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Zhu ZY, Zhang W, Zhu SH, Zhang GJ, Chen J. Stereotactic radiosurgery alone for brain arteriovenous malformations: a single-institute experience. BMC Neurol 2024; 24:368. [PMID: 39350126 PMCID: PMC11440702 DOI: 10.1186/s12883-024-03876-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2024] [Accepted: 09/20/2024] [Indexed: 10/04/2024] Open
Abstract
OBJECTIVE Brain arteriovenous malformations (BAVMs) represent an ongoing clinical challenge because of their complex nature. The long-term outcomes of BAVMs patients treated with stereotactic radiosurgery (SRS) alone are unclear. METHODS We conducted a retrospective analysis of 201 patients treated for BAVMs from January 2010 to December 2019. The identified predictors of obliteration or hemorrhage in the multivariate analysis were estimated by odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS A total of 201 patients treated with gamma knife radiosurgery (GKRS) alone as the primary treatment for BAVMs were included. The mean age at GKRS treatment was 31.4 ± 1.1 years, and 61.2% of the patients were male. Multivariate logistic regression revealed that a higher radiosurgery-based AVM score (OR 1.847, 95% CI = 1.292-2.641; p = 0.001) was significantly associated with worse obliteration, and a higher margin dose significantly favored obliteration (OR 0.352, 95% CI = 0.189-0.658; p = 0.001). Multivariate analysis revealed that an increased lesion volume of 1 cm3 (OR 1.279, 95% CI = 1.023-1.600; p = 0.031) and a high margin dose (OR 0.363, 95% CI = 0.134-0.983; p = 0.046) were significant prognostic factors for post-SRS hemorrhage. CONCLUSIONS In conclusion, our study investigated the available clinical and radiological prognostic factors for BAVMs and revealed that a higher margin dose significantly improved both the obliteration rate and nonhemorrhagic outcomes. Currently, the most appropriate candidates, Spetzler-Martin grade, and optimal radiation dose are still being defined by prospective trials.
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Affiliation(s)
- Zhao-Ying Zhu
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Wei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Shi-Hong Zhu
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Gui-Jun Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China
| | - Jing Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, Sichuan, 610041, China.
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Maroufi SF, Fallahi MS, Khorasanizadeh M, Waqas M, Sheehan JP. Radiosurgery With Prior Embolization Versus Radiosurgery Alone for Intracranial Arteriovenous Malformations: A Systematic Review and Meta-Analysis. Neurosurgery 2024; 94:478-496. [PMID: 37796184 DOI: 10.1227/neu.0000000000002699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/02/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The addition of adjuvant embolization to radiosurgery has been proposed as a means of improving treatment outcomes of intracranial arteriovenous malformations (AVMs). However, the relative efficacy and safety of radiosurgery with adjuvant embolization vs radiosurgery alone remain uncertain. Moreover, previous systematic reviews and meta-analyses have included a limited number of studies and did not consider the effects of baseline characteristics, including AVM volume, on the outcomes. This systematic review aimed to evaluate the efficacy of preradiosurgery embolization for intracranial AVMs with consideration to matching status between participants in each treatment group. METHODS A systematic review and meta-analysis were conducted by searching electronic databases, including PubMed, Scopus, and Cochrane Library, up to January 2023. All studies evaluating the utilization of preradiosurgery embolization were included. RESULTS A total of 70 studies (9 matched and 71 unmatched) with a total of 12 088 patients were included. The mean age of the included patients was 32.41 years, and 48.91% of the patients were female. Preradiosurgery embolization was used for larger AVMs and patients with previous hemorrhage ( P < .01, P = .02, respectively). The obliteration rate for preradiosurgery embolization (49.44%) was lower compared with radiosurgery alone (61.42%, odds ratio = 0.56, P < .01), regardless of the matching status of the analyzed studies. Although prior embolization was associated higher rate of cyst formation ( P = .04), it lowered the odds of radiation-induced changes ( P = .04). The risks of minor and major neurological deficits, postradiosurgery hemorrhage, and mortality were comparable between groups. CONCLUSION This study provides evidence that although preradiosurgery embolization is a suitable option to reduce the AVM size for future radiosurgical interventions, it may not be useful for same-sized AVMs eligible for radiosurgery. Utilization of preradiosurgery embolization in suitable lesions for radiosurgery may result in the added cost and burden of an endovascular procedure.
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Affiliation(s)
- Seyed Farzad Maroufi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran , Iran
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran , Iran
| | - Mohammad Sadegh Fallahi
- Neurosurgical Research Network (NRN), Universal Scientific Education and Research Network (USERN), Tehran , Iran
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran , Iran
| | - MirHojjat Khorasanizadeh
- Department of Neurosurgery, Mount Sinai Hospital, Icahn School of Medicine, New York City , New York , USA
| | - Muhammad Waqas
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo , New York , USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville , Virginia , USA
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3
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Verhaegen F, Butterworth KT, Chalmers AJ, Coppes RP, de Ruysscher D, Dobiasch S, Fenwick JD, Granton PV, Heijmans SHJ, Hill MA, Koumenis C, Lauber K, Marples B, Parodi K, Persoon LCGG, Staut N, Subiel A, Vaes RDW, van Hoof S, Verginadis IL, Wilkens JJ, Williams KJ, Wilson GD, Dubois LJ. Roadmap for precision preclinical x-ray radiation studies. Phys Med Biol 2023; 68:06RM01. [PMID: 36584393 DOI: 10.1088/1361-6560/acaf45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 12/30/2022] [Indexed: 12/31/2022]
Abstract
This Roadmap paper covers the field of precision preclinical x-ray radiation studies in animal models. It is mostly focused on models for cancer and normal tissue response to radiation, but also discusses other disease models. The recent technological evolution in imaging, irradiation, dosimetry and monitoring that have empowered these kinds of studies is discussed, and many developments in the near future are outlined. Finally, clinical translation and reverse translation are discussed.
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Affiliation(s)
- Frank Verhaegen
- MAASTRO Clinic, Radiotherapy Division, GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
- SmART Scientific Solutions BV, Maastricht, The Netherlands
| | - Karl T Butterworth
- Patrick G. Johnston, Centre for Cancer Research, Queen's University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Anthony J Chalmers
- School of Cancer Sciences, University of Glasgow, Glasgow G61 1QH, United Kingdom
| | - Rob P Coppes
- Departments of Biomedical Sciences of Cells & Systems, Section Molecular Cell Biology and Radiation Oncology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, The Netherlands
| | - Dirk de Ruysscher
- MAASTRO Clinic, Radiotherapy Division, GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Sophie Dobiasch
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine and Klinikum rechts der Isar, Germany
- Department of Medical Physics, Institute of Radiation Medicine (IRM), Department of Radiation Sciences (DRS), Helmholtz Zentrum München, Germany
| | - John D Fenwick
- Department of Medical Physics & Biomedical Engineering University College LondonMalet Place Engineering Building, London WC1E 6BT, United Kingdom
| | | | | | - Mark A Hill
- MRC Oxford Institute for Radiation Oncology, University of Oxford, ORCRB Roosevelt Drive, Oxford OX3 7DQ, United Kingdom
| | - Constantinos Koumenis
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Kirsten Lauber
- Department of Radiation Oncology, University Hospital, LMU München, Munich, Germany
- German Cancer Consortium (DKTK), Partner site Munich, Germany
| | - Brian Marples
- Department of Radiation Oncology, University of Rochester, NY, United States of America
| | - Katia Parodi
- German Cancer Consortium (DKTK), Partner site Munich, Germany
- Department of Medical Physics, Faculty of Physics, Ludwig-Maximilians-Universität München, Garching b. Munich, Germany
| | | | - Nick Staut
- SmART Scientific Solutions BV, Maastricht, The Netherlands
| | - Anna Subiel
- National Physical Laboratory, Medical Radiation Science Hampton Road, Teddington, Middlesex, TW11 0LW, United Kingdom
| | - Rianne D W Vaes
- MAASTRO Clinic, Radiotherapy Division, GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | | | - Ioannis L Verginadis
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Jan J Wilkens
- Department of Radiation Oncology, Technical University of Munich (TUM), School of Medicine and Klinikum rechts der Isar, Germany
- Physics Department, Technical University of Munich (TUM), Germany
| | - Kaye J Williams
- Division of Pharmacy and Optometry, University of Manchester, Manchester, United Kingdom
| | - George D Wilson
- Department of Radiation Oncology, Beaumont Health, MI, United States of America
- Henry Ford Health, Detroit, MI, United States of America
| | - Ludwig J Dubois
- The M-Lab, Department of Precision Medicine, GROW-School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
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Mendez C, Gete E. Volume staging for arteriovenous malformation SRS treatment using VMAT. J Appl Clin Med Phys 2022; 23:e13815. [PMID: 36354977 PMCID: PMC9797165 DOI: 10.1002/acm2.13815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/25/2022] [Accepted: 09/27/2022] [Indexed: 11/11/2022] Open
Abstract
Volume staging involves dividing the target volume into smaller parts and treating each part separately. In this study, the feasibility of volume-staged stereotactic radiosurgery (VS-SRS) on a linear accelerator using volumetric modulated arc therapy (VMAT) and a frameless patient positioning system is investigated. Ten patients, previously treated with hypofractionated stereotactic radiotherapy with arteriovenous malformation (AVM) sized from 1.6 to 4.0 cm in diameter, were selected. VS-SRS plans were created with the VMAT technique on the Varian Eclipse treatment planning system (TPS) using the TrueBeam STx linear accelerator. For each patient, an AVM-VMAT set was planned with the AVM as the target and a PTV-VMAT set using the (PTV = AVM+1 mm) as the target. All targets were divided into two sub-volumes. The TPS data from the AVM-VMAT plans was compared to Gamma Knife (GK) VS-SRS plan data available in the literature. The AVM-VMAT and PTV-VMAT plans were compared to investigate the effect of a 1 mm PTV margin on normal brain (NB) dose. End-to-end testing was performed using a GaFchromic EBT3 film and point-dose measurements. Dosimetric effects of multiple setups were investigated through film-to-film comparisons. Median target dose coverage, NB V12Gy , and conformity index for the AVM-VMAT plans were 97.5%, 17 cm3 , and 0.8, respectively. PTV-VMAT plans attained comparable target dose coverage, but the average NB V12Gy increased by 48.9% when compared to the AVM-VMAT plans. Agreement of point-dose measurements with TPS calculations was -0.6% when averaged over all patients. Gamma analysis passing rates were above 90% for all film-to-film comparisons (2%/1 mm criteria), and for the film to TPS comparison (5%/1 mm). This work suggests that VMAT is capable of producing VS-SRS plans with similar dose falloff characteristics as GK plans. NB dose depends on PTV margin size, and two-stage treatment setups do not appear to contribute additional uncertainty to treatment delivery.
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Affiliation(s)
- Claudia Mendez
- Department of Physics and AstronomyUniversity of British ColumbiaVancouverBritish ColumbiaCanada,BC Cancer, Abbotsford CenterAbbotsfordBritish ColumbiaCanada
| | - Ermias Gete
- BC Cancer, Vancouver CenterVancouverBritish ColumbiaCanada
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5
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Loebel F, Pontoriero A, Kluge A, Iatì G, Acker G, Kufeld M, Cacciola A, Pergolizzi S, Vinci S, Lillo S, Xu R, Stromberger C, Budach V, Vajkoczy P, Senger C, Conti A. Image-guided robotic radiosurgery for the treatment of arteriovenous malformations. PLoS One 2022; 17:e0266744. [PMID: 36137082 PMCID: PMC9499208 DOI: 10.1371/journal.pone.0266744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 03/26/2022] [Indexed: 11/26/2022] Open
Abstract
Background Cerebral arteriovenous malformations (AVMs) are challenging lesions, often requiring multimodal interventions; however, data on the efficacy of stereotactic radiosurgery for cerebral AVMs are limited. This study aimed to evaluate the clinical and radiographic results following robotic radiosurgery, alone or in combination with endovascular treatment, and to investigate factors associated with obliteration and complications in patients with AVM. Methods We retrospectively analyzed the clinical and imaging characteristics of 123 patients with AVMs of all Spetzler-Martin grades treated at two institutions by robotic radiosurgery in single-fraction doses (CyberKnife). Embolization was performed before radiosurgery in a subset of patients to attempt to downgrade the lesions. Factors associated with AVM obliteration and complications (toxicity) were identified via univariate and multivariate analyses. Results The median follow-up time was 48.1 months (range, 3.6–123 months). Five patients were lost to follow-up. The obliteration rate in the 59 patients with a follow-up period exceeding four years was 72.8%. Complete obliteration and partial remission were achieved in 67 (56.8%) and 31 (26.3%) cases, respectively, whereas no change was observed in 20 cases (17.8%). Embolization was performed in 54/123 cases (43.9%). Complete and partial obliteration were achieved in 29 (55.7%) and 14 (26.9%) embolized patients, respectively. In the multivariate analysis, the factors associated with obliteration were age (p = .018) and the Spetzler-Martin grade (p = .041). Treatment-induced toxicity (radiation necrosis and/or edema) was observed in 15 cases (12.7%), rebleeding occurred in three cases (2.5%), and the rate of mortality associated with rebleeding was 1.7%. Conclusions CyberKnife radiosurgery is a valid approach for treating AVMs of all Spetzler-Martin-grades, with satisfactory obliteration rates, low toxicity, and a relatively rare incidence of rebleeding.
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Affiliation(s)
- Franziska Loebel
- Department of Neurosurgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
- Department of Radiation Oncology, Charité Universitaetsmedizin Berlin, Berlin, Germany
- * E-mail:
| | | | - Anne Kluge
- Department of Radiation Oncology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Giuseppe Iatì
- Department of Radiation Oncology, University of Messina, Messina, Italy
| | - Gueliz Acker
- Department of Neurosurgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
- Department of Radiation Oncology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Markus Kufeld
- Department of Radiation Oncology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Alberto Cacciola
- Department of Radiation Oncology, University of Messina, Messina, Italy
| | | | - Sergio Vinci
- Department of Neuroradiology, University of Messina, Messina, Italy
| | - Sara Lillo
- Department of Radiation Oncology, University of Messina, Messina, Italy
| | - Ran Xu
- Department of Neurosurgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Carmen Stromberger
- Department of Radiation Oncology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Volker Budach
- Department of Radiation Oncology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Carolin Senger
- Department of Radiation Oncology, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - Alfredo Conti
- Department of Neurosurgery, Charité Universitaetsmedizin Berlin, Berlin, Germany
- Department of Neurosurgery, Alma Mater Studiorum University of Bologna, Bologna, Italy
- IRCCS ISNB-Istituto delle Scienze Neurologiche Bologna, Bologna, Italy
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6
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LINAC stereotactic radiosurgery for brain arteriovenous malformations: An updated single centre analysis of outcomes. J Clin Neurosci 2022; 102:54-59. [PMID: 35728395 DOI: 10.1016/j.jocn.2022.06.003] [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: 11/11/2021] [Revised: 06/03/2022] [Accepted: 06/05/2022] [Indexed: 10/18/2022]
Abstract
Arteriovenous malformations (AVM) of the brain are congenital, high pressure vascular malformations, which are at risk of haemorrhage. Stereotactic radiosurgery (SRS) can obliterate the nidus by delivering a precise high dose of ionising radiation in a single fraction. This paper updates long term AVM obliteration rates, time to obliteration and retreatment outcomes in LINAC delivered SRS treatment at the Royal Adelaide Hospital. A retrospective review of a prospectively maintained AVM SRS database supplemented by clinical case notes, patient correspondence and electronic medical records was performed. 89 AVMs received primary SRS treatment for which the crude obliteration rate was 61% (68% for 79 patients with adequate follow up). Higher marginal dose, smaller nidus size and lower Pollock-Flickinger (PF) score were significantly associated with AVM obliteration. The crude obliteration rates for patients with adequate follow-up and AVM diameter < 3 cm vs ≥ 3 cm were 76% vs 48%, respectively, and 93% with PF score < 1.0. Median time to obliteration was 36 months. Higher dose and lower PF score were associated with earlier obliteration. The crude obliteration rate after second SRS was 56% (9/16 patients) and no significant associations were found. These obliteration rates after primary and retreatment LINAC SRS are comparable to other studies. Marginal dose and PF score were the main predictors of obliteration overall as well as early (<36 months) obliteration.
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Gamma Knife radiosurgery for cerebral arteriovenous malformations: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:1987-2004. [PMID: 35178626 PMCID: PMC9160151 DOI: 10.1007/s10143-022-01751-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/16/2022]
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Xu MC, Khattab MH, Luo G, Sherry AD, Morales-Paliza M, Chaballout BH, Anderson JL, Attia A, Cmelak AJ. Effects of cone versus multi-leaf collimation on dosimetry and neurotoxicity in patients with small arteriovenous malformations treated by stereotactic radiosurgery. JOURNAL OF RADIOSURGERY AND SBRT 2021; 7:287-294. [PMID: 34631230 PMCID: PMC8492055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 02/15/2021] [Indexed: 06/13/2023]
Abstract
PURPOSE/OBJECTIVE Linear accelerator (LINAC) based stereotactic radiosurgery (SRS) for arteriovenous malformations (AVMs) is delivered with cone or multileaf collimators (MLCs), and favorable dosimetry is associated with reduced radionecrosis in normal brain tissue. This study aims to determine whether cones or MLCs has better dosimetric characteristics, to predict differences in toxicity. METHODS All patients treated for AVMs using LINAC SRS from 2003-2017 were examined retrospectively. Demographic data, volumes of normal tissue exposed to 12Gy (V12Gy[cc]) and 4Gy (V4Gy[cc]), maximal dose, and dose gradient were analyzed. Univariate and multivariate analyses were used to evaluate relationships between collimator type, dosimetric parameters, and toxicity. Propensity score matching was used to adjust for AVM size. RESULTS Compared to MLC, cones were independently associated with reduced V12Gy[cc] after propensity score matching (p=0.008) and reduced neurotoxicity (p=0.016). Higher V12Gy[cc] (p=0.0008) and V4Gy[cc] (p=0.002) were associated with increased neurotoxicity. CONCLUSIONS Treating AVMs with cone-based SRS over MLC-based SRS may improve dosimetry and reduce toxicities.
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Affiliation(s)
- Mark C Xu
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Manuel Morales-Paliza
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Basil H. Chaballout
- University of South Carolina School of Medicine Greenville, Greenville, SC, USA
| | | | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
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9
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Critical review of brain AVM surgery, surgical results and natural history in 2017. Acta Neurochir (Wien) 2017; 159:1457-1478. [PMID: 28555270 DOI: 10.1007/s00701-017-3217-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/09/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND An understanding of the present standing of surgery, surgical results and the role in altering the future morbidity and mortality of untreated brain arteriovenous malformations (bAVMs) is appropriate considering the myriad alternative management pathways (including radiosurgery, embolization or some combination of treatments), varying risks and selection biases that have contributed to confusion regarding management. The purpose of this review is to clarify the link between the incidence of adverse outcomes that are reported from a management pathway of either surgery or no intervention with the projected risks of surgery or no intervention. METHODS A critical review of the literature was performed on the outcomes of surgery and non-intervention for bAVM. An analysis of the biases and how these may have influenced the outcomes was included to attempt to identify reasonable estimates of risks. RESULTS In the absence of treatment, the cumulative risk of future hemorrhage is approximately 16% and 29% at 10 and 20 years after diagnosis of bAVM without hemorrhage and 35% and 45% at 10 and 20 years when presenting with hemorrhage (annualized, this risk would be approximately 1.8% for unruptured bAVMs and 4.7% for 8 years for bAVMs presenting with hemorrhage followed by the unruptured bAVM rate). The cumulative outcome of these hemorrhages depends upon whether the patient remains untreated and is allowed to have a further hemorrhage or is treated at this time. Overall, approximately 42% will develop a new permanent neurological deficit or death from a hemorrhagic event. The presence of an associated proximal intracranial aneurysm (APIA) and restriction of venous outflow may increase the risk for subsequent hemorrhage. Other risks for increased risk of hemorrhage (age, pregnancy, female) were examined, and their purported association with hemorrhage is difficult to support. Both the Spetzler-Martin grading system (and its compaction into the Spetzler-Ponce tiers) and Lawton-Young supplementary grading system are excellent in predicting the risk of surgery. The 8-year risk of unfavorable outcome from surgery (complication leading to a permanent new neurological deficit with a modified Rankin Scale score of greater than one, residual bAVM or recurrence) is dependent on bAVM size, the presence of deep venous drainage (DVD) and location in critical brain (eloquent location). For patients with bAVMs who have neither a DVD nor eloquent location, the 8-year risk for an unfavorable outcome increases with size (increasing from 1 cm to 6 cm) from 1% to 9%. For patients with bAVM who have either a DVD or eloquent location (but not both), the 8-year risk for an unfavorable outcome increases with the size (increasing from 1 cm to 6 cm) from 4% to 35%. For patients with bAVM who have both a DVD and eloquent location, the 8-year risk for unfavorable outcome increases with size (increasing from 1 cm to 3 cm) from 12% to 38%. CONCLUSION Patients with a Spetzler-Ponce A bAVM expecting a good quality of life for the next 8 years are likely to do better with surgery in expert centers than remaining untreated. Ongoing research is urgently required on the outcome of management pathways for bAVM.
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10
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Bitaraf MA, Katoozpour R, Azar M, Nouri M, Mortazavi SA, Amirjamshidi A. Radiosurgery in treatment of cerebral arteriovenous malformation: Mid-term results of 388 cases from a single center. Asian J Neurosurg 2017; 12:159-166. [PMID: 28484523 PMCID: PMC5409359 DOI: 10.4103/1793-5482.145121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Objectives: The purpose of this study is to evaluate the outcome and risks of radiosurgery for patients with arteriovenous malformations (AVM) of the brain all treated in a single center in the 3rd world with all its limitations. Materials and Methods: We performed a retrospective analysis of 388 patients with AVM treated with radiosurgery during an 8-year period. Factors associated with increased chance of AVM obliteration or hemorrhages during the follow-up period were analyzed. Results: Among 388 cases included in our series, 74 were Spetzler-Martin (SM) grade IV or V. Forty-four patients (11.3%) experienced post-radiosurgery hemorrhage in their follow-up period. The number of feeders (one/multiple) and deep location of the AVM did not alter the chance of bleeding (P < 0.05). Higher SM grading of the AVM was associated with increased chance of hemorrhage and decreased obliteration rate (P > 0.05) in the mid-term follow up. Conclusions: Our case series showed that radiosurgery can be considered a viable alternative in the treatment of even large AVMs which might not be considered good candidates for surgery or endovascular treatment. Further data including large size lesions are warranted to further support our findings.
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Affiliation(s)
| | | | | | - Mohsen Nouri
- Consultant Neurosurgeon, Gundishapour Academy of Neuroscience, Ahvaz, Iran
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11
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Yahya S, Heyes G, Nightingale P, Lamin S, Chavda S, Geh I, Spooner D, Cruickshank G, Sanghera P. Linear accelerator radiosurgery for arteriovenous malformations: Updated literature review. J Clin Neurosci 2017; 38:91-95. [PMID: 28117260 DOI: 10.1016/j.jocn.2016.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 12/26/2016] [Indexed: 10/20/2022]
Abstract
Arteriovenous malformations (AVMs) are the leading causing of intra-cerebral haemorrhage. Stereotactic radiosurgery (SRS) is an established treatment for arteriovenous malformations (AVM) and commonly delivered using Gamma Knife within dedicated radiosurgery units. Linear accelerator (LINAC) SRS is increasingly available however debate remains over whether it offers an equivalent outcome. The aim of this project is to evaluate the outcomes using LINAC SRS for AVMs used within a UK neurosciences unit and review the literature to aid decision making across various SRS platforms. Results have shown comparability across platforms and strongly supports that an adapted LINAC based SRS facility within a dynamic regional neuro-oncology department delivers similar outcomes (in terms of obliteration and toxicity) to any other dedicated radio-surgical platform. Locally available facilities can facilitate discussion between options however throughput will inevitably be lower than centrally based dedicated national radiosurgery units.
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Affiliation(s)
- S Yahya
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - G Heyes
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - P Nightingale
- Wolfson Computer Laboratory, University Hospitals Birmingham, NHS Foundation Trust, United Kingdom
| | - S Lamin
- Department of Neuroradiology, University Hospitals Birmingham, NHS Foundation Trust, United Kingdom
| | - S Chavda
- Department of Neuroradiology, University Hospitals Birmingham, NHS Foundation Trust, United Kingdom
| | - I Geh
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - D Spooner
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - G Cruickshank
- Department of Neurosurgery, University Hospitals Birmingham, NHS foundation Trust, United Kingdom
| | - P Sanghera
- Hall-Edwards Radiotherapy Research Group, Queen Elizabeth Hospital, Birmingham, United Kingdom.
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12
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Abstract
Objective:To investigate predictive factors of complete obliteration following treatment with linac-based stereotactic radiosurgery for intracerebral arteriovenous malformations.Methods:Archived plans for 48 patients treated at the British Columbia Cancer Agency and who underwent post-treatment digital subtraction angiography to assess obliteration were studied. Actuarial estimates of obliteration were calculated using the Kaplan-Meier method. Univariate and multivariate Cox proportional hazards models were used for analysis of incidence of obliteration. Log-rank test was used to search for parameters associated with obliteration.Results:Complete nidus obliteration was achieved in 38/48 patients (79.2%). Actuarial rate of obliteration was 75.9% at 4 years (95% confidence interval 63.1%-88.6%). On univariate analysis, prescribed dose to the margin (p=0.002) and dose to isocentre (p=0.022) showed statistical significance. No parameters were significant in a multivariate model. According to the log-rank test, prescribed dose to the margin of >20 Gy (p=0.004) and dose to the isocentre of >25 Gy (p=0.004) were associated with obliteration.Conclusion:Reported series in the literature suggest a number of different factors are predictive of complete obliteration of arteriovenous malformations following radiosurgery. However, differing definitions of volume and complete obliteration makes direct comparison between series difficult. This study demonstrates that complete obliteration of the nidus following linear accelerator-based stereotactic radiosurgery for arteriovenous malformations appears to be most closely related to the prescribed marginal dose. In particular, a marginal dose of >20Gy is strongly associated with obtaining complete obliteration of the nidus.
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13
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Abstract
Purpose:To identify the predictors of symptomatic post-radiation T2 signal change in patients with arteriovenous malformations (AVM) treated with radiosurgery.Materials and Methods:The charts of 211 consecutive patients with arteriovenous malformations treated with either gamma knife radisurgery or linear accelerator radiosurgery between 2000-2009 were retrospectively reviewed. 168 patients had a minimum of 12 months of clinical and radiologic follow-up following the procedure and complete dosage data. Pretreatment characteristics and dosimetric variables were analyzed to identify predictors of adverse radiation effects.Results:141 patients had no clinical symptomatic complications. 21 patients had global or focal neurological deficits attributed to symptomatic edema. Variables associated with development of symptomatic edema included a non-hemorrhagic symptomatic presentation compared to presentation with hemorrhage, p=0.001; OR (95%CI) = 6.26 (1.99, 19.69); the presence of venous rerouting compared to the lack of venous rerouting, p=0.031; OR (95% CI) = 3.25 (1.20, 8.80); radiosurgery with GKS compared to linear accelerator radiosurgery p = 0.012; OR (95% CI) = 4.58 (1.28, 16.32); and the presence of more than one draining vein compared to a single draining vein p = 0.032; OR (95% CI) = 2.82 (1.06, 7.50).Conclusions:We postulated that the higher maximal doses used with gamma knife radiosurgery may be responsible for the greater number of adverse radiation effects with this modality compared to linear accelerator radiosurgery. We found that AVMs with greater venous complexity and therefore instability resulted in more adverse treatment outcomes, suggesting that AVM angioarchitecture should be considered when making treatment decisions.
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14
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Veeravagu A, Hansasuta A, Jiang B, Karim AS, Gibbs IC, Chang SD. Volumetric analysis of intracranial arteriovenous malformations contoured for CyberKnife radiosurgery with 3-dimensional rotational angiography vs computed tomography/magnetic resonance imaging. Neurosurgery 2013; 73:262-70. [PMID: 23615081 DOI: 10.1227/01.neu.0000430285.00928.30] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Accurate target delineation has significant impact on brain arteriovenous malformation (AVM) obliteration, treatment success, and potential complications of stereotactic radiosurgery. OBJECTIVE We compare the nidal contouring of AVMs using fused images of contrasted computed tomography (CT) and magnetic resonance imaging (MRI) with matched images of 3-dimensional (3-D) cerebral angiography for CyberKnife radiosurgery (CKRS) treatment planning. METHODS Between May 2009 and April 2012, 3-D cerebral angiography was integrated into CKRS target planning for 30 consecutive patients. The AVM nidal target volumes were delineated using fused CT and MRI scans vs fused CT, MRI, and 3-D cerebral angiography for each patient. RESULTS The mean volume of the AVM nidus contoured with the addition of 3-D cerebral angiography to the CT/MRI fusion (9.09 cm(3), 95% confidence interval: 5.39 cm(3)-12.8 cm(3)) was statistically smaller than the mean volume contoured with CT/MRI fused scans alone (14.1 cm(3), 95% confidence interval: 9.16 cm(3)-19.1 cm(3)), with a mean volume difference of δ = 5.01 cm(3) (P = .001). Diffuse AVM nidus was associated with larger mean volume differences compared with a compact nidus (δ = 6.51 vs 2.11 cm(3), P = .02). The mean volume difference was not statistically associated with the patient's sex (male δ = 5.61, female δ = 5.06, P = .84), previous hemorrhage status (yes δ = 5.69, no δ = 5.23, P = .86), or previous embolization status (yes δ = 6.80, no δ = 5.95, P = .11). CONCLUSION For brain AVMs treated with CKRS, the addition of 3-D cerebral angiography to CT/MRI fusions for diagnostic accuracy results in a statistically significant reduction in contoured nidal volume compared with standard CT/MRI fusion-based contouring.
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Affiliation(s)
- Anand Veeravagu
- †Departments of Neurological Surgery, Stanford University School of Medicine, Stanford, California; ‡Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California; §Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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15
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Fuetsch M, El Majdoub F, Hoevels M, Müller RP, Sturm V, Maarouf M. Stereotactic LINAC radiosurgery for the treatment of brainstem cavernomas. Strahlenther Onkol 2012; 188:311-6. [PMID: 22314579 DOI: 10.1007/s00066-011-0050-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 09/15/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND The management of deep-seated cerebral cavernous malformations (CCMs) is still controversial. Although surgery remains the treatment of choice in patients with recurrent hemorrhage, patients with CCMs located in the brainstem are in many cases not eligible for resection due to high procedure-related morbidity and mortality. We evaluated the long-term outcome of LINAC radiosurgery (LINAC-RS) for the treatment of brainstem CCMs. PATIENTS AND METHODS Between December 1992 and March 2008, 14 patients (6 men, 8 women) harboring brainstem CCMs underwent LINAC-RS. Pretreatment neuroimaging showed no associated developmental venous angiomas (DVAs) in any of our patients. Prior to treatment, all patients suffered at least from one symptomatic hemorrhage (median 1.8, range 1–3). A median follow-up of 7.1 years (range 2.0–16.8 years) could be obtained in 12 patients. We applied a median tumor surface dose of 13.9 Gy (range 11–18 Gy; median tumor volume 1.6 ml, range 0.4–4.3 ml). RESULTS Following LINAC-RS, neurological outcome improved in 4 (33.3%) and remained unchanged in 8 patients (66.7%). Rebleeding with subsequent transient neurological status deterioration occurred in 4 patients (33.3%), leading to additional surgical resection in 2 patients (16.7%). The corresponding annual hemorrhage rate was 4.8% (4/82.8 patient–years). Adverse radiation effects (ARE, defined by perilesional hyperintensity on T2-weighted MR images) were revealed in 3 patients (25%), leading to transient neurological deficits in 2 patients (16.7%). There were no procedure-related complications leading to either permanent morbidity or mortality. CONCLUSION Our results support the role of LINAC-RS as an efficient and safe treatment to significantly reduce the annual hemorrhage rate in patients suffering from brainstem CCMs not eligible to microsurgery. Compared with radiosurgery for arteriovenous malformations (AVMs), the intervention-related morbidity is higher.
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Affiliation(s)
- M Fuetsch
- Department of Stereotaxy and Functional Neurosurgery, University of Cologne, Cologne
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16
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Plasencia AR, Santillan A. Embolization and radiosurgery for arteriovenous malformations. Surg Neurol Int 2012; 3:S90-S104. [PMID: 22826821 PMCID: PMC3400489 DOI: 10.4103/2152-7806.95420] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 03/28/2012] [Indexed: 12/24/2022] Open
Abstract
The treatment of arteriovenous malformations (AVMs) requires a multidisciplinary management including microsurgery, endovascular embolization, and stereotactic radiosurgery (SRS). This article reviews the recent advancements in the multimodality treatment of patients with AVMs using endovascular neurosurgery and SRS. We describe the natural history of AVMs and the role of endovascular and radiosurgical treatment as well as their interplay in the management of these complex vascular lesions. Also, we present some representative cases treated at our institution.
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Affiliation(s)
- Andres R Plasencia
- Interventional Neuroradiology Service, Clinica Tezza e Internacional, Lima, Peru
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17
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Flores GL, Sallabanda K, dos Santos MA, Gutiérrez J, Salcedo JCBP, Beltrán C, Fernández CP, Atienza MG, Samblás J. Linac stereotactic radiosurgery for the treatment of small arteriovenous malformations: lower doses can be equally effective. Stereotact Funct Neurosurg 2011; 89:338-45. [PMID: 22005899 DOI: 10.1159/000330837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 07/12/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the efficacy and toxicity of treating small arteriovenous malformations (AVMs) (≤3 cm in diameter) with a median marginal applied dose of 14 Gy. METHODS Two hundred and thirteen patients diagnosed with AVMs were treated between January 1991 and December 2005. Seventy-three percent of the patients had hemorrhaged prior to treatment, 13% had had previous surgery and 19.2% had had previous embolization. The median follow-up duration was 48.1 months. RESULTS The Kaplan-Meier analysis estimated that the 36-month obliteration rate was 65.5% for patients undergoing their first stereotactic radiosurgery (SRS) and 68.3% for those undergoing repeated SRS. The Kaplan-Meier analysis estimated the 60-month AVMs obliteration rate for the entire cohort to be 82.4%. The median time to AVM obliteration was 40 ± 2.8 months. We found a statistically significant relationship between the time of obliteration and the following factors: site of the AVMs (sites other than brainstem), a higher prescribed dose and a positive history of previous hemorrhage. Thirteen patients (7.6%) experienced toxicities. CONCLUSIONS SRS was an effective and safe treatment for AVMs ≤3 cm in diameter, with acceptable toxicity.
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Affiliation(s)
- G L Flores
- Radiotherapy Department, Instituto Madrileño de Oncologia/Grupo IMO, Madrid, Spain
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18
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Stahl JM, Chi YY, Friedman WA. Repeat Radiosurgery for Intracranial Arteriovenous Malformations. Neurosurgery 2011; 70:150-4; discussion 154. [PMID: 21743357 DOI: 10.1227/neu.0b013e31822c5740] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Despite a high success rate in the stereotactic radiosurgical treatment of intracranial arteriovenous malformations (AVMs) that cannot be safely resected with microsurgery, some patients must be managed after treatment failure.
OBJECTIVE
To provide an update on the use of repeat linear accelerator radiosurgery as a treatment for failed AVM radiosurgery at the University of Florida.
METHODS
We reviewed 103 patients who underwent repeat radiosurgical treatment for residual AVM at the University of Florida between December 1991 and December 2007. Each of these patients had at least 2 radiosurgical treatments for the same AVM. Patient information, including AVM nidus volume, prescription dose, age, and sex, was collected at the time of initial treatment and again at the time of retreatment. Patients were followed up after treatment with magnetic resonance, computed tomography, and angiographic imaging at standard intervals to determine the status of their AVM. The median follow-up after retreatment was 31 months.
RESULTS
Between the first and second treatments, the median AVM nidus volume was decreased by 69% (from a median volume of 12.7 to 4.0 cm3), allowing the median prescribed dose to be increased from 1500 cGy on initial treatment to 1750 cGy on retreatment. The final obliteration rate on retreatment was 65.3%. After salvage retreatment, 5 patients (4.9%) experienced radiation-induced complications, and 6 patients (5.8%) experienced posttreatment hemorrhage.
CONCLUSION
Repeat radiosurgery is a safe and effective salvage treatment for AVMs.
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Affiliation(s)
- John M. Stahl
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Yueh-Yun Chi
- Department of Epidemiology and Health Policy Research, University of Florida, Gainesville, Florida
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Douglas JG, Goodkin R. Treatment of arteriovenous malformations using Gamma Knife surgery: the experience at the University of Washington from 2000 to 2005. J Neurosurg 2008; 109 Suppl:51-6. [DOI: 10.3171/jns/2008/109/12/s9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The purpose of this study was to examine the efficacy and toxicity of treating arteriovenous malformations (AVMs) with the model 3C Gamma Knife at the University of Washington Medical Center.
Methods
Ninety-five evaluable patients with 99 treatable AVMs were treated at the University of Washington Medical Center from April 2000 through June 2005. The median patient age at the time of treatment was 40 years (range 6–68 years). The male to female patient ratio was 0.98:1. The median AVM volume treated was 3.8 cm3 (range 0.12–32 cm3). Forty-four percent of the patients had hemorrhaged prior to treatment. The median peripheral Gamma Knife surgery dose was 20 Gy with a median of 12 isocenters treated. The median follow-up duration was 38 months (range 3–91 months). Eighty-one percent of the patients had no previous stereotactic radiosurgery (SRS), whereas the remaining 19% had previously been treated with linear accelerator–based SRS.
Results
The Kaplan–Meier estimated 6-year AVM obliteration rate for the entire cohort was 71.4%. The Kaplan–Meier estimated 6-year obliteration rate was 72% for patients having no prior SRS and 54.5% for those undergoing repeat SRS. The median time to AVM obliteration was 47 months, with 90% of the obliterations occurring between 24 and 58 months. Eight patients (7.4%) experienced late toxicities. There were 2 fatal bleeds and 13 (13.8%) nonfatal bleeds after Gamma Knife surgery.
Conclusions
Gamma Knife surgery is an effective treatment for AVMs, resulting in an excellent obliteration rate with acceptable toxicity.
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Affiliation(s)
- James G. Douglas
- 1Departments of Radiation Oncology,
- 2Neurological Surgery, and
- 3Pediatrics, University of Washington Cancer Center, Seattle, Washington
| | - Robert Goodkin
- 1Departments of Radiation Oncology,
- 2Neurological Surgery, and
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