diagnosis and treatment. Neurosurg Focus 2020; 48:E17. [DOI: 10.3171/2020.1.focus19899] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 01/28/2020] [Indexed: 11/06/2022]
Abstract
Arteriovenous malformation (AVM) presenting with epilepsy significantly impacts patient quality of life, and it should be considered very much a seizure disorder. Although hemorrhage prevention is the primary treatment aim of AVM surgery, seizure control should also be at the forefront of therapeutic management. Several hemodynamic and morphological characteristics of AVM have been identified to be associated with seizure presentation. This includes increased AVM flow, presence of long pial draining vein, venous outflow obstruction, and frontotemporal location, among other aspects. With the advent of high-throughput image processing and quantification methods, new radiographic attributes of AVM-related epilepsy have been identified. With respect to therapy, several treatment approaches are available, including conservative management or interventional modalities; this includes microsurgery, radiosurgery, and embolization or a combination thereof. Many studies, especially in the domain of microsurgery and radiosurgery, evaluate both techniques with respect to seizure outcomes. The advantage of microsurgery lies in superior AVM obliteration rates and swift seizure response. In addition, by incorporating electrophysiological monitoring during AVM resection, adjacent or even remote epileptogenic foci can be identified, leading to extended lesionectomy and improved seizure control. Radiosurgery, despite resulting in reduced AVM obliteration and prolonged time to seizure freedom, avoids the risks of surgery altogether and may provide seizure control through various antiepileptic mechanisms. Embolization continues to be used as an adjuvant for both microsurgery and radiosurgery. In this study, the authors review the latest imaging techniques in characterizing AVM-related epilepsy, in addition to reviewing each treatment modality.
Collapse
|
12
|
Unnithan AKA. Overview of the current concepts in the management of arteriovenous malformations of the brain. Postgrad Med J 2020; 96:212-220. [DOI: 10.1136/postgradmedj-2019-137202] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/12/2019] [Accepted: 01/11/2020] [Indexed: 12/12/2022]
Abstract
BackgroundThere is a lack of consensus in the management of arteriovenous malformations (AVMs) of the brain since ARUBA (A Randomised trial of Unruptured Brain Arteriovenous malformations) trial showed that medical management is superior to interventional therapy in patients with unruptured brain AVMs. The treatment of brain AVM is associated with significant morbidity.Objectives and methodsA review was done to determine the behaviour of brain AVMs and analyse the risks and benefits of the available treatment options. A search was done in the literature for studies on brain AVMs. Descriptive analysis was also done.ResultsThe angiogenic factors such as vascular endothelial growth factor and inflammatory cytokines are involved in the growth of AVMs. Proteinases such as matrix metalloproteinase-9 contribute to the weakening and rupture of the nidus. The risk factors for haemorrhage are prior haemorrhage, deep and infratentorial AVM location, exclusive deep venous drainage and associated aneurysms. The advancements in operating microscope and surgical techniques have facilitated microsurgery. Stereotactic radiosurgery causes progressive vessel obliteration over 2–3 years. Endovascular embolisation can be done prior to microsurgery or radiosurgery and for palliation.ConclusionsSpetzler-Martin grades I and II have low surgical risks. The AVMs located in the cerebellum, subarachnoid cisterns and pial surfaces of the brainstem can be treated surgically. Radiosurgery is preferable for deep-seated AVMs. A combination of microsurgery, embolisation and radiosurgery is recommended for deep-seated and Spetzler-Martin grade III AVMs. Observation is recommended for grades IV and V.
Collapse
|
13
|
Chen CJ, Ding D, Wang TR, Buell TJ, Ilyas A, Ironside N, Lee CC, Kalani MY, Park MS, Liu KC, Sheehan JP. Microsurgery Versus Stereotactic Radiosurgery for Brain Arteriovenous Malformations: A Matched Cohort Study. Neurosurgery 2020; 84:696-708. [PMID: 29762746 DOI: 10.1093/neuros/nyy174] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 04/05/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Microsurgery (MS) and stereotactic radiosurgery (SRS) remain the preferred interventions for the curative treatment of brain arteriovenous malformations (AVM), but their relative efficacy remains incompletely defined. OBJECTIVE To compare the outcomes of MS to SRS for AVMs through a retrospective, matched cohort study. METHODS We evaluated institutional databases of AVM patients who underwent MS and SRS. MS-treated patients were matched, in a 1:1 ratio based on patient and AVM characteristics, to SRS-treated patients. Statistical analyses were performed to compare outcomes data between the 2 cohorts. The primary outcome was defined as AVM obliteration without a new permanent neurological deficit. RESULTS The matched MS and SRS cohorts were each comprised of 59 patients. Both radiological (85 vs 11 mo; P < .001) and clinical (92 vs 12 mo; P < .001) follow-up were significantly longer for the SRS cohort. The primary outcome was achieved in 69% of each cohort. The MS cohort had a significantly higher obliteration rate (98% vs 72%; P = .001), but also had a significantly higher rate of new permanent deficit (31% vs 10%; P = .011). The posttreatment hemorrhage rate was significantly higher for the SRS cohort (10% for SRS vs 0% for MS; P = .027). In subgroup analyses of ruptured and unruptured AVMs, no significant differences between the primary outcomes were observed. CONCLUSION For patients with comparable AVMs, MS and SRS afford similar rates of deficit-free obliteration. Nidal obliteration is more frequently achieved with MS, but this intervention also incurs a greater risk of new permanent neurological deficit.
Collapse
Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Tony R Wang
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Natasha Ironside
- Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - M Yashar Kalani
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Min S Park
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kenneth C Liu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| |
Collapse
|
14
|
Niranjan A, Kashkoush A, Kano H, Monaco EA, Flickinger JC, Lunsford LD. Seizure control after radiosurgery for cerebral arteriovenous malformations: a 25-year experience. J Neurosurg 2019; 131:1763-1772. [PMID: 30554186 DOI: 10.3171/2018.7.jns18304] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 07/19/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Seizures are the second-most common presenting symptom in patients with lobar arteriovenous malformations (AVMs). However, few studies have assessed the long-term effect of stereotactic radiosurgery (SRS) on seizure control. The authors of this study assess the outcome of SRS for these patients to identify prognostic factors associated with seizure control. METHODS Patients with AVM who presented with a history of seizure and underwent SRS at the authors' institution between 1987 and 2012 were retrospectively assessed. The total cohort included 155 patients with a mean follow-up of 86 months (range 6-295 months). Primary outcomes assessed were seizure frequency, antiepileptic drug regimen, and seizure freedom for 6 months prior to last follow-up. RESULTS Seizure-free status was achieved in 108 patients (70%), with an additional 23 patients (15%) reporting improved seizure frequency as compared to their pre-SRS status. The median time to seizure-free status was estimated to be 12 months (95% CI 0-27 months) as evaluated via Kaplan-Meier survival analysis. The mean seizure frequency prior to SRS was 14.2 (95% CI 5.4-23.1) episodes per year. Although not all patients tried, the proportion of patients successfully weaned off all antiepileptic drugs was 18% (28/155 patients). On multivariate logistic regression, focal impaired awareness seizure type (also known as complex partial seizures) and superficial venous drainage were significantly associated with a decreased odds ratio for seizure-free status at last follow-up (OR 0.37 [95% CI 0.15-0.92] for focal impaired awareness seizures; OR 0.36 [95% CI 0.16-0.81] for superficial venous drainage). The effects of superficial venous drainage on seizure outcome were nonsignificant when excluding patients with < 2 years of follow-up. AVM obliteration did not correlate with long-term seizure freedom (p = 0.202, chi-square test). CONCLUSIONS This study suggests that SRS improves long-term seizure control and increases the likelihood of being medication free, independently of AVM obliteration. Patients with focal impaired awareness seizures were less likely to obtain long-term seizure relief.
Collapse
|
15
|
Ding D, Brew S, McGuinness B, Mee EW. Iatrogenic dural arteriovenous fistula after surgical resection of a ruptured brain arteriovenous malformation. J Neurosci Rural Pract 2019; 7:604-606. [PMID: 27695251 PMCID: PMC5006483 DOI: 10.4103/0976-3147.188631] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Dale Ding
- Department of Neurosurgery, University of Virginia, Charlottesville, VA 22908, USA; Department of Neurosurgery, Auckland City Hospital, Auckland 1142, New Zealand
| | - Stefan Brew
- Department of Radiology, Auckland City Hospital, Auckland 1142, New Zealand
| | - Ben McGuinness
- Department of Radiology, Auckland City Hospital, Auckland 1142, New Zealand
| | - Edward W Mee
- Department of Neurosurgery, Auckland City Hospital, Auckland 1142, New Zealand
| |
Collapse
|
16
|
Seizure Presentation in Patients with Brain Arteriovenous Malformations Treated with Stereotactic Radiosurgery: A Multicenter Study. World Neurosurg 2019; 126:e634-e640. [DOI: 10.1016/j.wneu.2019.02.104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/10/2019] [Accepted: 02/11/2019] [Indexed: 11/23/2022]
|
17
|
Traylor JI, Johnson GS, Ashour R, Ghafoori P, Buchanan RJ. Volume-Staged CyberKnife Stereotactic Radiosurgery for Treatment of Drug-Resistant Epilepsy for a Spetzler-Martin Grade V Arteriovenous Malformation: A Case Report and Review of the Literature. World Neurosurg 2019; 125:329-332. [PMID: 30797935 DOI: 10.1016/j.wneu.2019.01.296] [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: 12/26/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Evidence to support the use of stereotactic radiosurgery (SRS) in the treatment of epilepsy secondary to cerebral arteriovenous malformations (AVMs) is emerging. However, these studies have not clearly demonstrated the use of SRS in the treatment of drug-resistant epilepsy (DRE) in high Spetzler-Martin grade (IV-V) AVMs. CASE DESCRIPTION We present a 48-year-old woman with DRE secondary to a Spetzler-Martin grade V cerebral AVM. She was treated with volume-staged SRS (VS-SRS) and achieved near-complete resolution of her seizures with incomplete obliteration of the AVM. Six years after treatment, she has experienced no serious complications. CONCLUSIONS VS-SRS successfully controlled seizures (Engel Outcome Measure of 1A) in a patient with intractable, DRE secondary to a high-grade cerebral AVM.
Collapse
Affiliation(s)
- Jeffrey I Traylor
- Department of Neurosurgery, Dell Medical School, The University of Texas, Austin, Texas, USA.
| | - Garrett S Johnson
- Department of Neurosurgery, Dell Medical School, The University of Texas, Austin, Texas, USA
| | - Ramsey Ashour
- Department of Neurosurgery, Dell Medical School, The University of Texas, Austin, Texas, USA
| | - Paiman Ghafoori
- Department of Women's Health, Dell Medical School, The University of Texas, Austin, Texas, USA
| | - Robert J Buchanan
- Department of Neurosurgery, Dell Medical School, The University of Texas, Austin, Texas, USA
| |
Collapse
|
18
|
Izawa M, Hayashi M, Chernov M. Surgery for Intractable Seizures After Successful Radiosurgery of Cerebral Arteriovenous Malformation. World Neurosurg 2019; 122:724. [PMID: 30716879 DOI: 10.1016/j.wneu.2018.10.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 10/16/2018] [Indexed: 11/29/2022]
Affiliation(s)
| | - Motohiro Hayashi
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Mikhail Chernov
- Faculty of Advanced Techno-Surgery, Tokyo Women's Medical University, Tokyo, Japan
| |
Collapse
|
19
|
Ironside N, Chen CJ, Ding D, Ilyas A, Kumar JS, Buell TJ, Taylor D, Lee CC, Sheehan JP. Seizure Outcomes After Radiosurgery for Cerebral Arteriovenous Malformations: An Updated Systematic Review and Meta-Analysis. World Neurosurg 2018; 120:550-562.e3. [DOI: 10.1016/j.wneu.2018.08.121] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 08/14/2018] [Accepted: 08/16/2018] [Indexed: 11/30/2022]
|
20
|
Meneghelli P, Pasqualin A, Nicolato A. In Reply to "Surgery for Intractable Seizures After Successful Radiosurgery of Cerebral Arteriovenous Malformation". World Neurosurg 2018; 122:725. [PMID: 30481623 DOI: 10.1016/j.wneu.2018.11.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 11/16/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Pietro Meneghelli
- Institute of Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy.
| | - Alberto Pasqualin
- Section of Vascular Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| | - Antonio Nicolato
- Section of Radiosurgery and Stereotactic Neurosurgery, Institute of Neurosurgery, University and City Hospital, Verona, Italy
| |
Collapse
|
21
|
Zhang B, Feng X, Peng F, Wang L, Guo EK, Zhang Y, Liu P, Wu Z, Liu A. Seizure predictors and outcome after Onyx embolization in patients with brain arteriovenous malformations. Interv Neuroradiol 2018; 25:124-131. [PMID: 30269666 DOI: 10.1177/1591019918801290] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Brain arteriovenous malformation (bAVM)-related epilepsy can significantly affect patient quality of life. We aimed to identify the factors associated with seizures occurrence and evaluate the long-term outcome following Onyx embolization in bAVM patients. METHODS Between July 2014 and July 2016, 239 consecutive patients underwent treatment for bAVMs in our institute and were respectively analyzed. Demographics, seizure status and bAVM morphologic characteristics were recorded. Modified Engel classification was used to evaluate the long-term seizure outcomes. RESULTS Of 239 bAVM patients, 68 (28.5%) initially presented with seizures. Seizure occurrence was associated with cerebral hemorrhage history, frontal-temporal location and arterial borderzone location. Of the 37 patients who presented with initial seizures and were treated with Onyx embolization, 23 (62.2%) were treated with antiepileptic drugs (AEDs) before Onyx embolization. At the last follow-up visit, 19 (51.4%) of the 37 patients reached modified Engel class I outcome. Of the 23 patients who had ever been treated with AEDs, 12 (52.2%) were still taking AEDs at the last follow-up visit. Single-factor analysis showed that arterial borderzone location was significantly correlated with higher modified Engel class outcome ( p = 0.046). CONCLUSION Patients with bAVM hemorrhage history, frontal-temporal location and arterial borderzone location were associated with seizure occurrence. Seizure-free status was not obtained in AVM patients with arterial borderzone after embolization, though it may have benefits in other ways. The seizure-free mechanism of bAVM with Onyx embolization is worth further study.
Collapse
Affiliation(s)
- Baorui Zhang
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Feng
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fei Peng
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Luyao Wang
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Er Kang Guo
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yupeng Zhang
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Liu
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongxue Wu
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Aihua Liu
- 1 Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.,2 Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
22
|
Ding D, Ilyas A, Sheehan JP. Contemporary Management of High-Grade Brain Arteriovenous Malformations. Neurosurgery 2018; 65:24-33. [DOI: 10.1093/neuros/nyy107] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/03/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Dale Ding
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| |
Collapse
|
23
|
Chen CJ, Ding D, Kano H, Mathieu D, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Sheehan DE, Grills IS, Barnett G, Lunsford LD, Sheehan JP. Effect of Advanced Age on Stereotactic Radiosurgery Outcomes for Brain Arteriovenous Malformations: A Multicenter Matched Cohort Study. World Neurosurg 2018; 119:e429-e440. [PMID: 30071340 DOI: 10.1016/j.wneu.2018.07.178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/18/2018] [Accepted: 07/20/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND The effect of age on adult brain arteriovenous malformation (AVM) outcomes after stereotactic radiosurgery (SRS) remains unclear. The aim of this study is to compare AVM outcomes between elderly (age ≥60 years) and nonelderly adult patients. METHODS We retrospectively reviewed pooled data comprising patients who underwent SRS for AVMs between 1987 and 2014 at 8 centers participating in the International Gamma Knife Research Foundation. Adult (age ≥18 years) patients with ≥12 months follow-up were dichotomized into elderly and nonelderly cohorts, and matched in a 1:1 ratio. Favorable outcome was AVM obliteration without permanent symptomatic radiation-induced changes (RIC) or post-SRS hemorrhage. RESULTS The study cohort consisted of 1845 patients (188 elderly vs. 1657 nonelderly) who met the inclusion criteria, and subsequent matching resulted in 181 patients in each cohort. In the matched cohorts, rates of obliteration (54.7% vs. 64.6%; P = 0.054) favorable outcome (51.4% vs. 61.3%; P = 0.056) were no different between the elderly and nonelderly cohorts. The rates of post-SRS hemorrhage (9.9% vs. 5.5%; P = 0.115), RIC (26.5% vs. 30.9%; P = 0.353), symptomatic RIC (9.4% vs. 9.4%; P = 1.000), and permanent symptomatic RIC (3.3% vs. 2.2%; P = 0.750) were also not significantly different between the elderly and nonelderly cohorts. Elderly patients with AVM did have a significantly higher rate of all-cause mortality (27.7% vs. 5.5%; P < 0.001). CONCLUSIONS Advanced age does not seem to significantly affect obliteration or complication rates after SRS for AVMs. Although the decision to recommend intervention for AVMs in the elderly population is multifactorial, SRS may be a viable modality when treatment is deemed appropriate.
Collapse
Affiliation(s)
- Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.
| | - Dale Ding
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David Mathieu
- Division of Neurosurgery, Centre de recherché du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
| | - Caleb Feliciano
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico, USA
| | | | - Darrah E Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan, USA
| | - Gene Barnett
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| |
Collapse
|
24
|
Ye Z, Ai X, You C. Letter to the Editor. Volume-staged vs dose-staged SRS for large brain AVMs. J Neurosurg 2018; 129:262-265. [PMID: 29726773 DOI: 10.3171/2017.11.jns172921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
25
|
Russell D, Peck T, Ding D, Chen CJ, Taylor DG, Starke RM, Lee CC, Sheehan JP. Stereotactic radiosurgery alone or combined with embolization for brain arteriovenous malformations: a systematic review and meta-analysis. J Neurosurg 2018; 128:1338-1348. [DOI: 10.3171/2016.11.jns162382] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEEmbolization of brain arteriovenous malformations (AVMs) prior to stereotactic radiosurgery (SRS) has been reported to negatively affect obliteration rates. The goal of this systematic review and meta-analysis was to compare the outcomes of AVMs treated with embolization plus SRS (E+SRS group) and those of AVMs treated with SRS alone (SRS group).METHODSA literature review was performed using PubMed to identify studies with 10 or more AVM patients and obliteration data for both E+SRS and SRS groups. A meta-analysis was performed to compare obliteration rates between the E+SRS and SRS groups.RESULTSTwelve articles comprising 1716 patients were eligible for analysis. Among the patients with radiological follow-up data, complete obliteration was achieved in 48.4% of patients (330/681) in the E+SRS group compared with 62.7% of patients (613/978) in the SRS group. A meta-analysis of the pooled data revealed that the obliteration rate was significantly lower in the E+SRS group (OR 0.51, 95% CI 0.41–0.64, p < 0.00001). Symptomatic adverse radiation effects were observed in 6.6% (27/412 patients) and 11.1% (48/433 patients) of the E+SRS and SRS groups, respectively. The annual post-SRS hemorrhage rate was 2.0%–6.5% and 0%–2.0% for the E+SRS and SRS groups, respectively. The rates of permanent morbidity were 0%–6.7% and 0%–13.5% for the E+SRS and SRS groups, respectively.CONCLUSIONSArteriovenous malformation treatment with combined embolization and SRS is associated with lower obliteration rates than those with SRS treatment alone. However, this comparison does not fully account for differences in the initial AVM characteristics in the E+SRS group as compared with those in the SRS group. Further studies are warranted to address these limitations.
Collapse
Affiliation(s)
| | | | - Dale Ding
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Ching-Jen Chen
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Davis G. Taylor
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Robert M. Starke
- 4Deparment of Neurological Surgery, University of Miami, Florida
| | - Cheng-Chia Lee
- 3Deparment of Neurological Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Jason P. Sheehan
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| |
Collapse
|
26
|
Ye Z, Ai X, You C. Letter to the Editor. Cyst formation after stereotactic radiosurgery for brain AVMs. J Neurosurg 2018; 129:259-262. [PMID: 29676692 DOI: 10.3171/2017.11.jns172776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
27
|
Ding D, Buell TJ, Raper DM, Chen CJ, Mastorakos P, Liu KC, Vollmer DG. Sylvian Arteriovenous Malformation Resection and Associated Middle Cerebral Artery Aneurysm Clipping: Technical Nuances of Concurrent Surgical Treatment. Cureus 2018; 10:e2166. [PMID: 29805922 PMCID: PMC5963952 DOI: 10.7759/cureus.2166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Approximately 10-30% of brain arteriovenous malformations (AVM) have associated arterial aneurysms (AAA), and the management of these lesions can be challenging. In this video technical note, we demonstrate the microsurgical treatment of an unruptured, Spetzler-Martin grade I AVM in the distal Sylvian fissure with two AAAs arising proximally from the inferior M2 trunk immediately distal to the middle cerebral artery (MCA) bifurcation. First, we resected the superficially located AVM to normalize the blood flow through the Sylvian vein. Next, we performed a Sylvian fissure dissection to access and clip the two MCA AAAs. We also discuss the technical nuances of tandem surgical intervention for AVMs with AAAs as it pertains to this case, particularly with respect to the order of lesion treatment, Sylvian fissure dissection, nidal resection, and aneurysm clipping.
Collapse
Affiliation(s)
- Dale Ding
- Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia
| | - Daniel M Raper
- Department of Neurological Sugery, University of Virginia, Charlottesville, United States
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia
| | | | - Kenneth C Liu
- Department of Neurological Surgery, University of Virginia, Charlottesville, United States
| | | |
Collapse
|
28
|
Patibandla MR, Ding D, Kano H, Starke RM, Lee JYK, Mathieu D, Whitesell J, Pierce JT, Huang PP, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP. Effect of treatment period on outcomes after stereotactic radiosurgery for brain arteriovenous malformations: an international multicenter study. J Neurosurg 2018; 130:579-588. [PMID: 29393755 DOI: 10.3171/2017.8.jns171336] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 08/01/2017] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The role of and technique for stereotactic radiosurgery (SRS) in the management of arteriovenous malformations (AVMs) have evolved over the past four decades. The aim of this multicenter, retrospective cohort study was to compare the SRS outcomes of AVMs treated during different time periods. METHODS The authors selected patients with AVMs who underwent single-session SRS at 8 different centers from 1988 to 2014 with follow-up ≥ 6 months. The SRS eras were categorized as early (1988-2000) or modern (2001-2014). Statistical analyses were performed to compare the baseline characteristics and outcomes of the early versus modern SRS eras. Favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RICs). RESULTS The study cohort comprised 2248 patients with AVMs, including 1584 in the early and 664 in the modern SRS eras. AVMs in the early SRS era were significantly smaller (p < 0.001 for maximum diameter and volume), and they were treated with a significantly higher radiosurgical margin dose (p < 0.001). The obliteration rate was significantly higher in the early SRS era (65% vs 51%, p < 0.001), and earlier SRS treatment period was an independent predictor of obliteration in the multivariate analysis (p < 0.001). The rates of post-SRS hemorrhage and radiological, symptomatic, and permanent RICs were not significantly different between the two groups. Favorable outcome was achieved in a significantly higher proportion of patients in the early SRS era (61% vs 45%, p < 0.001), but the earlier SRS era was not statistically significant in the multivariate analysis (p = 0.470) with favorable outcome. CONCLUSIONS Despite considerable advances in SRS technology, refinement of AVM selection, and contemporary multimodality AVM treatment, the study failed to observe substantial improvements in SRS favorable outcomes or obliteration for patients with AVMs over time. Differences in baseline AVM characteristics and SRS treatment parameters may partially account for the significantly lower obliteration rates in the modern SRS era. However, improvements in patient selection and dose planning are necessary to optimize the utility of SRS in the contemporary management of AVMs.
Collapse
Affiliation(s)
| | - Dale Ding
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Hideyuki Kano
- 2Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Robert M Starke
- 3Department of Neurological Surgery, University of Miami, Florida
| | - John Y K Lee
- 4Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Mathieu
- 5Department of Neurosurgery, University of Sherbrooke, Quebec, Canada
| | - Jamie Whitesell
- 4Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John T Pierce
- 4Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul P Huang
- 6Gamma Knife Center, New York University, New York, New York
| | | | - Caleb Feliciano
- 7Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Luis Almodovar
- 8Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Inga S Grills
- 8Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Danilo Silva
- 9Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mahmoud Abbassy
- 9Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Symeon Missios
- 9Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gene H Barnett
- 9Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - L Dade Lunsford
- 2Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| |
Collapse
|
29
|
Ding D, Starke RM, Kano H, Lee JYK, Mathieu D, Pierce J, Huang P, Missios S, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Kondziolka D, Barnett GH, Lunsford LD, Sheehan JP. Radiosurgery for Unruptured Brain Arteriovenous Malformations: An International Multicenter Retrospective Cohort Study. Neurosurgery 2018; 80:888-898. [PMID: 28431024 DOI: 10.1093/neuros/nyx181] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 04/10/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The role of intervention in the management of unruptured brain arteriovenous malformations (AVM) is controversial. OBJECTIVE To analyze in a multicenter, retrospective cohort study, the outcomes following radiosurgery for unruptured AVMs and determine predictive factors. METHODS We evaluated and pooled AVM radiosurgery data from 8 institutions participating in the International Gamma Knife Research Foundation. Patients with unruptured AVMs and ≥12 mo of follow-up were included in the study cohort. Favorable outcome was defined as AVM obliteration, no postradiosurgical hemorrhage, and no permanently symptomatic radiation-induced changes. RESULTS The unruptured AVM cohort comprised 938 patients with a median age of 35 yr. The median nidus volume was 2.4 cm 3 , 71% of AVMs were located in eloquent brain areas, and the Spetzler-Martin grade was III or higher in 57%. The median radiosurgical margin dose was 21 Gy and follow-up was 71 mo. AVM obliteration was achieved in 65%. The annual postradiosurgery hemorrhage rate was 1.4%. Symptomatic and permanent radiation-induced changes occurred in 9% and 3%, respectively. Favorable outcome was achieved in 61%. In the multivariate logistic regression analysis, smaller AVM maximum diameter ( P = .001), the absence of AVM-associated arterial aneurysms ( P = .001), and higher margin dose ( P = .002) were found to be independent predictors of a favorable outcome. A margin dose ≥ 20 Gy yielded a significantly higher rate of favorable outcome (70% vs 36%; P < .001). CONCLUSION Radiosurgery affords an acceptable risk to benefit profile for patients harboring unruptured AVMs. These findings justify further prospective studies comparing radiosurgical intervention to conservative management for unruptured AVMs.
Collapse
Affiliation(s)
- Dale Ding
- Department of Neurosurgery, Uni-versity of Virginia, Charlottesville, Virginia
| | - Robert M Starke
- Department of Neurosurgery, Uni-versity of Virginia, Charlottesville, Virginia
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pensylvania
| | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Mathieu
- Division of Neurosurgery, University of Sher-brooke, Centre de recherché du CHUS, Sherbrooke, Quebec, Canada
| | - John Pierce
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul Huang
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Symeon Missios
- Department of Neurosurgery, Cleveland Clinic Foun-dation, Cleveland, Ohio
| | - Caleb Feliciano
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Luis Almodovar
- Section of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Danilo Silva
- Department of Neurosurgery, Cleveland Clinic Foun-dation, Cleveland, Ohio
| | - Mahmoud Abbassy
- Department of Neurosurgery, Cleveland Clinic Foun-dation, Cleveland, Ohio
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Gene H Barnett
- Department of Neurosurgery, Cleveland Clinic Foun-dation, Cleveland, Ohio
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pensylvania
| | - Jason P Sheehan
- Department of Neurosurgery, Uni-versity of Virginia, Charlottesville, Virginia
| |
Collapse
|
30
|
Ilyas A, Chen CJ, Ding D, Taylor DG, Moosa S, Lee CC, Cohen-Inbar O, Sheehan JP. Volume-staged versus dose-staged stereotactic radiosurgery outcomes for large brain arteriovenous malformations: a systematic review. J Neurosurg 2018; 128:154-164. [PMID: 28128692 DOI: 10.3171/2016.9.jns161571] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Several recent studies have improved our understanding of the outcomes of volume-staged (VS) and dose-staged (DS) stereotactic radiosurgery (SRS) for the treatment of large (volume > 10 cm3) brain arteriovenous malformations (AVMs). In light of these recent additions to the literature, the aim of this systematic review is to provide an updated comparison of VS-SRS and DS-SRS for large AVMs. METHODS A systematic review of the literature was performed using PubMed to identify cohorts of 5 or more patients with large AVMs who had been treated with VS-SRS or DS-SRS. Baseline data and post-SRS outcomes were extracted for analysis. RESULTS A total of 11 VS-SRS and 10 DS-SRS studies comprising 299 and 219 eligible patients, respectively, were included for analysis. The mean obliteration rates for VS-SRS and DS-SRS were 41.2% (95% CI 31.4%-50.9%) and 32.3% (95% CI 15.9%-48.8%), respectively. Based on pooled individual patient data, the outcomes for patients treated with VS-SRS were obliteration in 40.3% (110/273), symptomatic radiation-induced changes (RICs) in 13.7% (44/322), post-SRS hemorrhage in 19.5% (50/256), and death in 7.4% (24/323); whereas the outcomes for patients treated with DS-SRS were obliteration in 32.7% (72/220), symptomatic RICs in 12.2% (31/254), post-SRS hemorrhage in 10.6% (30/282), and death in 4.6% (13/281). CONCLUSIONS Volume-staged SRS appears to afford higher obliteration rates than those achieved with DS-SRS, although with a less favorable complication profile. Therefore, VS-SRS or DS-SRS may be a reasonable treatment approach for large AVMs, either as stand-alone therapy or as a component of a multimodality management strategy.
Collapse
Affiliation(s)
- Adeel Ilyas
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Dale Ding
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Davis G Taylor
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Shayan Moosa
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Cheng-Chia Lee
- 2Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Or Cohen-Inbar
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| |
Collapse
|
31
|
Pomeraniec IJ, Ding D, Starke RM, Liu KC, Mrachek EK, Lopes MB, Sheehan JP. Delayed cyst formation after stereotactic radiosurgery for brain arteriovenous malformations. J Neurosurg 2017; 129:937-946. [PMID: 29192860 DOI: 10.3171/2017.6.jns17559] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is a commonly employed treatment modality for brain arteriovenous malformations (AVMs). However, due to the low frequency of delayed cyst formation after AVM SRS, as well as the prolonged time interval between treatment and its occurrence, the characteristics of post-SRS cyst formation are not well defined. Therefore, the aims of this retrospective cohort study are to determine the rate of cyst formation after SRS for AVMs, identify predictive factors, and evaluate the clinical sequelae of post-SRS cysts. METHODS The authors analyzed an SRS database for AVM patients who underwent SRS at the University of Virginia and identified those who developed post-SRS cysts. Statistical analyses were performed to determine predictors of post-SRS cyst formation and the effect of cyst formation on new or worsening seizures after SRS. RESULTS The study cohort comprised 1159 AVM patients treated with SRS; cyst formation occurred in 17 patients (post-SRS cyst rate of 1.5%). Compared with patients who did not develop post-SRS cysts, those with cyst formation were treated with a greater number of radiosurgical isocenters (mean 3.8 vs 2.8, p = 0.047), had a longer follow-up (mean 132 vs 71 months, p < 0.001), were more likely to develop radiological radiation-induced changes (RIC) (64.7% vs 36.1%, p = 0.021), and had a longer duration of RIC (57 vs 21 months, p < 0.001). A higher number of isocenters (p = 0.014), radiological RIC (p = 0.002), and longer follow-up (p = 0.034) were found to be independent predictors of post-SRS cyst formation in the multivariate analysis. There was a trend toward a significant association between cyst formation and new or worsening seizures in univariate analysis (p = 0.054). CONCLUSIONS Patients with greater nidal complexity appear to be more prone to post-SRS cyst formation. The findings of this study emphasize the importance of long-term follow-up for patients who have undergone AVM SRS, even after nidal obliteration is achieved. Post-SRS cysts may be epileptogenic, although seizure outcomes after AVM SRS are multifactorial.
Collapse
Affiliation(s)
| | | | - Robert M Starke
- 5Departments of Neurosurgery and Radiology, Jackson Memorial Hospital and University of Miami Hospital, Miami, Florida
| | | | - E Kelly Mrachek
- 4Neuropathology, University of Virginia Health System, Charlottesville, Virginia; and
| | - M Beatriz Lopes
- 4Neuropathology, University of Virginia Health System, Charlottesville, Virginia; and
| | | |
Collapse
|
32
|
Ilyas A, Chen CJ, Ding D, Buell TJ, Raper DMS, Lee CC, Xu Z, Sheehan JP. Radiation-Induced Changes After Stereotactic Radiosurgery for Brain Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2017; 83:365-376. [DOI: 10.1093/neuros/nyx502] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 09/11/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Adeel Ilyas
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
- Department of Neurosurgery, Barrow Neurologic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Daniel M S Raper
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Cheng-Chia Lee
- Department of Neurological Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| |
Collapse
|
33
|
Patibandla MR, Ding D, Kano H, Xu Z, Lee JYK, Mathieu D, Whitesell J, Pierce JT, Huang PP, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic radiosurgery for Spetzler-Martin Grade IV and V arteriovenous malformations: an international multicenter study. J Neurosurg 2017; 129:498-507. [PMID: 28885118 DOI: 10.3171/2017.3.jns162635] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Due to the complexity of Spetzler-Martin (SM) Grade IV-V arteriovenous malformations (AVMs), the management of these lesions remains controversial. The aims of this multicenter, retrospective cohort study were to evaluate the outcomes after single-session stereotactic radiosurgery (SRS) for SM Grade IV-V AVMs and determine predictive factors. METHODS The authors retrospectively pooled data from 233 patients (mean age 33 years) with SM Grade IV (94.4%) or V AVMs (5.6%) treated with single-session SRS at 8 participating centers in the International Gamma Knife Research Foundation. Pre-SRS embolization was performed in 71 AVMs (30.5%). The mean nidus volume, SRS margin dose, and follow-up duration were 9.7 cm3, 17.3 Gy, and 84.5 months, respectively. Statistical analyses were performed to identify factors associated with post-SRS outcomes. RESULTS At a mean follow-up interval of 84.5 months, favorable outcome was defined as AVM obliteration, no post-SRS hemorrhage, and no permanently symptomatic radiation-induced changes (RIC) and was achieved in 26.2% of patients. The actuarial obliteration rates at 3, 7, 10, and 12 years were 15%, 34%, 37%, and 42%, respectively. The annual post-SRS hemorrhage rate was 3.0%. Symptomatic and permanent RIC occurred in 10.7% and 4% of the patients, respectively. Only larger AVM diameter (p = 0.04) was found to be an independent predictor of unfavorable outcome in the multivariate logistic regression analysis. The rate of favorable outcome was significantly lower for unruptured SM Grade IV-V AVMs compared with ruptured ones (p = 0.042). Prior embolization was a negative independent predictor of AVM obliteration (p = 0.024) and radiologically evident RIC (p = 0.05) in the respective multivariate analyses. CONCLUSIONS In this multi-institutional study, single-session SRS had limited efficacy in the management of SM Grade IV-V AVMs. Favorable outcome was only achieved in a minority of unruptured SM Grade IV-V AVMs, which supports less frequent utilization of SRS for the management of these lesions. A volume-staged SRS approach for large AVMs represents an alternative approach for high-grade AVMs, but it requires further investigation.
Collapse
Affiliation(s)
| | - Dale Ding
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Hideyuki Kano
- 2Department of Neurosurgery, University of Pittsburgh
| | - Zhiyuan Xu
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - John Y K Lee
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Mathieu
- 4Department of Neurosurgery, University of Sherbrooke, Quebec, Canada
| | - Jamie Whitesell
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John T Pierce
- 3Gamma Knife Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul P Huang
- 5Gamma Knife Center, New York University, New York, New York
| | | | - Caleb Feliciano
- 6Department of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico
| | | | - Luis Almodovar
- 7Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Inga S Grills
- 7Gamma Knife Center, Beaumont Health System, Royal Oak, Michigan; and
| | - Danilo Silva
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Mahmoud Abbassy
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Symeon Missios
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gene H Barnett
- 8Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Jason P Sheehan
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| |
Collapse
|
34
|
Yang H, Deng Z, Yang W, Liu K, Yao H, Tong X, Wu J, Zhao Y, Cao Y, Wang S. Predictive Factors of Postoperative Seizure for Pediatric Patients with Unruptured Arteriovenous Malformations. World Neurosurg 2017; 105:37-46. [DOI: 10.1016/j.wneu.2017.05.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 05/02/2017] [Accepted: 05/04/2017] [Indexed: 10/19/2022]
|
35
|
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]
|
36
|
Ding D, Starke RM, Kano H, Mathieu D, Huang PP, Kondziolka D, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Barnett GH, Lunsford LD, Sheehan JP. Stereotactic Radiosurgery for ARUBA (A Randomized Trial of Unruptured Brain Arteriovenous Malformations)–Eligible Spetzler-Martin Grade I and II Arteriovenous Malformations: A Multicenter Study. World Neurosurg 2017; 102:507-517. [DOI: 10.1016/j.wneu.2017.03.061] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/12/2017] [Accepted: 03/14/2017] [Indexed: 11/12/2022]
|
37
|
Patibandla MR, Ding D, Xu Z, Sheehan JP. Stereotactic Radiosurgery for Pediatric High-Grade Brain Arteriovenous Malformations: Our Experience and Review of Literature. World Neurosurg 2017; 102:613-622. [DOI: 10.1016/j.wneu.2017.03.064] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 01/23/2023]
|
38
|
Ilyas A, Chen CJ, Ding D, Mastorakos P, Taylor DG, Pomeraniec IJ, Lee CC, Sheehan J. Cyst formation after stereotactic radiosurgery for brain arteriovenous malformations: a systematic review. J Neurosurg 2017; 128:1354-1363. [PMID: 28548596 DOI: 10.3171/2016.12.jns162478] [Citation(s) in RCA: 23] [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 Cyst formation can occasionally occur after stereotactic radiosurgery (SRS) for brain arteriovenous malformations (AVMs). Given the limited data regarding post-SRS cyst formation in patients with AVM, the time course, natural history, and management of this delayed complication are poorly defined. The aim of this systematic review was to determine the incidence, time course, and optimal management of cyst formation after SRS for AVMs. METHODS A literature review was performed using PubMed to identify studies reporting cyst formation in AVM patients treated with SRS. Baseline and outcomes data, including the incidence and management of post-SRS cysts, were extracted from each study that reported follow-up duration. The mean time to cyst formation was calculated from the subset of studies that reported individual patient data. RESULTS Based on pooled data from 22 studies comprising the incidence analysis, the overall rate of post-SRS cyst formation was 3.0% (78/2619 patients). Among the 26 post-SRS cyst patients with available AVM obliteration data, nidal obliteration was achieved in 20 (76.9%). Of the 64 cyst patients with available symptomatology and management data, 21 (32.8%) were symptomatic; 21 cysts (32.8%) were treated with surgical intervention, whereas the remaining 43 (67.2%) were managed conservatively. Based on a subset of 19 studies reporting individual time-to-cyst-formation data from 63 patients, the mean latency period to post-SRS cyst formation was 78 months (6.5 years). CONCLUSIONS Cyst formation is an uncommon complication after SRS for AVMs, with a relatively long latency period. The majority of post-SRS cysts are asymptomatic and can be managed conservatively, although enlarging or symptomatic cysts may require surgical intervention. Long-term follow-up of AVM patients is crucial to the appropriate diagnosis and management of post-SRS cysts.
Collapse
Affiliation(s)
- Adeel Ilyas
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Dale Ding
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Panagiotis Mastorakos
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Davis G Taylor
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - I Jonathan Pomeraniec
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Cheng-Chia Lee
- 2Department of Neurological Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jason Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| |
Collapse
|
39
|
Ilyas A, Ding D, Robert Hixson H, Xu Z, Starke RM, Sheehan JP. Volume-staged stereotactic radiosurgery for large intracranial arteriovenous malformations. J Clin Neurosci 2017; 43:202-207. [PMID: 28495425 DOI: 10.1016/j.jocn.2017.04.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 12/07/2016] [Accepted: 04/22/2017] [Indexed: 10/19/2022]
Abstract
Stereotactic radiosurgery (SRS) is an effective treatment option for intracranial arteriovenous malformations (AVM). However, the treatment of large AVMs (nidus volume ≥12cm3) with single-session SRS alone yields generally poor outcomes. Volume-staged SRS (VS-SRS) is a therapeutic strategy for large AVMs which seeks to avoid the disadvantages of single-session SRS, but reports regarding its efficacy remain limited. The aim of this retrospective cohort study is to assess the outcomes of VS-SRS for large AVMs. We identified all AVM patients who underwent VS-SRS at our institution from 2000 to 2015 with ≥12months follow-up. Baseline and outcomes data were analyzed. A total of 12 patients were selected for the study cohort, with a median age of 30years. The median maximum AVM diameter and nidus volume were 4.3cm and 13.6cm3, respectively. The Spetzler-Martin grade was III and IV each in six AVMs (50%). All patients underwent VS-SRS in two stages, and the median margin dose was 17Gy for both VS-SRS procedures. The median time interval between the two procedures was three months. After a median radiologic follow-up duration of 39months, the median degree of AVM volume reduction (evaluable in nine patients) was 87% (range 12-99%). The rates of radiologically evident, symptomatic, and permanent radiation-induced changes were 58%, 25%, and 8%, respectively. There were no cases of post-SRS hemorrhage. VS-SRS substantially reduces the size of large AVMs. A potential role for VS-SRS may be to facilitate subsequent definitive intervention to obliterate a shrunken, residual nidus.
Collapse
Affiliation(s)
- Adeel Ilyas
- University of Virginia, School of Medicine, Charlottesville, VA 22908, United States
| | - Dale Ding
- University of Virginia, Department of Neurosurgery, Charlottesville, VA 22908, United States
| | - H Robert Hixson
- University of Virginia, Department of Radiology and Medical Imaging, Charlottesville, VA 22908, United States
| | - Zhiyuan Xu
- University of Virginia, Department of Neurosurgery, Charlottesville, VA 22908, United States
| | - Robert M Starke
- University of Virginia, Department of Neurosurgery, Charlottesville, VA 22908, United States; University of Miami, Department of Neurological Surgery, Miami, FL 33136, United States
| | - Jason P Sheehan
- University of Virginia, Department of Neurosurgery, Charlottesville, VA 22908, United States.
| |
Collapse
|
40
|
Ding D, Starke RM, Crowley RW, Liu KC. Surgical Approaches for Symptomatic Cerebral Cavernous Malformations of the Thalamus and Brainstem. J Cerebrovasc Endovasc Neurosurg 2017; 19:19-35. [PMID: 28503485 PMCID: PMC5426196 DOI: 10.7461/jcen.2017.19.1.19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 01/04/2017] [Accepted: 02/18/2017] [Indexed: 11/27/2022] Open
Abstract
Objective Surgical resection of thalamic and brainstem cerebral cavernous malformations (CCMs) is associated with significant operative morbidity, but it may be outweighed, in some cases, by the neurological damage from recurrent hemorrhage in these eloquent areas. The goals of this retrospective cohort study are to describe the technical nuances of surgical approaches and determine the postoperative outcomes for CCMs of the thalamus and brainstem. Materials and Methods We reviewed an institutional database of patients harboring thalamic or brainstem CCMs, who underwent surgical resection from 2010 to 2014. The baseline and follow-up neuroimaging and clinical findings of each patient and the operative details of each case were evaluated. Results A total of eight patients, including two with thalamic and six with brainstem CCMs, were included in the study cohort. All patients had progressive neurological deterioration from recurrent CCM hemorrhage, and the median modified Rankin Scale (mRS) at presentation was 3. The median CCM maximum diameter and volume were 1.7 cm and 1.8 cm3, respectively. The thalamic CCMs were resected using the anterior transcallosal transchoroidal and supracerebellar infratentorial approaches each in one case (13%). The brainstem CCMs were resected using the retrosigmoid and suboccipital trans-cerebellomedullary fissure approaches each in three cases (38%). After a median follow-up of 11.5 months, all patients were neurologically stable or improved, with a median mRS of 2. The rate of functional independence (mRS 0-2) was 63%. Conclusion Microneurosurgical techniques and approaches can be safely and effectively employed for the management of thalamic and brainstem CCMs in appropriately selected patients.
Collapse
Affiliation(s)
- Dale Ding
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
| | - R Webster Crowley
- Department of Neurological Surgery, Rush University, Chicago, IL, USA
| | - Kenneth C Liu
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.,Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
41
|
Ding D, Starke RM, Kano H, Mathieu D, Huang PP, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Kondziolka D, Barnett GH, Dade Lunsford L, Sheehan JP. International multicenter cohort study of pediatric brain arteriovenous malformations. Part 1: Predictors of hemorrhagic presentation. J Neurosurg Pediatr 2017; 19:127-135. [PMID: 27911248 DOI: 10.3171/2016.9.peds16283] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain arteriovenous malformations (AVMs) are the most common cause of spontaneous intracranial hemorrhage in pediatric patients (age < 18 years). Since the cumulative lifetime risk of AVM hemorrhage is considerable in children, an improved understanding of the risk factors influencing hemorrhagic presentation may aid in the management of pediatric AVMs. The aims of this first of a 2-part multicenter, retrospective cohort study are to evaluate the incidence and determine the predictors of hemorrhagic presentation in pediatric AVM patients. METHODS The authors analyzed pooled AVM radiosurgery data from 7 institutions participating in the International Gamma Knife Research Foundation (IGKRF). Patients younger than 18 years at the time of radiosurgery and who had at least 12 months of follow-up were included in the study cohort. Patient and AVM characteristics were compared between unruptured and ruptured pediatric AVMs. RESULTS A total of 357 pediatric patients were eligible for analysis, including 112 patients in the unruptured and 245 patients in the ruptured AVM cohorts (69% incidence of hemorrhagic presentation). The annual hemorrhage rate prior to radiosurgery was 6.3%. Hemorrhagic presentation was significantly more common in deep locations (basal ganglia, thalamus, and brainstem) than in cortical locations (frontal, temporal, parietal, and occipital lobes) (76% vs 62%, p = 0.006). Among the factors found to be significantly associated with hemorrhagic presentation in the multivariate logistic regression analysis, deep venous drainage (OR 3.2, p < 0.001) was the strongest independent predictor, followed by female sex (OR 1.7, p = 0.042) and smaller AVM volume (OR 1.1, p < 0.001). CONCLUSIONS Unruptured and ruptured pediatric AVMs have significantly different patient and nidal features. Pediatric AVM patients who possess 1 or more of these high-risk features may be candidates for relatively more aggressive management strategies.
Collapse
Affiliation(s)
- Dale Ding
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
| | - Robert M Starke
- University of Miami, Department of Neurological Surgery, Miami, Florida
| | - Hideyuki Kano
- University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania
| | - David Mathieu
- University of Sherbrooke, Division of Neurosurgery, Sherbrooke, Quebec, Canada; and
| | - Paul P Huang
- New York University Langone Medical Center, Department of Neurosurgery, New York, New York
| | - Caleb Feliciano
- University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico
| | | | - Luis Almodovar
- University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico
| | - Inga S Grills
- Beaumont Health System, Department of Radiation Oncology, Royal Oak, Michigan
| | - Danilo Silva
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Mahmoud Abbassy
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Symeon Missios
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Douglas Kondziolka
- New York University Langone Medical Center, Department of Neurosurgery, New York, New York
| | - Gene H Barnett
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - L Dade Lunsford
- University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
| |
Collapse
|
42
|
Starke RM, Ding D, Kano H, Mathieu D, Huang PP, Feliciano C, Rodriguez-Mercado R, Almodovar L, Grills IS, Silva D, Abbassy M, Missios S, Kondziolka D, Barnett GH, Dade Lunsford L, Sheehan JP. International multicenter cohort study of pediatric brain arteriovenous malformations. Part 2: Outcomes after stereotactic radiosurgery. J Neurosurg Pediatr 2017; 19:136-148. [PMID: 27911249 DOI: 10.3171/2016.9.peds16284] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Pediatric patients (age < 18 years) harboring brain arteriovenous malformations (AVMs) are burdened with a considerably higher cumulative lifetime risk of hemorrhage than adults. Additionally, the pediatric population was excluded from recent prospective comparisons of intervention versus conservative management for unruptured AVMs. The aims of this multicenter, retrospective cohort study are to analyze the outcomes after stereotactic radiosurgery for unruptured and ruptured pediatric AVMs. METHODS We analyzed and pooled AVM radiosurgery data from 7 participating in the International Gamma Knife Research Foundation. Patients younger than 18 years of age who had at least 12 months of follow-up were included in the study cohort. Favorable outcome was defined as AVM obliteration, no post-radiosurgical hemorrhage, and no permanently symptomatic radiation-induced changes (RIC). The post-radiosurgery outcomes of unruptured versus ruptured pediatric AVMs were compared, and statistical analyses were performed to identify predictive factors. RESULTS The overall pediatric AVM cohort comprised 357 patients with a mean age of 12.6 years (range 2.8-17.9 years). AVMs were previously treated with embolization, resection, and fractionated external beam radiation therapy in 22%, 6%, and 13% of patients, respectively. The mean nidus volume was 3.5 cm3, 77% of AVMs were located in eloquent brain areas, and the Spetzler-Martin grade was III or higher in 59%. The mean radiosurgical margin dose was 21 Gy (range 5-35 Gy), and the mean follow-up was 92 months (range 12-266 months). AVM obliteration was achieved in 63%. During a cumulative latency period of 2748 years, the annual post-radiosurgery hemorrhage rate was 1.4%. Symptomatic and permanent radiation-induced changes occurred in 8% and 3%, respectively. Favorable outcome was achieved in 59%. In the multivariate logistic regression analysis, the absence of prior AVM embolization (p = 0.001) and higher margin dose (p < 0.001) were found to be independent predictors of a favorable outcome. The rates of favorable outcome for patients treated with a margin dose ≥ 22 Gy vs < 22 Gy were 78% (110/141 patients) and 47% (101/216 patients), respectively. A margin dose ≥ 22 Gy yielded a significantly higher probability of a favorable outcome (p < 0.001). The unruptured and ruptured pediatric AVM cohorts included 112 and 245 patients, respectively. Ruptured AVMs had significantly higher rates of obliteration (68% vs 53%, p = 0.005) and favorable outcome (63% vs 51%, p = 0.033), with a trend toward a higher incidence of post-radiosurgery hemorrhage (10% vs 4%, p = 0.07). The annual post-radiosurgery hemorrhage rates were 0.8% for unruptured and 1.6% for ruptured AVMs. CONCLUSIONS Radiosurgery is a reasonable treatment option for pediatric AVMs. Obliteration and favorable outcomes are achieved in the majority of patients. The annual rate of latency period hemorrhage after radiosurgery for both ruptured and unruptured pediatric AVM patients conveys a significant risk until the nidus is obliterated.
Collapse
Affiliation(s)
- Robert M Starke
- University of Miami, Department of Neurological Surgery, Miami, Florida
| | - Dale Ding
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
| | - Hideyuki Kano
- University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania
| | - David Mathieu
- University of Sherbrooke, Division of Neurosurgery, Sherbrooke, Quebec, Canada; and
| | - Paul P Huang
- New York University Langone Medical Center, Department of Neurosurgery, New York, New York
| | - Caleb Feliciano
- University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico
| | | | - Luis Almodovar
- University of Puerto Rico, Section of Neurological Surgery, San Juan, Puerto Rico
| | - Inga S Grills
- Beaumont Health System, Department of Radiation Oncology, Royal Oak, Michigan
| | - Danilo Silva
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Mahmoud Abbassy
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Symeon Missios
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - Douglas Kondziolka
- New York University Langone Medical Center, Department of Neurosurgery, New York, New York
| | - Gene H Barnett
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, Ohio
| | - L Dade Lunsford
- University of Pittsburgh, Department of Neurological Surgery, Pittsburgh, Pennsylvania
| | - Jason P Sheehan
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
| |
Collapse
|
43
|
Ding D, Starke RM, Sheehan JP. Radiosurgery for the management of cerebral arteriovenous malformations. HANDBOOK OF CLINICAL NEUROLOGY 2017; 143:69-83. [PMID: 28552160 DOI: 10.1016/b978-0-444-63640-9.00007-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Cerebral arteriovenous malformations (AVMs) are rare, unstable vascular lesions which spontaneously rupture at a rate of approximately 2-4% annually. Stereotactic radiosurgery is a minimally invasive treatment for AVMs, with a favorable risk-to-benefit profile in most patients, with respect to obliteration, hemorrhage, and seizure control. Radiosurgery is ideally suited for small to medium-sized AVMs (diameter <3cm or volume <12cm3) located in deep or eloquent brain regions. Obliteration is ultimately achieved in 70-80% of cases and is directly associated with nidus volume and radiosurgical margin dose. Adverse radiation effects, which appear as T2-weighted hyperintensities on magnetic resonance imaging, develop in 30-40% of patients after AVM radiosurgery, are symptomatic in 10%, and fail to clinically resolve in 2-3%. The risk of AVM hemorrhage may be reduced by radiosurgery, but the hemorrhage risk persists during the latency period between treatment and obliteration. Delayed postradiosurgery cyst formation occurs in 2% of cases and may require surgical treatment. Radiosurgery abolishes or ameliorates seizure activity in the majority of patients with AVM-associated epilepsy and induces de novo seizures in 1-2% of those without preoperative seizures. Strategies for the treatment of large-volume AVMs include neoadjuvant embolization and either dose- or volume-staged radiosurgery.
Collapse
Affiliation(s)
- Dale Ding
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.
| |
Collapse
|
44
|
Abstract
Various types of seizures and epilepsy are associated with 20-45% of cerebral arteriovenous malformations (AVMs). The necessity to differentiate between occasional seizures, epilepsy with repetitive seizures, and the much rarer drug-resistant epilepsy (DRE) is underlined. It is clear that where there is frequent seizures or DRE, vascular surgeons should take epilepsy surgery aspects into account. The epidemiology of AVM-associated seizures, assumed pathophysiologic mechanisms, most frequent seizures types, and medical treatment are described. Depending on the severity of the epilepsy, the diagnostic workup, including electroencephalogram (EEG), video-EEG, and, rarely, invasive evaluation, is explained. An invasive presurgical workup is only necessary in rare cases of DRE. The indication to extend the resection to more than just removal of the AVM is defined and the various specific resection techniques for this rare form are outlined. In the vast majority of AVM cases removal of the AVM with some adjoining gliotic or hemosiderotic rim of cortex will be sufficient, however. In the majority of cases with preoperative epilepsy, patients will be seizure-free after surgery. Patients who never had a seizure before AVM removal may develop de novo epilepsy postoperatively (5-15%). Rates of seizure freedom after different treatments (microsurgery, radiosurgery, endovascular) vary.
Collapse
|
45
|
Time-Staged Gamma Knife Stereotactic Radiosurgery for Large Cerebral Arteriovenous Malformations: A Preliminary Report. PLoS One 2016; 11:e0165783. [PMID: 27806123 PMCID: PMC5091869 DOI: 10.1371/journal.pone.0165783] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 10/18/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We retrospectively analyzed our experience with time-staged gamma knife stereotactic radiosurgery (GKS) in treating large arteriovenous malformation(AVM)s;≥ 10 cm3). METHODS Forty-five patients who underwent time-staged GKS (2-stage, n = 37;3-stage,n = 8) between March 1998 and December 2011 were included. The mean volume treated was 20.42±6.29 cm3 (range, 10.20-38.50 cm3). Obliteration rates of AVMs and the associated complications after GKS were evaluated. RESULTS Mean AVM volume (and median marginal dose) at each GKS session in the 37 patients who underwent 2-stage GKS was 19.67±6.08 cm3 (13 Gy) at session 1 and 6.97±6.92 cm3 (17 Gy) at session 2. The median interval period was 39 months. After follow-up period of 37 months, the complete obliteration rate was 64.9%. The mean AVM volume (and median marginal dose) at each GKS session in the 8 patients who underwent 3-stage GKS was 23.90±6.50 cm3 (12.25 Gy), 19.43±7.46 cm3 (13.5 Gy), 7.48±6.86 cm3 (15.5 Gy) at session 1, 2, and 3, respectively. The median interval duration between each GKS session was 37.5 and 38 months, respectively. After a median follow-up period of 47.5 months, 5 patients (62.5%) achieved complete obliteration. Postradiosurgical hemorrhage developed in 5 patients (11.1%) including one case of major bleeding and 4 cases of minor bleeding. No patient suffered from clinically symptomatic radiation necrosis following radiation. CONCLUSION Time-staged GKS could be an effective and safe treatment option in the management of large AVMs.
Collapse
|
46
|
Intervention for A randomized trial of unruptured brain arteriovenous malformations (ARUBA) - Eligible patients: An evidence-based review. Clin Neurol Neurosurg 2016; 150:133-138. [PMID: 27656780 DOI: 10.1016/j.clineuro.2016.09.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 11/21/2022]
Abstract
While intervention for ruptured arteriovenous malformations (AVMs) of the brain is typically warranted, the management of unruptured AVMs remains controversial. Despite numerous retrospective studies, only one randomized controlled trial has been conducted, comparing the role of medical management alone to medical management plus surgical and/or radiosurgical intervention in patients with unruptured AVMs: A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA). To great controversy, ARUBA concluded that medical management alone was superior to intervention for unruptured AVMs, which was subsequently challenged by various single-institution and multi-center studies analyzing outcomes of ARUBA-eligible patients. This review summarizes studies returned from a PubMed database search querying, 'ARUBA,' 'ARUBA-eligible,' 'surgery unruptured AVM,' and "radiosurgery unruptured AVM". The rates of the primary endpoint of symptomatic stroke or death were low among the analyzed studies (0-12.2%, mean 8.0%) and similar to the medically managed arm of ARUBA (10.1%). Likewise, the percentage of patients with impaired functional outcomes (modified Rankin score ≥2) in the reviewed studies was low (5.9%-13.1%; mean: 9.9%) and comparable to the 14.0% observed in the medically management arm of ARUBA. The key findings of ARUBA and subsequent work in its aftermath are overviewed and analyzed for the role of surgery and/or radiosurgery in patients with unruptured AVMs.
Collapse
|
47
|
Ding D, Xu Z, Shih HH, Starke RM, Yen CP, Cohen-Inbar O, Sheehan JP. Worse Outcomes After Repeat vs Initial Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations. Neurosurgery 2016; 79:690-700. [DOI: 10.1227/neu.0000000000001409] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Abstract
BACKGROUND:
Incompletely obliterated cerebral arteriovenous malformations (AVMs) after initial treatment with stereotactic radiosurgery (SRS) can be treated with a repeat session of SRS. However, the relative efficacy of repeat vs initial SRS is not well specified.
OBJECTIVE:
To retrospectively compare in matched cohorts the outcomes of repeat vs initial SRS for the treatment of matched cohorts with angioarchitecturally similar AVMs.
METHODS:
We studied a data set of patients with AVM treated with radiosurgery during the period spanning 1989 to 2013. Patients with AVM who underwent repeat SRS with radiologic follow-up of ≥2 years or nidus obliteration were identified for the study and matched, in a 1:1 fashion that was blinded to outcome, to patients with previously untreated AVMs who underwent initial SRS. Statistical analyses were performed to compare the outcomes after repeat vs initial SRS.
RESULTS:
The matching approach resulted in 84 patients for the repeat and the initial SRS cohort (mean margin doses, 20.7 and 20.9 Gy, respectively; P =.74). In the repeat SRS cohort, obliteration was achieved in 67%; the radiologic, symptomatic, and permanent radiation-induced change rates were 35%, 10%, and 4%, respectively; and the post-SRS hemorrhage rate was 3.1%/y. Compared with the initial SRS cohort, the repeat SRS cohort had significantly lower obliteration rates (P =.04) and higher post-SRS hemorrhage rates (P =.04). The radiation-induced change rates of the 2 cohorts were not significantly different.
CONCLUSION:
Repeat SRS yields considerably poorer outcomes than initial SRS for angioarchitecturally comparable AVMs. Further studies in AVM radiobiology and vascular structure are necessary to elucidate this potentially differential response.
Collapse
Affiliation(s)
- Dale Ding
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Han-Hsun Shih
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert M. Starke
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Chun-Po Yen
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Or Cohen-Inbar
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| |
Collapse
|
48
|
Conger JR, Ding D, Raper DM, Starke RM, Durst CR, Liu KC, Jensen ME, Evans AJ. Preoperative Embolization of Cerebral Arteriovenous Malformations with Silk Suture and Particles: Technical Considerations and Outcomes. J Cerebrovasc Endovasc Neurosurg 2016; 18:90-99. [PMID: 27790398 PMCID: PMC5081503 DOI: 10.7461/jcen.2016.18.2.90] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 03/25/2016] [Accepted: 05/30/2016] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Embolization of cerebral arteriovenous malformations (AVMs) is commonly performed prior to surgical resection in order to reduce intraoperative bleeding and improve the safety of resection. Although most modern embolization procedures utilize permanent embolic agents, silk suture and polyvinyl alcohol (PVA) particles may offer unique advantages for preoperative devascularization. The aims of this retrospective cohort study are to describe the technical considerations and determine the outcomes for preoperative silk suture and PVA particle embolization (SPE) of AVMs. MATERIALS AND METHODS We performed a retrospective review of our AVM embolization database. AVM patients who underwent preoperative SPE and subsequent surgical resection were included for analysis. Baseline patient demographics, AVM characteristics, embolization and operative records, and post-treatment outcomes were reviewed. RESULTS A total of 11 patients who underwent 12 preoperative SPE procedures were included for analysis. Five AVMs were ruptured (45%), and the median nidus volume was 3.0 cm3 (range: 1.3-42.9 cm3). The Spetzler-Martin grade was I-II in seven patients (64%) and III-IV in four patients (36%). The degree of nidal obliteration was less than 25% in two procedures (17%), 25-50% in one procedure (8%), 50-75% in eight procedures (67%), and greater than 75% in one procedure (8%). The rates of post-embolization AVM hemorrhage and mortality were 8% and 0%, respectively. The postoperative angiographic obliteration rate was 100%, and the modified Rankin Scale score improved or stable in 91% of patients (median follow-up duration 2 months). CONCLUSION Preoperative AVM SPE affords a reasonable risk to benefit profile for appropriately selected patients.
Collapse
Affiliation(s)
- Jordan R Conger
- School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Dale Ding
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Daniel M Raper
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
| | - Christopher R Durst
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Kenneth C Liu
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.; Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Mary E Jensen
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Avery J Evans
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
49
|
Ding D, Starke RM, Liu KC, Crowley RW. Cortical plasticity in patients with cerebral arteriovenous malformations. J Clin Neurosci 2016; 22:1857-61. [PMID: 26256067 DOI: 10.1016/j.jocn.2015.06.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/20/2015] [Indexed: 10/22/2022]
Abstract
The aim of this review is to ascertain the evidence for cortical plasticity in arteriovenous malformation (AVM) patients. Chronic hypoperfusion due to vascular steal from cerebral AVM can result in a translocation of eloquent neurological functions to other brain areas, a phenomenon known as cortical plasticity. We performed a systematic literature review of the studies that have evaluated cortical plasticity in AVM patients. A total of 22 studies from 1996 to 2014 were included for the analyses. The evaluation of cortical plasticity was performed prior to AVM intervention in 109 patients, and during or after AVM intervention in 18. The most commonly assessed neurological functions were motor in 85% and language in 11% of the former cohort, and motor in 78% and language, cognition, and memory each in 39% of the latter cohort. Functional MRI was the most frequently used method for evaluating cortical plasticity, and was performed in 63% of the former and 56% of the latter cohort. In conclusion, cortical plasticity appears to be influenced by both AVM pathogenesis and intervention. Given the limited evidence that is currently available for cortical plasticity in AVM patients, further studies are warranted to determine its incidence and impact on long term clinical outcomes.
Collapse
Affiliation(s)
- Dale Ding
- Department of Neurosurgery, University of Virginia, Post Office Box 800212, Charlottesville, VA 22908, USA.
| | - Robert M Starke
- Department of Neurosurgery, University of Virginia, Post Office Box 800212, Charlottesville, VA 22908, USA
| | - Kenneth C Liu
- Department of Neurosurgery, University of Virginia, Post Office Box 800212, Charlottesville, VA 22908, USA; Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - R Webster Crowley
- Department of Neurosurgery, University of Virginia, Post Office Box 800212, Charlottesville, VA 22908, USA; Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
50
|
Relief of epilepsy and headache and quality of life after microsurgical treatment of unruptured brain AVM—audit of a single-center series and comprehensive review of the literature. Neurosurg Rev 2016; 40:59-65. [DOI: 10.1007/s10143-016-0750-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 01/29/2016] [Accepted: 04/09/2016] [Indexed: 10/21/2022]
|