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Lim JH, Kim MJ. Considerations for the Use of Stereotactic Radiosurgery to Treat Large Arteriovenous Malformations. Biomedicines 2024; 12:2003. [PMID: 39335517 PMCID: PMC11428206 DOI: 10.3390/biomedicines12092003] [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: 07/30/2024] [Revised: 08/20/2024] [Accepted: 08/27/2024] [Indexed: 09/30/2024] Open
Abstract
Stereotactic radiosurgery (SRS) is an effective treatment strategy for cerebral arteriovenous malformations (AVMs). Aggressive treatment achieving complete obliteration is necessary to prevent further intracranial hemorrhage and neurological deficits. However, SRS treatment of large AVMs (>10 cm3) is challenging. To prevent toxicity in the normal brain tissue, it is imperative to reduce the radiation dose as the lesion volume increases; however, this also reduces the rate of obliteration. In this study, we review the various radiosurgical approaches for treating large AVMs and their outcomes, and suggest ways to improve treatment outcomes during SRS for large AVMs.
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Affiliation(s)
- Jong Hyun Lim
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, 123 Jeokgeum-ro, Danwon-gu, Ansan 15355, Gyeonggi-do, Republic of Korea
| | - Myung Ji Kim
- Department of Neurosurgery, Korea University Ansan Hospital, Korea University College of Medicine, 123 Jeokgeum-ro, Danwon-gu, Ansan 15355, Gyeonggi-do, Republic of Korea
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Niwa R, Ichi S, Nomura R, Sato K. Hypofractionated Stereotactic Radiotherapy with CyberKnife for Large Arteriovenous Malformations and Arteriovenous Malformations Located in Eloquent Areas. Neurol Med Chir (Tokyo) 2022; 62:445-450. [PMID: 36070959 PMCID: PMC9637402 DOI: 10.2176/jns-nmc.2022-0033] [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: 11/24/2022] Open
Abstract
Literature has yet to establish an appropriate treatment strategy for large arteriovenous malformations (AVMs) and AVMs located in eloquent areas. In this study, the treatment outcomes of hypofractionated stereotactic radiotherapy (HSRT) with CyberKnife (CK) for large AVMs and AVMs in eloquent areas were evaluated. This study retrospectively evaluated 38 consecutive patients with AVMs treated with HSRT in the Japanese Red Cross Medical Center between August 2010 and July 2015. Obliteration rates and hemorrhage rates at 3- and 5-years of follow-up were calculated. Factors for hemorrhage and obliteration were analyzed with logistic regression analysis. Fourteen (36.8%) patients had a history of hemorrhage. Twenty (52.6%) AVMs were larger than 10 mL, and 34 (89.5%) AVMs were located in eloquent areas. The majority of the AVMs (84.2%) were classified into high grades (grades 3, 4, and 5) using the Spetzler-Martin grading scale. The median modified radiosurgery-based AVM score was 2.05, and the median Virginia Radiosurgery AVM Score was 3. The mean marginal dose was 24.5 ± 2.5 Gy. Twenty-three and 15 patients received three- and five-fraction stereotactic radiotherapy, respectively. At 3 and 5 years posttreatment, two (2.0%/year) and six (6.7%/year) patients had hemorrhage with obliteration rates of 15.2% and 16.7%, respectively. AVM localization in eloquent areas was a risk factor for obliteration failure. This study revealed that HSRT with CK for large AVMs and AVMs located in eloquent areas contributed to hemorrhage risk reduction and obliteration, at least in the early stages.
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Affiliation(s)
- Ryoko Niwa
- CyberKnife Center, Japanese Red Cross Medical Center.,Department of Neurosurgery, The University of Tokyo Hospital
| | - Shunsuke Ichi
- CyberKnife Center, Japanese Red Cross Medical Center
| | - Ryutaro Nomura
- CyberKnife Center, Japanese Red Cross Medical Center.,CyberKnife Center, Chigasaki Chuo Hospital
| | - Kengo Sato
- CyberKnife Center, Japanese Red Cross Medical Center
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Tam AKY, Chan DYC, Lim K, Poon D, Kam M, Cheung M, Wong GKC. Long term treatment efficacy & complications of hypofractionated stereotactic radiosurgery in brain arteriovenous malformations. J Clin Neurosci 2020; 82:241-246. [PMID: 33246903 DOI: 10.1016/j.jocn.2020.10.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 10/09/2020] [Accepted: 10/23/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate long term treatment efficacy and complications of hypofractionated stereotactic radiosurgery (hfSRS) and identify factors that predict outcomes. METHODS A retrospective review was conducted on 34 consecutive patients who received hfSRS from 2008 to 2017. Demographic, clinical, angio-architectural characteristics, and radiosurgery data were extracted from the Clinical Data Analysis and Reporting System and our unit's iPlan (BrainLAB, Munich) system. Data was analysed using SPSS. RESULTS 5-year obliteration rate was 39.1%. Most patients (n = 29, 85.3%) recovered well with GOS of 4-5. 26.9% (n = 9) patients have at least one post-radiosurgery complication including hemorrhage, neurological deficits, radionecrosis. Neurological morbidity and mortality was 17.6% (n = 6). A higher modified radiosurgery arteriovenous malformation score (mRBAS) is associated with a lower 5-year obliteration rate (Rho = -0.486, p = 0.025). None of the bAVM were obliterated once mRBAS exceeds 5.35. As expected, a larger 20-Gy volume outside lesion is associated with more complications and poorer GOS. Interestingly, irradiated drainage vein volume indexed to AVM volume (iiDVV) correlates with increased risks of post-hfSRS haemorrhage (Rho = 0.472, p = 0.031) and reduced event-free survival (Rho = -0.472, p = 0.031). Once iiDVV exceeds 20%, a high rebleeding rate after hfSRS is anticipated (AUC under ROC 0.889). CONCLUSION Hypofractionated stereotactic radiosurgery is an alternative radiosurgery treatment for bAVM unsuitable for single-fraction SRS. mRBAS predicts obliteration rate and morbidity in hfSRS. Index irradiated drainage vein volume (iiDVV) is associated with event-free survival and rebleeding and should be minimized if feasible.
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Affiliation(s)
- Aurora K Y Tam
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - David Y C Chan
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Kevin Lim
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Darren Poon
- Department of Clinical Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Michael Kam
- Department of Clinical Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Michael Cheung
- Department of Clinical Oncology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - George K C Wong
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong.
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Choi MS, Joo M, Choi CY. Chronic encapsulated expanding hematoma after stereotactic radiosurgery of cerebral arteriovenous malformation. J Cerebrovasc Endovasc Neurosurg 2019; 21:152-157. [PMID: 31886150 PMCID: PMC6911927 DOI: 10.7461/jcen.2019.21.3.152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/18/2019] [Accepted: 09/28/2019] [Indexed: 11/23/2022] Open
Abstract
Stereotactic radiosurgery has become excellent alternative treatment for cerebral arteriovenous malformations (AVM). This technique has expanded to treatment of larger AVM which is not amenable to surgical management. However, its variable adverse effects should be also taken into considerations sincerely because of radiobiological characteristics such as delayed onset and progressive neurological deteriorations. Herein, we report a case in which progressively expanding hemorrhagic cyst with repeated bleedings so called chronic encapsulated expanding hematoma was developed on several years after radiosurgery treatment. Neurological and radiological findings were improved by surgical removal.
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Affiliation(s)
- Mi-Sun Choi
- Department of Neurosurgery, Seoul Paik Hospital, College of Medicine, Inje University, Korea
| | - Mee Joo
- Department of Pathology, Ilsan Paik Hospital, College of Medicine, Inje University, Korea
| | - Chan-Young Choi
- Department of Neurosurgery, Ilsan Paik Hospital, College of Medicine, Inje University, Korea
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Raoufi-Rad N, McRobb LS, Lee VS, Bervini D, Grace M, Ukath J, Mchattan J, Sreenivasan VKA, Duong TTH, Zhao Z, Stoodley MA. In vivo imaging of endothelial cell adhesion molecule expression after radiosurgery in an animal model of arteriovenous malformation. PLoS One 2017; 12:e0185393. [PMID: 28949989 PMCID: PMC5614630 DOI: 10.1371/journal.pone.0185393] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 09/12/2017] [Indexed: 12/18/2022] Open
Abstract
Focussed radiosurgery may provide a means of inducing molecular changes on the luminal surface of diseased endothelium to allow targeted delivery of novel therapeutic compounds. We investigated the potential of ionizing radiation to induce surface expression of intercellular adhesion molecule 1 (ICAM-1) and vascular cell adhesion molecule 1 (VCAM-1) on endothelial cells (EC) in vitro and in vivo, to assess their suitability as vascular targets in irradiated arteriovenous malformations (AVMs). Cultured brain microvascular EC were irradiated by linear accelerator at single doses of 0, 5, 15 or 25 Gy and expression of ICAM-1 and VCAM-1 measured by qRT-PCR, Western, ELISA and immunocytochemistry. In vivo, near-infrared (NIR) fluorescence optical imaging using Xenolight 750-conjugated ICAM-1 or VCAM-1 antibodies examined luminal biodistribution over 84 days in a rat AVM model after Gamma Knife surgery at a single 15 Gy dose. ICAM-1 and VCAM-1 were minimally expressed on untreated EC in vitro. Doses of 15 and 25 Gy stimulated expression equally; 5 Gy was not different from the unirradiated. In vivo, normal vessels did not bind or retain the fluorescent probes, however binding was significant in AVM vessels. No additive increases in probe binding were found in response to radiosurgery at a dose of 15 Gy. In summary, radiation induces adhesion molecule expression in vitro but elevated baseline levels in AVM vessels precludes further induction in vivo. These molecules may be suitable targets in irradiated vessels without hemodynamic derangement, but not AVMs. These findings demonstrate the importance of using flow-modulated, pre-clinical animal models for validating candidate proteins for vascular targeting in irradiated AVMs.
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Affiliation(s)
- Newsha Raoufi-Rad
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Lucinda S. McRobb
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Vivienne S. Lee
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - David Bervini
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- Neurosurgery Department, Inselspital, University of Bern, Bern, Switzerland
| | - Michael Grace
- Genesis Cancer Care, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Jaysree Ukath
- Genesis Cancer Care, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Joshua Mchattan
- Carestream Molecular Imaging, Sydney, New South Wales, Australia
| | - Varun K. A. Sreenivasan
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- Department of Physics and Astronomy, Macquarie University, Sydney, New South Wales, Australia
| | - T. T. Hong Duong
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Zhenjun Zhao
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Marcus A. Stoodley
- Department of Clinical Medicine, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
- * E-mail:
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Knippen S, Putz F, Semrau S, Lambrecht U, Knippen A, Buchfelder M, Schlaffer S, Struffert T, Fietkau R. Predictors for occlusion of cerebral AVMs following radiation therapy : Radiation dose and prior embolization, but not Spetzler-Martin grade. Strahlenther Onkol 2016; 193:185-191. [PMID: 27757503 DOI: 10.1007/s00066-016-1056-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 09/21/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intracranial arteriovenous malformations (AVMs) may show a harmful development. AVMs are treated by surgery, embolization, or radiation therapy. OBJECTIVE This study investigated obliteration rates and side effects in patients with AVMs treated by radiation therapy. METHODS A total of 40 cases treated between 2005 and 2013 were analyzed. Single-dose stereotactic radiosurgery (SRS) was received by 13 patients and 27 received hypofractionated stereotactic radiation therapy (HSRT). In 20 patients, endovascular embolization had been performed prior to irradiation and 24 patients (60 %) had a history of previous intracranial hemorrhage. RESULTS Treatment resulted in complete obliteration (CO) in 23/40 cases and partial obliteration in 8/40. CO was achieved in 85 % of patients receiving SRS compared to 44 % of those receiving HSRT. In the HSRT group, a first indication of an influence of AVM volume on obliteration rate was found. Equivalent 2 Gy fraction doses (EQD2) >70 Gy showed an obliteration rate of 50 %. Prior embolization was significantly associated with a higher portion of CO (p = 0.032). Median latency period (24.2 vs. 26 months) until CO was similar in both groups (SRS vs. HSRT). The rate of intracranial hemorrhage in patients with no prior bleeding events was 0 %. CONCLUSION Excellent obliteration rates were achieved by SRS. Consistent with the literature, this data analysis suggests that the results of HSRT are volume-dependent. Furthermore, regimens with EQD2 doses >70 Gy appear more likely to achieve obliteration than schemes with lower doses. The findings indicate that radiation therapy does not increase the risk of bleeding. Prior embolization may have a good prognostic impact.
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Affiliation(s)
- Stefan Knippen
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany.
| | - Florian Putz
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Ulrike Lambrecht
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Arzu Knippen
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
| | - Michael Buchfelder
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Sven Schlaffer
- Department of Neurosurgery, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Tobias Struffert
- Department of Neuroradiology, Friedrich-Alexander-University Erlangen-Nuremberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitaetsstraße 27, 91054, Erlangen, Germany
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Hypofractionated stereotactic radiosurgery for treatment of cerebral arteriovenous malformations: outcome analysis with use of the modified arteriovenous malformation scoring system. J Clin Neurosci 2016; 29:155-61. [DOI: 10.1016/j.jocn.2015.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 12/12/2015] [Indexed: 11/19/2022]
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Maryashev SA, Golanov AV, Konovalov AN, Gorlachev GE, Yakovlev SB, Dalechina AV, Antipina NA, Kuznetsova AS, Fil'chenkova NV, Eliava SS, Bukharin EY, Vinogradov EV, Trunin YY. [The outcomes of stereotactic radiotherapy in patients with cerebral arteriovenous malformations]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2015; 79:14-32. [PMID: 25909742 DOI: 10.17116/neiro201579114-32] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Cerebral arteriovenous malformations (AVMs) are the congenital anomalies of development of cerebral vessels during the embryonic period. The conventional therapy for AVMs currently includes endovascular management, microneurosurgical resection, and stereotactic irradiation. MATERIAL AND METHODS A total of 315 patients with brain AVMs were subjected to stereotactic radiotherapy in 2005-2011. 238 (76%) patients had previous subarachnoid hemorrhage (SAH) within different time (6 months to 5 years) before the therapy; 214 (68%) patients had headaches; 113 (36%) patients had focal neurological symptoms caused by localization; and 82 (26%) patients had seizures. Twenty-three patients were subjected to surgical resection of an intracerebral hematoma prior to radiotherapy and 119 (36%) patients received endovascular treatment including partial embolization of the stroma of AVM. 267 patients received single-fraction radiosurgical irradiation. In patients with large AVMs, we used the hypofractionation technique consisting in target irradiation with several (usually 2-7) fractions; the radiation dose per fraction exceeds 2 Gy. Forty-six patients were irradiated in the hypofractionation mode; two patients had a course of stereotactic radiotherapy in the standard fractionation mode. The marginal dose of radiosurgical irradiation was 13-30 Gy (the average dose was 24 Gy). The main group of patients (38 individuals) with large AVMs was treated using hypofractionation of 35 Gy per 5 fractions. RESULTS Control angiography was carried out in 225 patients who had been followed up for at least 2 years after therapy showed that complete obliteration was achieved in 83% of cases. The rate of symptomatic radiation reactions was less than 10%. The higher risk of developing obliteration was observed for AVMs less than 2 cm3 in size at marginal doses more than 24 Gy. In the hypofractionation group consisting of 27 patients with complete follow-up data, obliteration was observed in 10 (37%) patients. The rate of symptomatic reactions was less than 35%. CONCLUSIONS The radiosurgical method is a minimally invasive choice of treatment for patients with brain AVM, which allows one to achieve sufficiently high degree of obliteration with the minimum complication rate. The hypofractionation procedure is the method of choice for treating large AVMs. Stereotactic irradiation using the Novalis linear accelerator makes it possible to treat patients with AVMs of virtually any location and volume.
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Affiliation(s)
| | - A V Golanov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | - S B Yakovlev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - N A Antipina
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | - Sh Sh Eliava
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | - Yu Yu Trunin
- Burdenko Neurosurgical Institute, Moscow, Russia
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Fareed MM, Amro AA, Bayoumi Y, Orz YI, Tunio M, Maklad A, Riaz K. LINAC Stereotactic Radiosurgery for brain arteriovenous malformation: a single institutional experience from Saudi Arabia. ACTA ACUST UNITED AC 2013. [DOI: 10.7243/2052-6946-1-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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HANAKITA S, KOGA T, SHIN M, SHOJIMA M, IGAKI H, SAITO N. Role of Stereotactic Radiosurgery in the Treatment of High-Grade Cerebral Arteriovenous Malformation. Neurol Med Chir (Tokyo) 2012; 52:845-51. [DOI: 10.2176/nmc.52.845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Shunya HANAKITA
- Department of Neurosurgery, The University of Tokyo Hospital
| | - Tomoyuki KOGA
- Department of Neurosurgery, The University of Tokyo Hospital
| | - Masahiro SHIN
- Department of Neurosurgery, The University of Tokyo Hospital
| | - Masaaki SHOJIMA
- Department of Neurosurgery, The University of Tokyo Hospital
| | - Hiroshi IGAKI
- Department of Radiology, The University of Tokyo Hospital
| | - Nobuhito SAITO
- Department of Neurosurgery, The University of Tokyo Hospital
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